What is Medical Underwriting?

If you have ever applied for a Medicare Supplement policy (AKA Medigap) you may have heard the phrase Medical underwriting.

So what exactly is medical underwriting?

Medical underwriting is a process used by insurance companies to evaluate the health risk of potential policyholders. The process includes inquiring about an individual’s medical history, current health conditions, and lifestyle choices through a series of detailed questions. The primary goal of medical underwriting is to determine the level of risk associated with insuring an individual and to make decisions regarding acceptance, pricing, and coverage limitations.

Medicare Supplement Medical UnderwritingMedical Underwriting Basics

During the underwriting process, insurance companies take into account various factors including pre-existing conditions, previous surgeries or hospitalizations, prescription medications, and any chronic illnesses or disabilities. They may also ask about lifestyle factors that could affect health risks, including smoking habits.

The insurer uses this information to evaluate the probability of future claims and make decisions regarding coverage, premiums, and any limitations or exceptions.

Medical underwriting plays a crucial role in enabling insurance companies to manage their risk effectively while ensuring fair pricing for individuals seeking coverage. By evaluating an applicant’s health status before extending insurance policies, insurers can mitigate adverse selection – a situation where only high-risk individuals seek coverage.

It is important for individuals to provide accurate information during underwriting as providing false or incomplete information can lead to claims being denied later.

What questions are asked during medical underwriting?

When applying for a Medicare Supplement plan, also known as a Medigap insurance plan, individuals can expect the underwriting process to involve a series of questions. It should be noted that insurance companies have their own specific questions, and the level of these inquiries may differ. However, most companies typically consider specific criteria when evaluating an individual’s eligibility for coverage.

Most companies ask Medicare Beneficiaries about the following:

  • Age
  • Alcohol Abuse
  • Chronic health conditions
  • Circulatory system including questions related to heart conditions
  • Drug use (prescription, over-the-counter, and drug abuse)
  • Family health history
  • Medical history
  • Mental health history
  • Tobacco use
  • Weight or BMI

Some examples of common Medicare supplement underwriting eligibility questions include:

  • In the last 5 years, have you been diagnosed with or received medical treatment for cancer, stent placement, diabetes, COPD, stroke, or heart attack?
  • Have you taken or been prescribed blood thinning medications within the last 5 years?
  • Have you received a diagnosis or received treatment for severe depression, schizophrenia, or bipolar disorder within the last 2 years?
  • Are you scheduled for a pending surgical procedure?

Depending on your answers, the cost of your Medigap policy could be higher, or the company could deny your application altogether.

What are the reasons for Medigap plan denial?

Medigap plans may be denied for various medical reasons if individuals apply outside the open enrollment periods. Although each insurance carrier is different (and some are more liberal than others) SOME medical conditions that may result in automatic coverage declines include:

  • Chronic respiratory diseases such as Chronic Obstructive Pulmonary Disorder (COPD), Chronic Bronchitis, Asthma, and pulmonary Hypertension.
  • Certain Chronic cardiac diseases including Atrial Fibrillation (AFIB) and Congestive Heart Failure
  • End-stage renal disease
  • Auto-immune disorders including AIDS, Human Immunodeficiency Virus (HIV), Rheumatoid Arthritis Psoriatic Arthritis, and Systemic Lupus
  • Cancer
  • Some Chronic cognitive disorders including Alzheimer’s Disease and Dementia,

Make sure you discuss these with your insurance broker because they may be able to direct you to a carrier that will accept your condition.

Specific state policy rules and regulations regarding Medigap denial criteria can vary from state to state so you should consult with an insurance professional about your particular needs.

Is underwriting necessary for Medicare Supplement plans?

Underwriting is not always required for Medicare Supplement plans. In fact, there are certain circumstances where underwriting is not allowed. Specifically, during your Medigap Open Enrollment Period. This is a 6 month period starting the first month you have Medicare Part B and you’re 65 or older. During this time, insurance companies cannot use medical underwriting to deny you coverage or charge you higher premiums based on your health status.

Situations where an insurance company can’t deny you a Medigap policy are called “guaranteed issue rights.”

Guaranteed Issue Rights are different from the Medicare Open Enrollment Period because they are based on specific circumstances.

Additionally, certain states have a “birthday rule” which allows you to change from one Medicare Supplement Plan to another without having to undergo underwriting (details vary by state).  We discuss this later in this article.

The Term Guaranteed Issue Means No Questions about HealthMedicare Supplement Medical Underwriting

If you have a guaranteed issue right, an insurance company:

  • Must sell you a Medigap policy
  • Coverage for pre-existing health conditions is required.
  • Can’t charge you more for a Medigap policy because of past or present health problems

Examples of Guaranteed Issue rights are:

  • Your Medicare Advantage Plan is ending, or you are leaving its service area.
  • Your employer group plan is ending (and you have Medicare).
  • You have a TRIAL right (you started Medicare Advantage when you were first eligible for Medicare at age 65, and you want to switch to original Medicare within the first year of joining).
  • You dropped your Medigap Plan for the first time to join a Medicare Advantage Plan or a SELECT plan. It’s been less than one year, and you want to change back.

We cover guaranteed issue rights in more detail at https://retirementrx.com//guaranteed-issue-rights/

States with special enrollment rules

Some states give special enrollment rules that provide guaranteed issue rights

States with special enrollment rules

Some states have special Medigap enrollment rules that provide added guaranteed issue protections to make Medigap enrollment more flexible.

In some states, there are special enrollment rules that provide additional guaranteed issue protections for Medigap plans. These rules aim to make Medigap enrollment more flexible and allow individuals to switch or enroll in a plan regardless of their health condition. Three states that have continuous or annual guaranteed issue protections are Connecticut, New York, and Vermont. This means that residents of these states can apply for a Medigap plan at any time throughout the year without being subject to medical underwriting.

Additionally, several states have birthday rules that allow individuals to switch from one Medigap plan to another with equal or lesser coverage during a specific period around their birthday. This rule provides individuals with an opportunity to reevaluate their current Medigap plan and potentially find a better fit based on their changing healthcare needs.

 To qualify for a “birthday rule” plan change, you need to already be enrolled in a Medigap plan.

The states that offer the “birthday rule” are:

California: You have 60 days from your birthday to change to another Medigap plan with the same level or a lower level of benefits.

Idaho: You have 63 days from your birthday to change to another Medigap plan with the same level or a lower level of benefits.

Illinois: You have 45 days from your birthday to change to another Medigap plan with the same level or a lower level of benefits. This only applies to plans with your current insurance carrier. (Legislation introduced in 2024 would extend this to include affiliates of your current insurer.)1 To qualify for this birthday rule, you must be 65 to 75 years old.

Kentucky: (effective starting in 2024): The Kentucky Birthday Rule allows a Medigap enrollee to switch to another insurer’s Medigap policy (same benefits as the plan they already have) within 60 days of their birthday.

Louisiana: You have 63 days from the date of your birthday to select a different Medigap plan with equal or lesser benefits. This only applies to plans with your current insurance carrier (or affiliates of your current insurer, under legislation that was enacted in 2023).

Nevada: You have 60 days from the first day of your birth month to change to another Medigap plan with the same level or a lower level of benefits. You can also change insurance carriers.

Oregon: Individuals have a 30-day window from the beginning of their birth month to switch to another Medigap plan that offers the same or lower level of benefits.

Missouri offers the “Anniversary Rule,” which allows Medigap enrollees to change their plans annually. Here is an explanation of how the Missouri Medigap Anniversary Rule operates for individuals with a Medigap plan who currently reside in Missouri.

You must switch your carrier 30 days before and 30 days after your policy’s anniversary date. You have the option to switch from your current plan to a similar one without any underwriting. For example, you can move from a Plan G to a Plan G or a Plan N to a Plan N, but not from a Plan N to a Plan G.

Residents in these states should be aware of the enrollment rules that apply to their specific state. By understanding these rules, individuals can benefit from the increased flexibility they offer in terms of enrolling in or changing Medigap plans.

If you are considering enrolling in Medigap or changing your Medigap plans, we are here to help!

Source:

medigap.com

Medicare.gov

  1. Illinois Senate Bill 56. BillTrack50. Introduced January 2024.
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