Healthcare Educators


What to Expect If You Need Medical Underwriting for a Medicare Supplement Plan

by | Jul 19, 2023

What happens if you decide you want to change your Medicare Supplement plan? Maybe it’s become too expensive or perhaps your circumstances have changed and your plan is no longer a good fit. Or maybe you would like to switch from a Medicare Advantage plan to Original Medicare and want to pick up a Supplement plan. In any of these circumstances, once you are outside of your Open Enrollment Period, you will most likely have to undergo medical underwriting.

What Is Medical Underwriting?

Medical underwriting is the process insurance companies use to decide if you are high risk. If you enroll in a Supplement plan during your initial enrollment period, you have what’s known as guaranteed-issue rights, which mean an insurer cannot deny you coverage or charge you more due to your health issues. Once you are outside this six-month window, insurers will use underwriting to determine if they are willing to insure you. If you have too many high-cost health conditions that could result in high-cost claims, the insurer may charge you a higher premium or deny you coverage altogether.

Enrollment periods and underwriting rules for Medicare Supplement plans vary by state. It’s important to know the rules in your state. There are also some specific situations where you can you extend your guaranteed-issue rights beyond your open enrollment period.

Underwriting Questions

Underwriting guidelines vary by insurance carrier, but they all assess your current and past health conditions. The insurer will ask you a series of questions regarding your age, gender, alcohol and tobacco use, prescriptions, and family health history. The insurer will also ask you about any pre-existing health conditions. You should always answer the questions with a “yes” or “no” and only provide additional information if asked.

Some chronic conditions that will lead to automatic denial include:

  • Advanced Diabetes
  • Alcoholism
  • Amyotrophic lateral sclerosis (ALS), Parkinson’s disease, and multiple sclerosis
  • Alzheimer’s disease and dementia
  • Bone marrow and organ transplant
  • Cancer, melanoma, leukemia, Hodgkin’s disease, and lymphoma
  • Chronic bronchitis
  • Cirrhosis of the liver and kidney failure
  • Congestive heart failure
  • COPD and emphysema
  • End-stage renal disease
  • Heart disease
  • Immune disorders
  • Hepatitis C, lupus, and Crohn’s disease
  • Mental and nervous disorders

Insurers will also deny you coverage if you reside in a nursing home or you have mobility issues and need a wheelchair.

If any of the above apply to you, don’t waste your time and effort moving forward with an application.

Proceeding with the Application

If you answered “no” everything above, the chances are good that you will move to the next step of the underwriting process. A representative of the insurance company may contact you to review your health history and to ask you additional questions. You will have to sign a privacy release to allow your doctors to share your medical records with the insurance company.

Most applications will ask you if you have any upcoming surgeries, treatments, or tests that you haven’t completed yet. If your answer is “yes,” you should consider delaying your application until after you complete these procedures, as it will reduce your chances of a denial.

You will need to complete a health examination that includes basics like your height, weight, blood pressure, temperature, and pulse. You may need to provide blood or urine samples. In some cases, you may need additional tests, such as a chest X-ray, stress test, or EKG. A healthcare practitioner contracted by the insurance company carries out the exam.

After you complete the application process, it can take up to two months for the insurance company to make a decision. Don’t cancel your existing coverage until you receive approval and know when your new coverage will start.

If your application is denied, you can file an appeal. Each insurer has its own appeal process.

How a Medicare Agent Can Help

A knowledgeable and experienced Medicare agent can help you navigate the underwriting process. A local agent will understand the rules and regulations in your state. The agent will know, based on your health history, your likelihood of receiving approval and can advise you which insurers to submit your application to. Medicare agents can also guide you through the application process to ensure it goes smoothly. If you are denied coverage, they can help you find a Medicare Advantage plan that offers the benefits you need. The good news is you can’t be turned down for Medicare Advantage – and it may even cost less.

The team at Medicare Educators is dedicated to helping you find Medicare coverage that best suits your needs. Contact us today.