Denial for Medicare Supplemental Insurance, often called Medigap, is possible but not always guaranteed. Medigap is private health insurance designed to work alongside Original Medicare (Parts A and B). It helps cover the “gaps” in that coverage, such as copayments, coinsurance, and deductibles. Since Original Medicare only pays for about 80% of covered services, Medigap policies provide financial protection against the remaining out-of-pocket costs. Understanding the specific enrollment periods and federal rules that govern these private plans is necessary to secure coverage, especially for those with existing health conditions.
The Role of Medical Underwriting
Outside of protected enrollment periods, Medigap insurers can use medical underwriting to evaluate an applicant’s health status. Medical underwriting is the process where an insurer assesses an applicant’s health history, current medical conditions, and lifestyle factors. This evaluation typically involves answering an extensive health questionnaire, reviewing medical records, or sometimes a physical exam.
If the insurer decides the applicant presents a high risk due to chronic or severe health issues, they have a few options. The company can deny the application outright. Alternatively, the insurer may approve the policy but charge a significantly higher premium. Underwriting can also result in a waiting period for pre-existing conditions, though this period is limited by law.
Guaranteed Acceptance: The Medigap Open Enrollment Period
Denial based on health is prohibited during the Medigap Open Enrollment Period (OEP). This is a six-month window that begins on the first day of the month an individual is both age 65 or older and enrolled in Medicare Part B. The OEP is a federal consumer protection that completely bypasses the medical underwriting process.
During this timeframe, insurers must sell the applicant any Medigap policy they offer, regardless of pre-existing conditions. They cannot deny the application, charge higher premiums due to health, or impose a waiting period. This is the best time to purchase a Medigap policy because it guarantees access to the plan of choice at the best available rate. Missing this enrollment window means the applicant will likely be subject to medical underwriting for any future attempt to buy a policy.
Other Triggers for Guaranteed Issue Rights
Federal law provides “Guaranteed Issue Rights” (GI Rights) for individuals who missed their initial OEP. These rights are triggered by specific life events, forcing insurers to sell a Medigap policy without medical underwriting or charging higher rates for health reasons. These protections are designed to prevent beneficiaries from losing supplemental coverage through circumstances outside of their control.
Common triggers for GI Rights include the involuntary loss of employer or union group health coverage that supplemented Medicare. Moving out of a Medicare Advantage plan’s service area or a Medicare Advantage plan leaving the program entirely also triggers this right. Additionally, a trial right exists for those who enroll in Medicare Advantage for the first time and then switch back to Original Medicare within the first year. GI Rights are time-sensitive, generally requiring the individual to apply for the Medigap policy within 63 days of the coverage loss or trigger event.
How State Laws Affect Eligibility
While federal rules establish a baseline for Medigap eligibility, state laws often provide additional protections that expand access to coverage. States have the authority to institute consumer protections beyond federal minimum standards, which is particularly relevant for beneficiaries under age 65 who qualify for Medicare due to disability or End-Stage Renal Disease.
Federal law does not require insurers to offer Medigap to individuals under 65. However, 36 states mandate that at least one policy must be offered to this group during an initial enrollment period. Furthermore, some states have implemented continuous or annual guaranteed issue periods, often called “birthday rules.” These rules allow beneficiaries to switch Medigap policies each year around their birthday without medical underwriting.