Enrolling in Original Medicare at 65 gives you a six-month Medigap open enrollment period. During this time, insurers cannot deny you any Medicare Supplement (Medigap) coverage or charge you more based on your health conditions. You also get the most plan choices. However, outside this protected period, you can be denied a Medicare Supplement plan.
If you apply outside of open enrollment, you can be denied a Medicare supplement policy.
Not meeting the eligibility rules, including not having Medicare Parts A and B, and being under 65 in most states can also result in Medicare supplement denial.
An existing Medigap policy can be canceled for nonpayment of premiums, enrollment in Medicare Advantage, or incorrect information on your application.
Enrolling in a Medicare supplement plan during your Medigap open enrollment period or when you have guaranteed issue rights gives you the best protection against denial.
If you’ve been denied a Medicare supplement plan, see if you can appeal the decision, consider applying to other carriers, or enroll in Medicare Advantage.
Can you be denied a Medicare supplement plan?
Yes, you can be denied a Medicare supplement (Medigap) plan in the following situations:
- You are signing up outside the Medigap open enrollment period. If you try to enroll outside the Medigap open enrollment period and don't qualify for guaranteed issue rights, the insurance company can deny coverage based on your health status. The plan may decide not to cover you if you have pre-existing conditions that would make your care too expensive.
- You don’t have Original Medicare. You’ll be denied a Medicare supplement plan if you’re not enrolled in Medicare Part A and Part B. Medigap policies are designed to fill gaps in Original Medicare, so you must be enrolled in Parts A and B first.
- You’re under 65. If you’re younger than 65 but have Medicare due to a disability, the Medigap insurer can refuse to cover you unless your state law allows Medigap coverage for people under 65.
- You pause your Medigap. You can voluntarily pause your Medicare supplement policy for up to 24 months if you become eligible for Medicaid. Furthermore, you'll have to reapply if you go longer than 24 months without reinstating the Medigap policy. At that point, you could be denied if the insurer decides not to cover you after reviewing your health history.
Can an existing Medicare Supplement plan be canceled by the insurer?
Generally, Medigap policies are guaranteed renewable. This means once you enroll in a Medicare Supplement plan, the insurance company must renew your policy yearly as long as you pay your monthly premiums. The insurer generally cannot cancel coverage if you develop health conditions while enrolled.
However, there are instances when the insurance company can cancel an existing Medicare Supplement plan. These include:
- Nonpayment of premiums. If you stop paying your monthly premiums, the insurer can cancel your coverage after giving you notice.
- Enrollment in a Medicare Advantage plan. If you join a Medicare Advantage plan, any previous Medigap policy you have will be canceled.
- Misrepresentation on application. If the insurance company finds you provided false or incomplete information on your application, they can retroactively cancel your Medigap policy.
- Discontinuation of the plan. Insurers can discontinue offering a particular Medigap plan. If this happens, they will terminate the existing programs but offer policyholders other options.
- Bankruptcy. If your Medigap insurer goes bankrupt, ending your coverage through no fault of your own. You’ll then have the right to buy most Medigap plans in your area for 63 days after coverage ends.
What are guaranteed issue rights?
Guaranteed issue rights allow you to buy a Medicare Supplement insurance policy outside of open enrollment without being denied coverage or charged more due to pre-existing conditions.
Some common situations where you have guaranteed issue rights include:
- Losing other creditable coverage like employer group health coverage or Medicare Advantage through no fault of your own.
- Your Medigap insurer goes bankrupt or ends your plan.
If you qualify for guaranteed issue rights, the Medigap insurer must:
- Sell you a Medigap policy if you want one. They cannot legally deny your application.
- Cover any pre-existing conditions you may have without exclusions or waiting periods.
- Charge the standard premium rates regardless of past or present health problems.
Some states offer added Medigap protection. For example, some states allow seniors already enrolled in Medigap to change plans anytime.
What is the Medicare supplement pre-existing condition waiting period?
The Medicare supplement pre-existing condition waiting period is when an insurer may refuse to cover costs related to medical conditions you had before enrolling. The waiting period for a pre-existing condition under a Medicare supplement policy may not go beyond six months.
However, you can avoid or reduce this waiting period if you buy a Medigap plan when you have guaranteed issue rights. After the six-month waiting period, the Medigap insurer must provide full coverage regardless of pre-existing conditions identified during the look-back period when you first enrolled.
How to avoid Medicare Supplement denial
Use the following tips to avoid Medicare Supplemental denial.
First, enroll during your Medigap open enrollment period when you turn 65 and join Medicare Part B. Insurers cannot deny you any Medigap plan due to health conditions or charge you more during this six-month window. By doing so, you also avoid Medigap underwriting, which is essential, especially if you have pre-existing health conditions.
You also have guaranteed issue rights to purchase a Medigap policy without underwriting if certain events occur, like losing other coverage or your insurer going bankrupt. Make sure you qualify for those protections if shopping outside open enrollment.
When applying for a plan, provide complete and accurate details about your health status, medications, and history. Insurers can retroactively terminate your policy if any information on the application is missing or false.
If you're transitioning from another plan, try to maintain continuous creditable coverage (previous health coverage that can be used to reduce the pre-existing condition waiting period).
Check your state's laws. Some states provide additional Medigap protections beyond federal requirements regarding open enrollment, community rating, and access.
If one insurer quotes high premiums or seems likely to deny your application, shop around and compare rates and terms from competitors. Each company makes its own underwriting decisions.
What should you do if you’re denied a Medicare Supplement plan?
Here are some steps to take if you're denied a Medicare Supplement plan:
- Request the denial in writing. This will explain the specific denial reasons. Review it to see if the insurer made an error.
- Appeal the decision. You may be able to appeal if you believe the denial was unjustified. Provide additional medical records if needed.
- Review state laws. Check if you live in a state with extra Medigap protections and see how they apply to you.
- Look into alternatives. Ask if the company offers any other Medicare Supplement plans for which you can qualify.
- Shop other carriers. Try applying with other insurers, as each company makes its own underwriting decisions. For example, one carrier may deny you because you have kidney disease. However, another carrier may have more favorable guidelines depending on the stage of your kidney disease.
- Check plan rules yearly. Reapply if you become eligible again due to improved health, plan rule changes, or new plans become available.
- Consider Medicare Advantage. Look into Medicare Advantage plans, which must accept all applicants during open enrollment.
Medicare Supplement plans can be denied in certain circumstances, but you can reduce your chance of denial. Take full advantage of the Medigap open enrollment period that prohibits denials for pre-existing conditions. Maintain continuous health coverage to minimize gaps that could trigger underwriting. Arm yourself with knowledge about state and federal consumer protections, and follow application instructions meticulously. If you’ve been denied, consider appealing and looking into alternatives.
What is Medigap underwriting?
Medigap underwriting is the process insurance companies use to evaluate your health risk and determine whether to approve your application and how to set your premiums when you apply for a Medicare Supplement plan.
What are considered pre-existing conditions?
Any medical conditions diagnosed or treated before your Medigap enrollment date (if outside the Medigap open enrollment period, and you don’t qualify for guaranteed issue rights) are considered pre-existing. These may include cancer, diabetes, stroke, kidney disease, and other health conditions.
How do I appeal a Medicare supplement denial?
You can appeal the decision directly with the insurer and provide more documentation to support your case. Your State Health Insurance Assistance Program (SHIP) offers free counselors to help guide you through the appeal process. You can also contact your state insurance department to get support for the denial.