Brian Penner, Medicare Insurance Agent

Utah's New Medigap Birthday Rule: What It Changes, What It Doesn't, and How to Use It

July 29, 2026

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Why does Medicare have so many coverage gaps, and is it designed that way on purpose?

Answer: Great question — and honestly, one I hear in my office more than almost any other. The frustrating answer: yes and no.

Medicare wasn't designed with "gaps" as a trap. It was designed in 1965 to mirror the private insurance of that era — hospital coverage (Part A) and doctor coverage (Part B), with cost-sharing so the program stayed solvent. What we call "gaps" today — deductibles, the 20% coinsurance with no cap, no dental/vision/hearing, limited long-term care — are mostly things that were never included in the original design, and Congress has patched them piecemeal ever since: Part D for drugs in 2006, the $2,100 out-of-pocket cap on prescriptions that took effect in 2025 under the Inflation Reduction Act (it's indexed annually).

The part that surprises people most: Original Medicare has no out-of-pocket maximum on Parts A and B. That 20% coinsurance can run forever on a serious illness. That single gap is why an entire industry of Medigap plans and Medicare Advantage exists — private coverage filling the spaces the public program left open.

So is it "on purpose"? The gaps exist because of when the program was written and the political compromises made since — not because anyone's trying to trick you. But the consequence is real: the coverage you end up with depends heavily on the choices you make at enrollment, and some of those choices (like Medigap enrollment windows) can close permanently.

That's exactly what a licensed agent is for — mapping your health needs and budget against those gaps before they cost you. Happy to walk through yours anytime, no charge. — Brian Penner, 22+ years, Medicare On Main

Can Medicare Advantage plans deny coverage for pre-existing conditions?

Answer: Short answer: no. Medicare Advantage plans are guaranteed issue. If you have Part A and Part B, live in the plan's service area, and enroll during a valid enrollment period, the plan has to take you — no health questions, no medical underwriting, no rate-ups for your history. That's been true across the board since 2021, when even the old End-Stage Renal Disease exclusion was removed. There is no health condition that can keep you out of a Medicare Advantage plan.

I think this question comes up so often because people are remembering how health insurance worked before 65, or they're mixing up two different products. The place pre-existing conditions do matter in Medicare is Medigap (Medicare Supplement). Outside your one-time six-month Medigap Open Enrollment window — and outside a handful of guaranteed-issue situations — Medigap carriers in most states can ask health questions and decline you based on your answers.

That distinction is worth sitting with, because it cuts both ways. Your health history can't keep you out of Medicare Advantage today — but if you join an Advantage plan and later decide you want to switch to Original Medicare with a Medigap policy, that's the move where your health may be underwritten. A lot of people don't learn this until they're trying to make that switch.

One more thing people confuse with a "denial": an Advantage plan can never deny you enrollment for a condition, but it can require prior authorization for specific treatments once you're a member. That's a coverage-management issue, not a pre-existing condition exclusion — and you have appeal rights when it happens.

If you're weighing Advantage vs. Medigap right now and you have health history, the order you make decisions in matters. A local independent agent can walk you through which doors stay open and which ones may close.

How likely am I to qualify for Medigap at 73 after the six-month enrollment period? I have some medical history and a possible cancer workup, but no diagnosis, hospitalizations, or treatment.

Answer: This comes up a lot, and the honest answer is: it depends on your state and on timing more than on your age. Outside your six-month Medigap Open Enrollment window, most states let carriers ask health questions, and they can approve, rate you up, or decline.

Here's the part that matters in your situation: Medigap applications don't just ask about diagnoses — they ask about pending tests, recommended treatment, and symptoms under investigation. A "possible cancer workup" with no diagnosis usually isn't a decline for being sick; it's a postpone for being unresolved. Most carriers won't approve while a workup is open, because they can't underwrite an unknown. Once the workup closes with a clean result, your odds improve dramatically — no hospitalizations, no diagnosis, and no treatment history is actually a decent underwriting profile at 73.

So the practical path is usually: (1) let the workup resolve first, (2) answer every application question truthfully — a misstatement can void the policy later, and (3) check your state's rules before assuming you'll be underwritten at all. A handful of states have birthday rules or year-round guaranteed-issue windows, and there are federal guaranteed-issue situations (like losing certain coverage) where health questions can't be asked. An independent agent who works with several Medigap carriers can pre-screen you against each carrier's health questions before you ever submit an application, so a decline never hits your record.

What are the reasons why I should work with a Medicare agent?

Answer: I'll give you a slightly different answer than most, because after 22 years I think the standard list — "it's free, we compare plans, we help with enrollment" — is all true but misses the real point.

Here it is: an agent's value isn't enrollment week. It's knowing what actually happens when you use the plan where you live.

I work in rural Utah and western Colorado. Out here, two plans can look identical on paper — same premium, same deductible — and one of them quietly assumes your cardiologist is in Salt Lake City, four hours away, while the other covers the specialist you can actually get to. The Plan Finder on medicare.gov won't tell you that. A TV ad definitely won't. Someone who has enrolled a thousand of your neighbors, and then answered the phone when their claims got denied and their doctors left networks, knows which plans hold up in your ZIP code and which ones only look good in the brochure. That's the actual product you're getting when you work with a local agent — the scar tissue.

And some honesty, since you asked for reasons: if you take no medications, love your plan, and nothing in your life changed this year, you may not need an agent this year. Where people get hurt is at the transitions — turning 65 while still working, retiring and leaving employer coverage, moving counties, a new diagnosis, a Medigap rate increase. Those are the moments a wrong move costs real money for years, sometimes with penalties that never go away. That's when having someone who does this every day, at no cost to you, stops being a convenience and starts being protection.

One tip whoever you choose: ask them how many carriers they represent, and ask them to name a plan they wouldn't put you in and why. The answer tells you whether you've found an advisor or a salesperson.