I applied for a Medigap plan and got denied because of my health history-how is that even legal when I've paid into Medicare for years?

Question

Cleo Martin · Accepted Answer

Medicare and a Medicare supplement are 2 completely different things.  Medicare is what you paid into. A Medicare supplement is from a private insurance company.  They have underwriting questions that you have to be able to answer correctly or they can  deny you. They are completely separate things. The supplement works with Medicare to pay what Medicare doesn't pay. Medicare is what you paid into all these years. A Medicare supplement is something you have to purchase. Different companies have different questions so depending on your health situation, you may or may not be able to by one. Hope this helps explain.

Cleo Martin 
803-730-8368

Timothy Brown · Answer

Your acceptance into a Medicare supplement/Medigap plan is guaranteed during the 6 month period of when Medicare Part B becomes effective. You're subject to underwriting beyond this timeframe unless you're leaving an employer plan. Unlike Medicare Advantage plans which are guaranteed issue with no health questions, Medigap plans are not regulated by CMS (Centers for Medicare & Medicaid Services). They are private companies.

Answered by Timothy Brown on April 8, 2025

Broker Licensed in PA, CT, DE & 15 other states

Answered by Timothy Brown Medicare Insurance Agent

Steve Brauer · Answer

You can get denied for a MediGap plan if you did not enroll in that plan when you were first eligible, at that time, it would have been given to you without underwriting. After a certain time, if you want to change plans, or try to enroll into one for the first time, they can deny you coverage.

Answered by Steve Brauer on April 8, 2025

Broker Licensed in AZ & CA

Answered by Steve Brauer Medicare Insurance Agent

Gary Henderson · Answer

There are several reasons. First of all, if you first sign up for Medicare parts a and then b. Even if b is later, you have a 6-month period where you cannot be denied coverage. 
After that, most insurance companies can deny you coverage when you're first signing up for Medicare plan. 
If you already have a Medicare plan and want to change it, there are a few states that have special consumer Medicare laws that allow you to change them, for example, for a period around your birthday 
People often think that with the ACA plans often called Obamacare that you couldn't be denied coverage that does not apply to Medicare. It applies to insurance in the ACA plans for people 65 and under only

Fred Manas · Answer

While it's frustrating to be denied a Medigap plan due to health history, it's legal for insurance companies to use medical underwriting to assess risk. This means they can decline coverage or impose restrictions based on your health, especially outside of the guaranteed issue period or other specific situations.

However, you do have rights during your open enrollment period and under specific guaranteed issue rights. 

Here's a more detailed explanation:

Medical Underwriting:
Medigap insurers use medical underwriting to assess risk. This involves reviewing your medical history to determine the likelihood of future claims and potential costs. 
Guaranteed Issue Rights:
During your Medigap open enrollment period (six months after enrolling in Medicare Part B), you have guaranteed issue rights, meaning you cannot be denied coverage based on health. You also have guaranteed issue rights in other specific situations, such as if you lose coverage from a previous health plan and enroll in Medicare within 63 days. 
Denial and Pre-existing Conditions:
Outside of guaranteed issue periods, Medigap insurers can deny coverage or impose restrictions (like waiting periods) for pre-existing conditions. 
State Variations:
Some states offer more extensive guaranteed issue protections than federal law, according to United American Insurance Company.
Appealing a Denial:
If you're denied coverage, you may have the right to appeal the decision. You can gather information from your provider, explain your situation, and potentially provide additional medical records according to The National Council on Aging. 
In summary: While it's understandable to feel frustrated about a denial, it's important to understand that Medigap insurers can deny coverage based on health history, particularly outside of guaranteed issue periods. However, you have rights during open enrollment and under other specific situations, and you may also have the right to appeal a denial.

Robert Simm · Answer

When we pay into Medicare what we're really paying into is part A coverage which is inpatient hospitalization. That includes nursing homes rehab centers hospice along with hospitalization. 
We have also paid into the Medicare system to reduce cost for Part B premiums along with out-of-pocket medical expenses like deductibles. When we first age into Medicare under the 12-month rule we have an option to move from Medicare Advantage to Medicare supplemental plan with original Medicare and a separate Part D prescription drug plan or you could just simply go with original Medicare Parts A and B along with a prescription drug plan. Within that 12 months everything is guaranteed acceptance. When you aged into Medicare the person should have explained the process on Medigap versus MAPD versus original Medicare. The insurance companies have a legal right to underwrite for risk and if they view a person as a high risk then they do have the right to deny the coverage. After the first year then Medigap underwriting will always continue until there's some government change for those plans.

David Christian · Answer

Medigap plans have Underwriting that determines your qualification for the plans and as you see your health history can make it so you get denied. My suggestion for you is a Medicare Advantage Plan because there is no underwriting for anyone of any age that has Medicare or to get a Medigap plan when a company waives the underwriting during a certain period of time.

Answered by David Christian on April 11, 2025

Broker Licensed in CA & TX

Answered by David Christian Medicare Insurance Agent

Michael Hixson · Answer

A "Medigap" or Medicare Supplement Plan is offered by insurance companies. They are not offered by the Centers of Medicare Medicaid Services. In other words, these are Private Plans that pay the Co-Pays that Original Medicare doesn't cover. The time to buy these types of plans is during your Open Enrollment Period. During this period there are no health questions. This period is up to 6 months be for your 65th birthday and up to 6 months after your 65th birthday or up to 6 months after your Part B effective date. If you missed these opportunities, there are some ways you may qualify for Guaranteed Enrollment with loss of credible insurance or in some states a birthday rule.

Answered by Michael Hixson on April 23, 2025

Broker Licensed in OK, AR & TX

Answered by Michael Hixson Medicare Insurance Agent

I applied for a Medigap plan and got denied because of my health history-how is that even legal when I've paid into Medicare for years?

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I applied for a Medigap plan and got denied because of my health history-how is that even legal when I've paid into Medicare for years?

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