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

Nikki Rowland · Answer

Paying into Medicare makes you entitled to Part A and Part B. Medigap (Medicare Supplement Insurance) is offered by private insurance companies, not the government. And outside of certain protected times, they’re legally allowed to deny you coverage based.

Answered by Nikki Rowland on May 11, 2025

Broker Licensed in SC & NC

Answered by Nikki Rowland Medicare Insurance Agent

Steven Bleicher · Answer

When you turned age 65, you had a true open enrollment (you are called a "GUARANTEED ISSUE person) since no medical questions will be asked of you. Plus, all pre-existing conditions are fully eliminated from disclosure. 

Thus, you chose a free Medicare Advantage plan as the alternative. That plan has always been totally free of monthly premiums because it is subsidized by the Federal government. However, the "give & take" with those plans is that every one of them will contain a fairly steep deductible each year. If you have had multiple hospitalizations, the # of days spent in a semi-private room will be applied toward that deductible. It will be charged based upon the discretionary rules of the firm's policy that you have joined. These daily hospital rates vary from firm to firm. Should you go over that threshold (for example, $2,900.00/year) including other Part B medical treatments, that is your Maximum Out-of-Pocket expense (or MOOP). Subsequently every brand new year, that amount begins all over again, potentially at a higher price based on our global economy.

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

Norman Smith · Answer

What you've paid for all these years is your Part A, which is your hospital coverage. Part B is an underwritten part of Medicare. This is why Open Enrollment is so important, the first time it comes around, when there is no Underwriting involved.

Answered by Norman Smith on May 27, 2025

Agent Licensed in FL & PA

Answered by Norman Smith Medicare Insurance Agent

DeeDee Whitlock · Answer

You are NOT being denied Medicare, that is available to you at 65 or if on disability at younger age. Medigap is an EXTRA plan that covers out of pocket that Medicare don't and therefore you are subject to underwriting!!

Answered by DeeDee Whitlock on June 10, 2025

Broker Licensed in LA

Answered by DeeDee Whitlock Medicare Insurance Agent

Christie Bondos · Answer

Some states have a Guaranteed Issue for Pre-existing Conditions while others do not. You should  consult with an Agent who is versed on these particulars in your state.

Christopher Orr · Answer

You only have a open /guarantee option when you first come on medicare or if later when coming off group coverage...

Irma Lopez · Answer

Underwriting is required if you don’t enroll during the Open Enrollment which is 3 months before you turn 65 or by no later than 3 months after your birthday.

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.

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

Marcie Barnes · Answer

Medigap policies are private insurance companies that coordinate with original Medicare.  They're not subject to CMS regulations.

There are ways around having to go through underwriting such as:

You are new to Medicare 
You lost credible coverage 
Some states have a birthday or anniversary rule.  Caveat is you must already be enrolled in a Medigap plan and wanting to switch to another one.

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

Deborah Webster · Answer

Medigap plans are a supplement to Medicare A and B ( Original Medicare). Medical plans do have health underwriting. The only time you do not have to pass underwriting is when you are first eligible for B outside of that you must be able to pass underwriting. Medigap companies do not all have the same health questions. It's important to work with an agent who has multiple options to look at underwriting and find a carrier who may take your current pre-existing conditions.

Answered by Deborah Webster on May 8, 2025

Broker Licensed in Ia & SC

Answered by Deborah Webster Medicare Insurance Agent

Larry Pereiro · Answer

Medicare policies are not Medicare plans. They are "supplemental plans", providing benefits to off set the cost of Original Medicare Plan A and B, and if you are outside of the Open Enrollment period when you turn 65, they are medically underwritten. You must have Medicare Part A and Part B in order to enroll in a Medigap, but that is not guaranteed issue status outside of the open enrollment period.

Answered by Larry Pereiro on June 2, 2025

Agent Licensed in IN

Answered by Larry Pereiro Medicare Insurance Agent

Linda Davies · Answer

If you are within your Medigap Open Enrollment Period or qualify for guaranteed issue rights, it is illegal for an insurance company to deny you a Medigap policy solely based on your health history. 

However, if you apply outside of these protected periods, insurance companies are generally allowed to consider your health history during the underwriting process and could deny your application or charge you higher premiums. 

It's highly recommended to apply for a Medigap policy during your Open Enrollment Period or if you have guaranteed issue rights to ensure guaranteed acceptance and potentially lower premiums.

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.

Charles Borg · Answer

A Medigap plan is issued by a private insurance company, not the government. You paid into government coverage, Medicare where you can’t be denied. You had a grace period when you-turned 65 for 6 months to get a Medigap policy, regardless of your health, but you didn’t take advantage of it.

Answered by Charles Borg on May 27, 2025

Agent Licensed in FL & NY

Answered by Charles Borg Medicare Insurance Agent

Tanja Roulhac · Answer

I understand your frustration—it's disappointing to be denied coverage after contributing to Medicare for years. Let me explain why this can happen and what your options might be. Medigap plans are offered by private insurance companies, not the government, so their rules differ from Medicare itself. Here's a clear breakdown:

Why Denials Based on Health History Are Legal
Medigap vs. Medicare: Original Medicare (Parts A and B) is guaranteed and doesn't consider your health history, but Medigap policies are supplemental insurance sold by private insurers. Under federal law (as outlined by CMS), these companies can deny coverage or charge higher premiums based on health factors outside of specific enrollment periods. This is allowed because Medigap is not part of the core Medicare program you paid into.

Open Enrollment Period: During your 6-month initial window (starting the month you turn 65 and enroll in Part B), insurers cannot deny you a Medigap plan or use your health against you—it's a guaranteed issue period. If you applied outside of this, denials are possible and legal, as states regulate but don't always prohibit underwriting.

Legality: This practice complies with the Affordable Care Act and state insurance laws, which balance consumer protections with insurer risks. It's not ideal, but it's how the system is structured to keep premiums affordable for everyone.

What You Can Do Next
Check for Guaranteed Issue Rights: If you qualify (e.g., due to losing other coverage, moving states, or your plan being canceled), you might still get a Medigap plan without health questions. Review your situation on Medicare.gov.

Explore Alternatives: Consider Medicare Advantage plans (Part C), which often include additional benefits like vision or dental and might not require health underwriting during enrollment periods. You could also look into state high-risk pools or other supplemental options.

Appeal or Shop Around: Contact the insurer for an appeal or reasons for den

Darko Bozic · Answer

Medigap plans are private plans and they are only guaranteed if you sign up for one within 6 months of being on Medicare. After that you can be denied based on your health history. These plans have nothing to do with what you've paid into Medicare. The original Medicare parts A and B cover that. Medigap plans are designed to cover some or all things that the original Medicare does not

Answered by Darko Bozic on May 13, 2025

Broker Licensed in OH

Answered by Darko Bozic Medicare Insurance Agent

Ingrid Kollmann · Answer

It's because you don't live in California which has a birthday rule.  A few other states may have a similar rule, depending on the available plans.

Scott Klag · Answer

Medicare Supplements are different than your Part C Medicare Advantage plans. Medicare supplements have a "Guarantee Issue" time period which is 3 months prior to your 65th Birthday, the month of your 65th Birthday and 3 months following your 65th Birthday. There are a few other situations that would offer the "Guarantee Issue" option. You would need to consult with your Medicare professional agent to see if you qualify. Otherwise, in order to get a Medigap plan you would be subject to medical approval.

Answered by Scott Klag on April 28, 2025

Agent Licensed in OH

Answered by Scott Klag 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

Jerry Wilson · Answer

When an individual enrolls into Medicare this is known as the Initial Enrollment Period.  With the Initial Enrollment Period (IEP) the Medicare Beneficiary will have a guaranteed right to enroll into Original Medicare, Medicare Supplement or Medicare Advantage Plan with any health underwriting or questions.  

However, once the guaranteed period has expired and Medicare beneficiary applies for a Medicare Supplement the private health insurer which issues the Medigap/supplement can deny coverage if the Medicare beneficiary is unable to pass the health underwriting questions.

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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