Can I Switch Medigap Plans Without Underwriting?

Medigap, also known as Medicare Supplement Insurance, provides coverage for some out-of-pocket costs not covered by Original Medicare (Parts A and B). These policies, sold by private insurance companies, help pay for expenses like copayments, coinsurance, and deductibles.

Insurance underwriting assesses an individual’s health information to determine eligibility and premium rates. This process helps insurers manage financial stability by evaluating the likelihood of future claims. A common concern is whether individuals can switch Medigap plans without this health-based underwriting, which could result in denial or higher premiums due to health conditions.

When You Can Switch Without Underwriting

Federal laws establish specific situations, known as “Guaranteed Issue Rights,” that allow individuals to enroll in a Medigap policy without medical underwriting. During these periods, insurers cannot deny coverage, impose waiting periods for pre-existing conditions, or charge higher premiums based on health status. These rights are distinct from the initial Medigap Open Enrollment Period, a one-time, six-month window beginning when one turns 65 and enrolls in Medicare Part B.

One common trigger for Guaranteed Issue Rights is the loss of employer-sponsored group health coverage, including COBRA. If this coverage ends, you generally have a 63-day window to apply for a Medigap plan without underwriting. Missing this timeframe typically means you would be subject to medical underwriting.

Another scenario involves your current Medigap plan leaving the market or going out of business. If your plan terminates or you move out of its service area, you also gain Guaranteed Issue Rights. This ensures continuity of coverage.

Individuals who joined a Medicare Advantage plan when first eligible for Medicare have a “trial right” to switch to Original Medicare and a Medigap plan within the first 12 months. This trial right extends to those who dropped a Medigap policy to join a Medicare Advantage plan for the first time and then disenroll within the first year. These trial periods grant a 63-day window after disenrollment to apply for a Medigap policy without underwriting.

If your Medicare Advantage plan leaves the market or you move out of its service area, you qualify for Guaranteed Issue Rights. You may also qualify if your current Medigap plan violated its contract or misrepresented its policy. These situations prevent individuals from being penalized due to actions of their insurance provider.

How to Apply Under Guaranteed Issue Rights

Once you qualify for Guaranteed Issue Rights, contact a new Medigap insurer and state your qualifying event.

You will need to provide documentation to demonstrate eligibility. This might include a letter from a former employer confirming the end of group coverage, a notice from a plan indicating it is leaving the market, or proof of relocation. For trial rights, documentation showing Medicare Advantage enrollment and disenrollment within the allowed timeframe may be required. Insurers may have different documentation requirements, so gather all relevant paperwork.

During this application process, health questions will not be used for eligibility or pricing decisions. While the application form might still contain health questions for statistical purposes, your answers will not impact your acceptance or premium. The insurer is obligated to sell you a Medigap policy at the best available rate for your age, regardless of your health status.

Submit your application within the designated window, often 63 days from the qualifying event. To ensure continuous coverage, apply for the new Medigap plan before your current coverage officially ends, if possible. This proactive approach helps prevent any gaps in your health insurance protection.

Applying When Underwriting is Required

When an individual does not qualify for a Guaranteed Issue Right or is outside their initial Medigap Open Enrollment Period, switching Medigap plans requires medical underwriting. This process involves the insurance company assessing your health risk to decide whether to offer coverage and at what cost. Medical underwriting is a standard practice for insurers to maintain financial stability and prevent individuals from waiting until they have significant health issues to purchase a policy.

During underwriting, you will answer detailed health questions about your medical history, current conditions, and medications. Insurers may also request access to your medical records to verify information. A physical exam or laboratory testing might also be required to further assess your health status.

The outcomes of medical underwriting can vary. Your application might be accepted at a standard premium, approved with a higher premium if the insurer perceives a greater health risk, or denied entirely. A waiting period, often up to six months, may be imposed for pre-existing conditions before the new Medigap policy covers them.

This process differs significantly from Guaranteed Issue situations, where health is not a factor in acceptance or pricing. When underwriting is required, the insurer evaluates your health, directly influencing coverage availability and cost. Understanding your health status and the specific underwriting questions of different carriers becomes important when considering a switch outside of guaranteed issue periods.

State-Specific Rules for Switching Medigap

While federal Guaranteed Issue Rights provide a baseline of protection, some states have implemented their own, often more generous, rules for switching Medigap plans without underwriting. These rules vary significantly by state.

One common state-specific rule is the “Birthday Rule,” adopted in states including California, Oregon, and Utah. Under this rule, individuals already enrolled in a Medigap plan can switch to another Medigap plan with equal or lesser benefits without medical underwriting during a specific period around their birthday. The exact timeframe for this window differs by state; for instance, California allows a 60-day window starting 30 days before the birthday, while Oregon’s window begins on the birthday and lasts for 30 days after.

Another state-specific protection is “Continuous Open Enrollment” or “Every-Year Open Enrollment,” found in states like New York, Connecticut, and Massachusetts. These rules often allow residents to change Medigap plans at any time without medical underwriting, offering greater flexibility than federal guidelines.

Individuals should consult their specific state’s insurance department website for precise details regarding eligibility, timeframes, and limitations. This ensures accurate information for switching Medigap plans without underwriting in their particular state.