Can You Change Medicare Supplement Plans With Pre-Existing Conditions?

Medicare Supplement, or Medigap, plans help cover out-of-pocket costs not covered by Original Medicare (Parts A and B), such as deductibles, copayments, and coinsurance. These plans are sold by private insurance companies and work alongside Original Medicare. This article clarifies how beneficiaries with pre-existing conditions can change their Medicare Supplement plans.

Understanding Medigap and Pre-existing Conditions

Medicare Supplement plans are standardized, meaning each plan type (e.g., Plan A, Plan G, Plan N) offers the same basic benefits regardless of the private insurance company selling it. A Medigap policy typically covers one person, and if both spouses desire coverage, each must purchase their own policy.

A “pre-existing condition” refers to a health problem or illness that an individual had before the effective date of a new insurance policy. This could include conditions for which medical advice was given or treatment was received within a specific timeframe prior to the new policy’s start. While Original Medicare itself covers services for pre-existing conditions without denial or increased premiums, Medigap policies have different rules. The ability to obtain or change a Medicare Supplement plan, especially outside specific enrollment periods, can be impacted by health status.

Situations Allowing Changes Without Medical Underwriting

Beneficiaries have specific opportunities to enroll in or change Medigap plans without medical underwriting, regardless of their health status or pre-existing conditions. The most significant of these is the Medigap Open Enrollment Period. This one-time, six-month period begins in the month an individual turns 65 and is enrolled in Medicare Part B. During this time, insurance companies cannot deny coverage, impose higher premiums, or apply waiting periods for pre-existing conditions.

Beyond the initial open enrollment period, certain life events trigger “guaranteed issue rights,” which allow individuals to purchase a Medigap policy without medical underwriting. These situations generally involve a loss of existing coverage through no fault of the beneficiary.

Examples of guaranteed issue situations include losing employer-sponsored group health coverage or COBRA. Another common trigger is when a Medicare Advantage plan leaves Medicare, stops providing services in the area, or the beneficiary moves out of the plan’s service area. Individuals also have trial rights, such as if they joined a Medicare Advantage plan when first eligible for Medicare and decide to switch back to Original Medicare within a certain period, typically 12 months. In these circumstances, individuals usually have a limited timeframe, often 63 days, to apply for a new Medigap policy.

Changing Plans Through Medical Underwriting

If a beneficiary seeks to change Medigap plans outside of their initial Medigap Open Enrollment Period or a guaranteed issue situation, they will likely be subject to medical underwriting. Medical underwriting is a process where the insurance company evaluates an applicant’s health history to determine eligibility for coverage and the premium amount. This assessment can involve detailed health questions about current conditions, past medical treatments, medications, and sometimes medical record reviews.

An insurer may deny the application, charge a higher premium based on the applicant’s health status, or impose a waiting period. For example, conditions like diabetes, heart disease, or a history of cancer could lead to higher premiums or denial of coverage.

If an application is accepted after underwriting, a waiting period for pre-existing conditions may apply, typically lasting up to six months. During this period, the new Medigap policy might not cover costs related to those specific pre-existing conditions. This waiting period can be reduced or eliminated if the applicant had continuous “creditable coverage” for at least six months prior to the new Medigap policy, provided there wasn’t a break in coverage exceeding 63 days.

Process for Changing Your Medigap Plan

Once an individual has determined they are eligible to change their Medigap plan, either through a guaranteed issue right or by successfully navigating medical underwriting, the process involves several practical steps. The first step is to research and compare available Medigap plans from different private insurance companies licensed in their state. While plan benefits are standardized, premiums can vary significantly between insurers for the same plan type.

After selecting a new plan, the individual must complete an application, providing necessary personal and Medicare information. If medical underwriting is required, they will need to accurately answer health questions and potentially provide medical records. It is important to be truthful on the application, as inaccuracies could lead to policy termination later.

A crucial step is coordinating the effective date of the new Medigap policy with the cancellation of the old one to prevent gaps in coverage or unnecessary overlap. It is generally advisable to wait until the new policy is confirmed and active before canceling the existing one.