California beneficiaries assume they can enroll in a Medicare Supplement plan at any time without health questions, but underwriting may apply. Underwriting depends primarily on when you apply, not just your health.

Outside protected enrollment periods, Medigap insurers decide to offer you coverage using a process called “underwriting” where they review your medical history and prescription medications.  

However, California offers consumer protections that can eliminate underwriting in a number of situations. Because underwriting varies by carrier, you’ll likely benefit from comparing multiple insurers before applying.

What Is Medicare Supplement Underwriting?

Medical underwriting is the process of being approved for a Medicare supplement (also called Medigap) policy. Underwriting evaluates your health history and prescription drug use. 

Medigap picks up costs Original Medicare leaves to you — the 20% Part B coinsurance, the Part A hospital deductible, coinsurance, and more. Because the insurer takes on those gaps, they want to know what they’re insuring before your protected windows expire. 

Underwriting works more like health insurance did before the Affordable Care Act, when a preexisting condition could prevent you from getting health insurance, or cause it to cost more. 

You still don’t need underwriting for an ACA Covered California plan, Original Medicare, Medicare Advantage plans or Part D drug plans, no matter your health.

When Underwriting Is Not Required

At some points in the Medicare Supplement enrollment process, underwriting isn’t required: 

• Medicare Supplement Open Enrollment: During the initial six-month Medigap Open Enrollment Period, no health questions are asked, and you can choose any available plan. However, a preexisting-condition waiting period can still apply during the first six months if you didn’t have at least six months of prior creditable coverage
• Guaranteed Issue protections: In some specific situations, you can qualify for guaranteed issue, including losing your employer’s health coverage, trying a Medicare Advantage plan for the first time, if your carrier exits the market, and other qualifying federal and state protections. In California, you get a six-month window after losing employer/retiree coverage and the extra 60 days after a Medicare Advantage plan terminates you. 
• California’s Birthday Rule: If you already have a Medigap plan, you get one annual 60-day window to switch to an equal or lesser-benefit Medigap plan from any carrier without answering a single health question. 
• You are no longer eligible for Medi-Cal benefits: If your income has increased and you no longer qualify for Medi-Cal, you might qualify for a guaranteed issue plan for six months after you were notified you no longer qualified for Medi-Cal. 
• Under-65 disability: California is one of the states that requires carriers to offer Medigap to beneficiaries under 65 who qualify for Medicare by disability, including a dedicated open-enrollment window. 

When Medical Underwriting Is Required

If you’re applying for or changing plans outside protected enrollment periods, the company could require medical underwriting. This often includes switching from Medicare Advantage back to Original Medicare, though trial-right situations in your first year of MA can still be guaranteed issue.

In California, this can also include transferring to an open plan with more benefits than your existing plan, such as Plan A to Plan N. Or if you want to switch to an equal-to-or-lesser plan outside of their open enrollment or “Birthday Rule” period.

How the Underwriting Process Works

Many aspects of Medicare are standardized, or follow the same rules. So it’s understandable to assume all Medicare Supplement companies have the same rules for accepting an applicant. 

But when it comes to Medicare Supplement, each company has a different underwriting process and set of rules. One carrier may approve you as an applicant while another declines you. Some carriers may offer coverage at a higher rate tier for certain conditions instead of declining.

This is because they have different: 

• Disqualifying health history or preexisting condition lists
• Prescription drug lists
• Height-weight charts
• Rules around nicotine use
• Waiting periods
• Cancer history requirements
• Cardiac underwriting requirements

Reviews and interviews 

You’ll work with a Medicare agent or directly with the company to apply for a plan. 

Depending on the Medigap company, this will typically include filling out or responding to questions about your health, with supporting information. It could include: 

• A health statement or questionnaire:  Usually yes/no if you’ve been diagnosed with specific health conditions, but may also ask for dates
• Contact Information about your physician 
• Information about specialists you’ve seen
• Your drug history: Any medications you’ve taken in the past or take now
• Verification of your identity, Medicare eligibility, any prior coverage, and documented California residency
• Medical records may be requested, or you may wish to provide them if appealing a decision.

Some companies will also ask for a phone interview to verify everything on your application is correct. Phone interviews aren’t automatic and happen only when the underwriter needs to verify or clarify something. Underwriters discuss medical questions only with you or your doctor’s office, not your agent.

Your prescription history often identifies medical conditions, and some medications have multiple uses and require clarification.

What Underwriters Evaluate

In general, the underwriters will review:

• Your age: generally you must be 65 or older. If you’re under 65, eligibility runs through your Medicare Part B enrollment based on disability. 
• Medicare Enrollment: You must be enrolled in Original Medicare Part A and B to get a Medigap plan
• Any answers on the health or drug sections
• If applicable, your claim history with the company within a specified number of years.

The combination of all conditions/diagnosis, medications and your claim history can be considered when reviewing the application. Companies may have something called a “decline list” where your application is automatically rejected based on any answer that has a “yes.” Other companies may accept you, but charge more. 

Medical History

Depending on the company, dozens of conditions can lead to your denial. Your medical history could include your current and past medical conditions and diagnoses. 

Chronic conditions are an important part of your medical history used in Medigap underwriting. General chronic condition categories that could require evaluation include: 

• Heart disease 
• Neurological disorders
• Respiratory disease
• Cancer history
• Kidney disease
• Autoimmune disorders
• Cognitive disorders

You may also be asked about recent surgeries, hospitalizations, and any testing you’re waiting on. 

The history portion may ask for contact information for any physician you’ve seen within a specified time period, such as the past several years. This includes your primary care provider and any specialists. You’ll list the physician’s name, specialty and diagnosis leading to the visit. 

Prescription Medications

Applications ask about both your conditions and your medications. Certain drugs can flag a condition that triggers an additional review, a higher rate or a decline. For example, the medication rivaroxaban could indicate atrial fibrillation or artery blockage, while leflunomide could be a treatment for rheumatoid arthritis.

Some medication combinations are more significant than individual prescriptions.

Drug lists are indicators, because many drugs treat more than one condition. So a listed drug doesn’t automatically mean a higher rate or decline, and you can have a ratable condition without ever taking a listed drug.

If you’re unsure why you take medication, ask your doctor; don’t guess.  

Reasons Carriers Decline Medicare Supplement Applications

You could be declined for many reasons. Depending on the Medigap carrier, you could be declined if you: 

• Had an emergency room visit or were hospitalized as an inpatient within a specific time window, such as the past three years. 
• Didn’t get surgery, biopsy, treatment, evaluation or other testing, or you’re awaiting surgery or results, or you have symptoms that require more tests or evaluation.
• Are currently confined to a bed or receiving nursing help.
• Make frequent specialist visits that indicate a possible declinable diagnosis. 
• Take a drug that’s on the list, even if your condition or diagnosis isn’t very serious.
• Your height and weight
• Whether you’re using tobacco

A “yes” answer to a health question or condition could lead to automatic disqualification. Unfortunately, some of the most common conditions found in those over age 65 could lead to a rejected application. These include chronic obstructive pulmonary disease (COPD). A cancer or respiratory disorder diagnosis, treatment, or medications within the past 3 years could also lead to rejection. 

Medigap applications can be denied for: 

• Active cancer treatment
• Parkinson’s disease
• Multiple sclerosis
• Dementia
• Congestive heart failure
• Oxygen use
• Pending surgery
• Recent serious cardiac events
• Diabetes with cardiovascular disease
• Wet macular degeneration requiring injections

Every carrier’s list differs, and this is illustrative, not a guarantee of how any one company will decide.

What happens if my application is denied?

You’ll get a letter stating the specific reason. Then you (not your agent) can decide whether to look elsewhere or appeal by following the letter’s instructions.

If you have a California-based guaranteed-issue right to another plan (such as one with the same or fewer benefits), typically no underwriting is required. You often don’t need a new application, and can redirect your enrollment with a phone call.

Some carriers require you to act within a set number of days of the decision letter; quickly confirm your guaranteed-issue rights with an agent or HICAP.

Improve Your Medicare Supplement Approval Chances

1. Complete every application accurately and completely, and explain any “Yes” answers thoroughly. Incomplete or inaccurate applications get rejected — that includes illegible or missing documents, and errors in your name, signature, or contact information.
2. Make sure you understand all the language used. A common reason Medicare Supplement applicants could be declined for coverage is when answering a question incorrectly because they don’t understand some of the medical terms. It’s important to ensure you answer as completely and accurately as possible, and if you don’t understand a term, ask questions. Your agent should be able to explain it to you. 
3. Don’t leave out physicians or diagnoses because you’re worried about being declined. There’s a good chance that the company will find out if you haven’t been truthful. 
4. Respond to any follow-up questions from the Medicare Supplement company. Status updates and the decision will go to your agent by email, with no medical details, while anything about your health comes to you by phone or letter. Not responding to attempts to reach you can result in your application being withdrawn, even if you would have qualified. Return calls and requests promptly.
5. Don’t cancel your insurance coverage before approval, and work with an experienced Medicare agent who can tell you whether guaranteed issue might apply, or if one carrier is more likely to accept you than another. 
6. Also ensure you understand whether any waiting periods apply before pre-existing conditions are covered, and whether a physician gave medical advice, treatment, or prescribed a drug for the condition. 

Frequently Asked Questions

Can I switch Medicare Supplement plans in California without underwriting?

Sometimes, yes, if you qualify for California’s Birthday Rule, which eliminates health questions. With the Birthday Rule, you can switch to plans with the same or fewer features. 

What medications can affect Medicare Supplement approval?

Hundreds of medications can affect Medicare Supplement approval because they indicate potential health conditions that could result in a decline. 

Can I be declined because of a pre-existing condition?

Yes, with Medicare Supplement underwriting, you can be declined due to a preexisting health condition, diagnosis, or even because you’re waiting for a result. You can also be declined for being recently hospitalized, and for many other reasons. 

Should I cancel my current coverage before I’m approved?

Never cancel your current plan until a new one is approved. A denial doesn’t affect the coverage you already have, so you’ll want to keep that in case your application is rejected, or you learn switching plans could cost more. 

How long does underwriting usually take?

It varies by carrier. A clean application can be approved almost instantly through automated review; if the underwriter needs records or a phone interview, it can take a few days to a few weeks. An immediate decline can also happen the moment you answer “yes” to certain questions.