Joanne (00:00):

Can you be denied certain types of Medicare coverage based on pre-existing conditions? The answer may surprise you, and that will be the focus of today's episode.

Cameron (00:08):

But before we start, my name is Cameron Giardini, and together with my co-host Joanne Giardini Russell, we operate Giardini Medicare, which is an independent insurance agency based out of Southeast Michigan. And although we are based in Michigan, we do work virtually over the phone to directly help consumers in about 13 states to find the right Medicare coverage for them. Even if you choose not to work with us, we know that the information in this podcast will help you have a successful and stress-free transition to Medicare. So, in a brief overview of today's episode, we will talk about how the Affordable Care Act impacted consumers' perceptions of pre-existing conditions when it comes to health insurance and Medicare. We will talk about when pre-existing conditions come into play with Medicare. We'll talk about how the rules can vary from one state to another. What does the process of actually changing plans and going through underwriting look like? And then finally, we'll finish it all with a recap. Joanne will start.

Joanne (01:03):

Yeah, let's talk about the ACA, which is often referred to as “Obamacare”. It unintentionally created this myth that preexisting conditions will no longer exclude you from any type of health insurance coverage. It was signed into law in 2010. And under the Affordable Care Act, health insurance companies cannot refuse to cover you or charge you more just because you have a pre-existing condition according to the Department of Health and Human Services.

Cameron (01:28):

So to this day, consumers still think this applies to all types of health insurance and more specifically to all types of Medicare coverage, which you will find out is not the case. So again, in this episode, we are talking about how pre-existing conditions specifically may impact you when it comes to Medicare coverage.

Joanne (01:46):

So, some important housekeeping… If you qualify for Medigap open enrollment during the first six months of your Part B effective date, or if you qualify for Medigap guaranteed issue, we are not talking about your situation in this episode. Please refer to the show notes for this episode where we'll link the official Choosing a Medigap handbook if you want to know more about Medigap open enrollment or guarantee issues.

Cameron (02:10):

And especially this time of year, it's good to know that the Annual Election Period is not free for all to enroll in a Medigap plan with no underwriting. Again, this is extra important right now because the annual election period, often called open enrollment for Medicare, goes from October 15th until December 7th. And it does not mean that you can get any plan you want with no restrictions in most scenarios. So, now we'll talk briefly about when do preexisting conditions actually come into play. I'll have Joanne ask me some questions and I'll answer them for you.

Joanne (02:40):

This is always kind of fun. It's like a little game show. So, if someone is signing up for Original Medicare Part A and Part B, do preexisting conditions come into play?

Cameron (02:49):

They do not. Your health and preexisting conditions have no impact on your ability to apply for Original Medicare when you're eligible, whether it's a disability or turning 65.

Joanne (03:00):

So how about when you go from one Part D plan, which is a prescription drug plan to another prescription drug plan?

Cameron (03:06):

And this is really important this time of year, but the answer again is no. So, if you go from one Part D plan to another Part D plan, even if you take 25 medications a day, you are not restricted in making that change.

Joanne (03:18):

All right. How about if you go from a Medicare Advantage plan to another Medicare Advantage plan during this time of year?

Cameron (03:24):

Again, the answer is no. Medicare Advantage used to exclude people that had end-stage renal disease (ESRD), but that is no longer the case.

Joanne (03:34):

All right, how about if you go from a Medicap plan to a Medicare Advantage plan?

Cameron (03:39):

No, this is not a case where there are pre-existing conditions that matter to you. So, enrolling in Medicare Advantage, again, does not depend on your health or preexisting conditions.

Joanne (03:49):

All right, let's go the other way. How about if you want to go from a Medicare Advantage plan and go to a Medigap plan?

Cameron (03:56):

Finally, I get to say something instead of no. So, in this case, yes, most likely going from a Medicare Advantage to a Medigap plan will require underwriting, and your ability to get the MEAP plan will depend on your health and pre-existing conditions at the time.

Joanne (04:11):

Okay. How about if you go from one Medigap to another Medigap plan

Cameron (04:15):

Also, most likely. In most states, this will require underwriting and your ability to switch to another Medigap plan will depend on your health.

Joanne (04:23):

And how about if you have only Part A and B (Original Medicare) and you want to add a Medigap plan?

Cameron (04:29):

You probably guessed it by now, but yes, most likely in most states, that will require underwriting. And your ability to switch to a Medigap plan from Original Medicare will depend on your health. So, as you can see, there are so many different situations that are unique. Just reach out to a Medicare broker to see what your options are. If you need to learn more about how a broker can help you, you can always listen to our episode about that. And for a lot of my questions you probably noticed, again, that I said, “most likely” “perhaps”, or “probably”, well, the reason for that is the rules for pre-existing conditions and Medicare, can vary greatly by state. So some states do have carriers and companies that offer no underwriting, even if the state does not mandate it. There are a couple I can think of.

Cameron (05:12):

I won't really list them right now, but just ask somebody in your state if that applies to you. There are also states with all that have unique guaranteed issues or open enrollment for Medigap plans. These consist of Connecticut, Maine, New York, Massachusetts, and Washington. And then there are also states with birthday or anniversary rules, which gives you a unique time to change your Medigap plans from one to another without health questions. And those include Illinois, Missouri, California, Oregon, Nevada, Louisiana, Maryland, and Idaho. Now, again, I listed a bunch of states there. I'm not saying there are no restrictions in any of those. They all have their unique rules. So, reach out to somebody familiar with those states and just ask about the unique circumstances you may have at your disposal.

Joanne (05:55):

Let's talk about the process of potentially changing your plan and underwriting. What is underwriting? It's a very common question. “Hey, what does underwriting really look like? What do I have to do?”

Cameron (06:04):

We don't want to discourage you from trying to make a change. If you are healthy or if you think you can qualify, we're just saying understand, you will have to go through some extra hoops to actually qualify for the plan.

Joanne (06:14):

Lots of people ask, and I think it's just a great topic. So, what types of conditions may exclude you from a Medigap policy if that's what you want? This is not an all-inclusive list, and these conditions and criteria can really vary from carrier to carrier and state to state. So, don't just listen to this episode and think that you have no chance of getting approved or the other way, don't think that we didn't cover it, and you can get approved. Reach out to a broker and see what may work for you in your area with a certain company. Things as simple as tobacco usage and height/weight can impact your premiums maybe if you are approved. Here are some other conditions that might prevent you from getting coverage, but keep in mind that most companies will also have a look-back period of two to five years when they're considering what conditions you have had in the past. So, just because you might be denied coverage now doesn't mean that that's always going to be the case.

Cameron (07:00):

And I'll list out the conditions that Joanne was just mentioning, but it's very important to know this is by far not an all-inclusive list. If you have other conditions, you still may be restricted from getting a Medigap plan in certain situations. So, some of the things that are more likely to get you disqualified or not make you able to qualify for a Medigap plan would be things like an upcoming surgery or pending test results that you don't have back. Cancer, strokes, kidney disease, arterial disease, dementia, diabetes with insulin usage that is high enough, heart attacks, nursing home confinements, and other chronic conditions like Parkinson's, MS, or COPD. Now, there are many more, but if any of those ring a bell, just know that you may be limited in your Medigap choices. So, if you do want to go through underwriting and you don't have many chronic illnesses, or you do think you can pass underwriting and get a plan, what is it actually going to look like? Do you have to get a physical? I'll have Joanne talk about that.

Joanne (07:54):

So, people think maybe a nurse will come to your house, things like that. And it's not like that. But, the first step is an insurance broker like ourselves will go over all of the health questions for a company and a plan that you want to apply for. And then based on your answers, both of us will decide how to proceed. This is typically done with us over the phone. You might be doing this with a local broker in an office, but with us, it'll be over the phone. There is no obligation or risk or cost to you to simply go through the questions with the broker. Once that application is then submitted to an insurance carrier that you decide on, they will underwrite that policy. And this does not involve a physical or any type of in-person exam. Instead, what they're going to do is they're going to look at your health records using third-party data. Milliman is a great example and it became the most common example of a source where they will look for all of your information, your medical data. And if you're being denied based on something that you disagree with in your records, you can reach out to the company and see what can be done to change the decision.

Cameron (08:49):

Something to go over that Joanne mentioned is a lot of this all starts with us, the insurance agent, or whoever you choose to work with, when you go through these questions, now, keep in mind that if you answer yes to certain questions and we truly don't believe there's any chance of you being approved, don't be offended if we say we won't do the application because there's no use on our end of doing applications where we know you'll likely get denied based on certain conditions. But on the flip side of that, lying does absolutely no good for you. So, not only will they be able to look at your health history to see if you are lying, but if your policy does get instated and then they find out you're lying shortly down the road, you can have your policy completely rescinded, and be without coverage once you're caught lying.

Cameron (09:32):

Now, sometimes this can slip through the cracks because insurance companies, may or may not call you to confirm all the answers and the health questions you did during the initial application and underwriting. It can be instant or it can take a couple of weeks. So, just give it some time, especially during the Annual Election Period this time of year. And the biggest thing to keep in mind through all of this is if you want to get a Medigap plan if you're trying to change to a new Medigap plan and go through the underwriting process, do not cancel your current policy while going through underwriting. Only cancel it if you are fully approved for the new policy at the rate you want, and you are willing to accept that plan as your new coverage going forward. Now Joanne can talk about what are your actual potential outcomes if you go through underwriting with the Medigap plan.

Joanne (10:16):

Yep, you're going to get an answer. One, it might be approved, at the preferred rate, which is what you're always going for and hoping for, right? You might be approved at a standard rate, which could be slightly higher than the preferred premium or hundreds of dollars more per month. You never know. It depends on the carrier, and you could be flat-out denied. Some companies don't even rate up your premiums for conditions, they'll just flat-out deny you. So those are a few options there. When can you enroll in Medigap and go through underwriting? If you want to go from a Medicare Advantage plan to a Medigap plan, you can do this a few times. The Annual Election Period from October 15th until December 7th is one window where you can apply for that Medigap plan.

Joanne (10:59):

You can also do this during the Medicare Advantage Open enrollment window, which is from January 1st to March 31st. And you can also do this during a special enrollment period window, which is really based on life events that you may have access to. How about if you want to go from a Medigap plan to another Medigap plan? Well, you can do that any day of the calendar year, 365 days a year. People really don't understand that. But you can do it at any time. If you have no coverage, let's say you only have traditional or Original Medicare with Part A and Part B, and you want to add a Medigap plan and you're healthy enough to do so, you can apply for that anytime during the calendar year as well.

Cameron (11:39):

And just to recap most of what Joanne just talked about, understand that every company is going to have different restrictions for what they will or will not accept when it comes to Medigap plans. This is where a broker is super helpful because again, we contract with dozens of different companies. So we are not just looking at one company, seeing whether or not you might be accepted or denied that coverage. We are looking at dozens at one time and looking at all of the different companies that may accept your specific circumstances. So, this will save you hours instead of calling each company and going through different health questions for each company at a time. But pre-existing conditions can still matter, and they do have a large impact on your Medicare choices. Therefore, we are so adamant that you do learn about all your Medicare options when you're first eligible and you make a decision you are comfortable with knowing how pre-existing conditions may impact you if you want to change coverage in the future. And with that being said, please leave us a review on your podcast app and subscribe for future episodes. If you want to ask us a question directly, please email us at info@gmedicareteam.com or give us a call at (248) 871-7756. Lastly, you can also schedule a call with us on our website gmedicareteam.com.