Garrett Ball

Medigap Underwriting – Can I Get Approved?

August 15, 2020 By Garrett Ball Leave a Comment

Medigap underwriting will determine if you are approved on a Medigap plan or not. If you haven’t enrolled in a Medigap plan (Medicare Supplement) during your Initial Enrollment Period (When is Medigap open enrollment?), during a Guaranteed Issue Period (When is a Medicare Supplement Guaranteed Issue?), or during your Birthday Rule (only available in some states – Medigap birthday rule states), your acceptance will not automatically be approved. It first must go through a medical underwriting process. This is when the underwriter assigned to your case will make a decision based upon your health status, prior medical history and any upcoming planned treatment or surgeries. Each insurance company uses their own set of Medigap underwriting guidelines. Even the application questions may vary widely. In addition, underwriters must go through rigorous training to become proficient at what they do. They must be experienced in the field of medical terminology and knowledgeable regarding pharmaceutical drugs and medications that the prospective applicants take.

Below are three categories of situations/results of Medigap underwriting on Medigap plans:

Medigap Underwriting: Very Unlikely to be Approved (or Possibly Will Be Immediately Declined)

The underwriter can decline an applicant based on one or more responses to questions on the application. Questions such as, “At any time, have you been medically diagnosed, treated or had surgery for any of the following: congestive heart failure, defibrillator, leukemia, Parkinson’s Disease, Alzheimer’s Disease, dementia, multiple sclerosis, chronic kidney disease or organ transplant?” There are several other conditions in this category, but for sake of brevity here, only some of these are listed. To see all conditions, you would have to refer to specifically to the application itself (which is different with different insurance companies). If you answered “Yes” to any of these questions, you would be immediately declined and not permitted to complete the application process. Some applications may say “Have you ever, instead of “At any time”, but this does not change how you would answer the question.

To give you an idea of what I mean, let’s say Betty Blue wants to enroll in a Medigap Plan G, with ABC Insurance Company. On the application, when she gets to the section on “At any time (or have you ever), she notes that one of the conditions she has is among those on the list. She stops and cannot proceed with the application.

Another reason to be declined would be because of one or more of the medications you currently take. If you are taking one or more medications that are on the insurance company’s “declinable drug list”, your application will likely be declined right away. Each company has their own declinable list, so it is worthwhile to evaluate your options before accepting for sure that companies will decline you. If you use a broker (Why You Should Use a Broker), he/she can help you navigate this process. He/she will be able to call the specific insurance company to ask if a certain drug is declinable or actually has that list at hand to find out, before you spend any time going through the application process.

A hypothetical illustration would be if Jim Smith wants to enroll in Medigap Plan N with Sunshine Insurance Company. He currently takes Eliquis to prevent strokes, as well as using insulin for Type 1 diabetes. He fills out the application but is declined because he takes a blood thinner and insulin for Type 1 diabetes. Sometimes, applications are declined based on the the combination of drugs you are taking.

Some insurance companies have stricter guidelines as far as which drugs you are taking for which diseases/conditions and how many of each type of drug you are on. One company may allow three high blood pressure medications and two diabetes medications. However, another company may only accept two high blood pressure medications with one diabetes medication (see below under #2 for another example).

Medigap Underwriting: Approval Depends on your Medical Records and on the Insurance Company

There is not one strict rule across the board for insurance companies to base their decisions on as far as Medigap underwriting goes. Each company uses their own criteria to approve or decline an applicant. That said, there is generally a 2-3 year “lookback” on the applications for certain conditions or procedures, i.e. heart procedures, stroke, lung problems requiring the use of oxygen, neuropathy, etc. It depends on whether you are currently being treated for one or more of these conditions, or when your last treatment occurred and when you were medically released by your provider.

An example would be that Angie Taylor underwent cardiac ablation caused by atrial fibrillation, 2-1/2 years ago, and was hospitalized for 1 day. She applies for Medigap Plan G with Good Health Insurance Company, but she’s declined as they have a 36-month lookback policy. She would need to wait 6 more months before she can re-apply. Angie doesn’t want to wait and subsequently completes an application with Winstar Insurance Company. She is approved since Winstar only has a two-year lookback policy.

Here’s a different scenario but still the same outcome: Joe has high blood pressure along with Type 2 diabetes but is not on insulin. He’s been taking his medications for more than 2 years. He applies to POP Insurance Company and is approved. Whereas, Jane applies to the same company and has high blood pressure along with Type 2 diabetes, but also takes insulin. She is declined. Again, the criteria is different with each company – some approve if taking insulin, some decline and some companies will not decline you with insulin but the amount you take daily must be under a certain amount.

Should Not Have a Problem Being Approved

This category is the easiest and quickest for the medical underwriter to decide upon. If you are on maintenance type medications or take no medications at all, you will most likely be approved.

Hypothetical Illustration 1: John Green applies to Happy Insurance Company; he currently takes one medication for high blood pressure and two medications for cholesterol. He is approved. The medications John takes are considered “maintenance medications”. In other words, a medication to keep a long-term condition stabilized.

Hypothetical Illustration 2: Nancy Best wants to enroll in a Medigap Plan N with Sowhat Insurance Company. She takes no medications except for some over-the-counter vitamins and supplements. She is approved by the insurance company.

Important Disclaimer: Each insurance company has different guidelines for underwriting including which conditions and/or which medications they will decline. They may also take into consideration when a person started taking a certain drug and the length of time they have been on that drug. The more stable someone is on a medication, the more likely they will be approved.

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65Medicare.org is a leading, independent Medicare insurance agency for people turning 65 and going on Medicare. If you have any questions about this information, you can contact us online or call us at 877.506.3378.

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COVID-19 and Medicare – How Do I Enroll in Medicare Online?

August 13, 2020 By Garrett Ball Leave a Comment

Due to the COVID-19 pandemic, Social Security offices are not accommodating walk-in visitors until further notice. This has an impact on those who need to enroll in Medicare. Formerly, one of the options for enrolling in Medicare was to go in to a local office. But now, if you need to see someone in person, you must make an appointment, and it must be for a limited, dire situation only. The Social Security Administration is dedicated to protecting the population they serve— older Americans and people with underlying medical conditions—as well as their staff during the COVID-19 pandemic. Please visit the Office Closings and Emergencies link for the most up-to-date information about office closings.

Although the Social Security offices are currently closed to walk-in visitors, there are, fortunately, still options for enrolling in Medicare online. These options have been expanded in recent months with a revamped and improved enrollment tool for signing up for Medicare Part B. Enroll in Medicare online

If you are already getting Social Security benefits, or Railroad Retirement Benefits, you will automatically be enrolled in Original Medicare Part A and Part B. The effective date will be the first of the month you turn 65. If your birthday falls on the 1^st of the month, then your Medicare benefits will start on the first day of the previous month. If you are under 65 and disabled, you will automatically get Part A and Part B if you have gotten disability benefits from Social Security (or from the RRB) for at least 24 months. If you have ALS, you’ll get Part A and Part B automatically the month your Social Security disability benefits begin. Note: If you are a resident of Puerto Rico or reside abroad, you will not get Part B automatically and must apply for it.

You should sign up for Medicare online:

If you are in your IEP (Initial Enrollment Period), you can sign up three months before your 65^th birthday
During the “General Enrollment Period” – If you haven’t enrolled in Medicare Part B during your initial enrollment period, you can still sign up each year from January 1 through March 31. Your coverage will start July 1 of the year in which you enroll.
If you are in a Special Enrollment Period (SEP) – you may enroll for Part B:
- in any month you remain covered under the group health plan and your, or your spouse’s, employment continues (in other words, while you or your spouse are still working); or
- in the 8-month period commencing with the month after your group health plan coverage or your or your spouse’s employment ends, whichever comes first.

What are the benefits of signing up for Medicare online?

You do not have to make an appointment at your local Social Security office (during the COVID pandemic, Social Security offices are not seeing walk-in visitors). During busy times of the year, your wait to get in to see someone may be up to 3 or 4 weeks;
The application online process can be started immediately;
You can save your application and go back to it later, without losing any of your information;
You can sign up in the comfort of your own home, using your own computer;
You will save time and money by not having to travel to your local Social Security office.
You can rest assured that the technology used to input your personal information is secure.

Here are some tips that will help you complete your online application:

Prior to enrolling online, go to the “Checklist for Online Applications” at www.ssa.gov/hlp/isba/10/isba-checklist.pdf. This information will help you to prepare for the process
Visit www.socialsecurity.gov/medicare/apply.html and choose “Apply for Medicare Only.”
If you need further information, click on “Related Information”.
The normal application process online usually takes from 10 to 30 minutes to complete.
Click on “Submit Now” and your application will electronically go to Social Security.

Once you have submitted your application, a receipt will be generated which you can print for your records. You will then be assigned an application number that will be necessary in case you want to check the status of your application. During the review process, if clarification is needed, including additional documentation, Social Security will contact you. A letter will be sent to you by mail with the decision (usually 7-10 days). Then, within 3-4 weeks, your Medicare card will arrive.

Although Social Security offices are not providing service to walk-in visitors, they are still available by phone. You can call your local office by using the Field Office Locator, under “Social Security Office Information”. Alternatively, you can call the toll-free national number at 1-800-772-1213. If you are hard of hearing or deaf, the TTY number is 800-325-0778. A staff member is available from 7:00 am to 7:00 pm, Monday through Friday.

At this time, Social Security is requesting that you should access their online services before reaching out by phone. That said, it’s understandable that if you don’t have a computer or are not computer savvy, you can always call them! Otherwise accessing their online services is the most practical way to contact them. Some advantages of using the online system are:

Applying for benefits
Getting useful information
Find publications
Get the answers to FAQs

You can create a My Social Security account, which will give you additional options, i.e. review your Social Security statement, verify earnings, print a Benefit Verification Letter, or modify your direct deposit information. If you need a replacement Medicare card or Social Security card (if there are no changes and your state participates), or a duplicate SSA-1099/1042S, you can request those as well.

Important note: If you are enrolling in Medicare Part B for the first time, that generates your initial open enrollment window for Medicare Supplement (Medigap) and Medicare Advantage plans as well. It is crucial to be aware of this and not miss any deadlines for enrolling.

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Part D Senior Savings Model

June 23, 2020 By Garrett Ball Leave a Comment

Diabetes is a deadly disease. It is the seventh leading cause of death in the U.S. It affects more than 34.2 million people or 10.5% of the U.S. population according to the CDC (Centers for Disease Control). Statistics show that 1 in 10 people have diabetes, and 1 out of every 3 people are pre-diabetic. Over 3.3 million Medicare recipients take one or more of the common forms of insulin. It is increasing at an alarming rate. For those beneficiaries who financially must weigh paying for their insulin or instead buying food, or paying their rent or bills, this might be a life or death situation. Unfortunately, their access to insulin can sometimes be a roadblock to the appropriate medical management of their condition. The consequences leading to serious complications, i.e. loss of vision, kidney failure or ulcers of the feet (many times requiring amputation), to heart attacks. part d senior savings model

On March 11, 2020, the CMS (Centers for Medicare and Medicaid Services) announced the “Part D Senior Savings Model (“the Model”). This 5-year model will make it mandatory for participating plans to limit cost-sharing for a 30-day supply of insulin to a maximum of $35. As of January 1, 2021, Part D sponsors that participate in the Model will be able to offer Medicare beneficiaries prescription drug plans which provide supplemental benefits for insulin during the coverage gap stage of the Part D benefit. Those pharmaceutical manufacturers who participate will pay the discount (70%) in the coverage gap for all types of insulin that are included in the Model. This effort to reduce out-of-pocket drug costs for Medicare beneficiaries is a huge step in the right direction to lowering drug costs for seniors. It will give seniors additional choices of enhanced alternative Part D plan options which offer lower out-of-pocket costs for insulin.

For the first time, CMS is recommending that Part D plans offer fixed copays for seniors. This would eliminate the need for seniors of having to pay the 25 percent for drug costs in the coverage gap. Thus, Medicare beneficiaries who use insulin, will be able to reap the benefits in this fight to lower drug costs. More specifically, Medicare beneficiaries who take insulin and are enrolled in this type of plan will potentially save $446 in out-of-pocket costs. In other words, they would be paying 66 percent less for their insulin. This discount will be funded partly by the drug manufacturers during the 5 years that this model will be in effect.

The response by Part D plan sponsors for Part D Senior Savings Model for the 2021 plan year has been overwhelmingly positive. More than 1,750 Medicare Advantage plans and Medicare Part D prescription drug plans with prescription drug coverage have voluntarily agreed to be part of this model. They will now be able to offer insulin at lower costs. As a result of this move, CMS hopes there will be availability to seniors for this plan model in all 50 states, including the District of Columbia, and Puerto Rico. This will be accomplished via a stand-alone prescription drug plan (PDP) or through a Medicare Advantage plan which includes prescription drugs. The roll out of the Part D Senior Savings Model will be during the annual open enrollment from October 15 through December 7, 2020, when beneficiaries can sign up.

For more information, please go online to CMS at https://innovation.cms.gov/innovation-models/part-d-savings-model.

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When and How To Sign Up for a Part D Plan?

May 18, 2020 By Garrett Ball Leave a Comment

Prescription drugs are not covered by Original Medicare. You need to enroll in a stand-alone drug plan (Medicare Part D) if you want drug coverage. These plans are run by private companies not the Federal Government, although they do get “approved” annually by CMS. You have the option to choose from many companies in the area/county in which you reside. This is called your “service area.” If you ever move out of your service area, then you will have to look for another prescription drug plan in your new location.

You can sign up for Medicare Part D during:

Your IEP (Initial Enrollment Period)
When you are about to turn 65, you have a seven-month period in which you can enroll in Medicare Parts A and B. This includes three months before you turn 65, your birthday month and three months after your 65th birthday.

The AEP (Annual Enrollment Period)
From October 15^th to December 7^th each year. You can change your prescription drug plan during this time frame. However, it will not go into effect until January 1^st.
If your birthday falls on the 1^st of the month, the your seven-month period would start the month before your birth month. Let’s say your birthday is on May 1^st. Then your IEP will be from January 1 to July 31.

Special Enrollment Periods such as:
Losing credible drug coverage
Losing drug coverage from an employer or union
You are eligible for Extra Help

Note: If you get Extra Help, or live in a nursing home, you may change your Part D plan once a month.

It is a good idea to sign up for Part D early to make sure your new plan begins when it should. If you do not sign up in a timely fashion, as indicated above, you will have to pay a late penalty, which may also delay the effective date of your Part D plan. This penalty is calculated at 1% of the “national base beneficiary premium” ($32.74 in 2020) multiplied by the number of months in which you were not covered. medicare part d late enrollment penalty

Are there any requirements to be eligible for a Part D prescription drug plan?

In order to enroll in a drug plan, you are required to:

Have Part A and/or Part B
Reside in the service area of the plan, i.e. zip code or county

You can sign up for a Part D plan by:

Calling Medicare at 1- 800-MEDICARE (800-633-4227); TTY: 877-486-2048;
Call the plan of your choice or go to their online website and enroll directly.
By using Medicare’s Plan Finder tool (see below)

If you take any medications, particularly if you take any that are expensive, it is very prudent that you use the Medicare.gov comparison tool (or have a broker do it for you) to compare the plans. The co-pays and lists of covered drugs can vary tremendously from company to company.

Here are the steps for using the plan finder tool:

Go to medicare.gov/plan-compare – you can either create a login or continue without logging in. If you create a login, you will be able to see drug prices based on any help you get, compare plans, create and save your drug list, and other helpful features;

Next you will be asked what type of drug plan you are looking for. Click on Drug Plan (Part D). You will then be asked to enter your zip code. If there is more than one county in your zip code, then it will bring up those counties and ask you to choose one.

You will be asked if you get help from certain programs

Do you want to see your drug costs?

It will then ask how you pay for your drug costs: Retail pharmacy, mail order or both.

If you have drugs to enter, you will be prompted to add those drugs. Once you are done adding drugs you will indicate your preferred pharmacy if that’s how you get your medications. A list of various pharmacies will come up in your zip code and neighboring ones.

You will then see a list of plans which can be sorted by going to the dropdown box at the top right of the page. The choices are – a) lowest monthly premium; b) lowest yearly drug deductible; c) lowest drug + premium cost. Note: If you did not enter any drugs, then the last option will not be available.

You can compare up to 3 plans at a time. You also can save and print the plan comparison(s).

As stated above, you may enroll directly on the plan-finder tool by clicking on the “enroll” button or by clicking on the plan to get the plan provider details.

How Do I Pay for My Part D Prescription Drug Plan?

The monthly premium will be deducted from your Social Security benefits every month in most cases. However, you also have the option to pay the plan directly via bank draft or have them bill you instead.

What Else Do You Need Besides Part D?

If you have Medicare Part A and Part B and you add Part D, you also have the option of getting a Medigap plan to fill in the gaps in Medicare A & B. Medigap plans pay the unlimited 20% that Medicare does not cover as well as, on some plans, covering the deductibles in Medicare. To compare the Medigap plans for your area, you can go here: Medigap quotes by email.

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Pennsylvania Medigap Plans

April 9, 2020 By Garrett Ball Leave a Comment

Pennsylvania Medigap plans can be an important part of your financial plan if you live in PA and are on Medicare. If you are enrolled in Original Medicare only, your coverage provides for hospital stays and doctor visits, but does not cover you for all these costs. In addition, there may be deductibles and copayments. As a result, these amounts (generally 20% of what Medicare doesn’t pay), can add up substantially and eat into your pockets deeper. For PA residents, that’s where a Pennsylvania Medigap plan can help.

Medigap insurance (also called Medicare Supplement insurance) is private insurance that covers the gaps that Medicare doesn’t cover. As an example, if you were admitted to the hospital and receive a bill, the amount that is approved by Medicare will be paid before your Medicare Supplement insurance company pays any other costs, i.e. deductibles or copays.

Each of the 10 Medicare Supplement plans offered in Pennsylvania are identified by a letter (A-N). All Medigap plans are standardized – not only do they have to follow federal and state laws implemented to protect the consumer, but they must be clearly marked as “Medicare Supplement Insurance”. All plans with the same letter offer the exact same benefits, no matter which insurance company sells the plan. However, premiums rates can vary considerably from company to company. The type of benefits and how many benefits covered by each plan determines how expensive it is. Below is a table outlining the various benefits provided by each plan:

medigap coverage chart

In addition to standardized benefits for Medigap plans, there are no “networks” of doctors/health care providers you must go to. You can see any provider that accepts Medicare patients. The same is true for the claims process. All claims, no matter which insurance company provides the plan, are paid the same according to Medicare’s “crossover” system. For example, claims are paid in the same manner and through the same system, whether you have an Aetna Plan G, Cigna Plan G, or a Pennsylvania Medigap Plan G with any other company.

As far as differences between Pennsylvania plans and other states, please see below:

There are over 30 insurance companies currently offering Medigap plans in the PA. Not all these companies offer plans in other states. Some are well-known names, i.e. Mutual of Omaha, AARP Medicare Supplement from United Healthcare, Aetna or Cigna. On the other hand, others are smaller, regional or local companies as Highmark and Capital BCBS. Competitive rates and the reputation of the company are two factors that will help to narrow down your options for going with one company over another. At present, the companies with the most competitive PA Medigap rates are Mutual of Omaha, Aetna and CSI Life. To get a Pennsylvania Medigap quotes by email, you can request Medigap quotes.
Another unique feature of PA Medigap rates is how those rates are determined. Most premiums are calculated based upon age, gender, and zip code. However, in PA, there are between two and three geographical rate areas depending on the company. Generally speaking, although there are exceptions, Medigap rates in highly populated cities are higher.
For those who are under 65 years of age, the availability of Medigap plans varies from state to state. Some states do not even offer plans to the under-65 population. However, PA under-65 plans are available, if you are applying during your open enrollment period, which starts when you enroll in Medicare Part B. Also, under-65 Medigap rates in PA are often the same as over-65 rates, which is not the case in most states.
Tobacco use rates during open enrollment can also vary from state to state. In PA, whether you use tobacco or not, does not apply here.

To get a plan with the most competitive rates, you should enroll in a Pennsylvania Medigap plan during your open enrollment, 6-month period. Otherwise, you may have to pay more for your plan. After your 6-month window closes, you will have to medically qualify for a plan and if you have any serious health conditions, you can even be declined.

Finally, there is a misconception that you can only apply for a Medicare Supplement during the annual enrollment period (Oct. 15-Dec. 7). This only pertains to Part D, prescription drug plans and Medicare Advantage plans.

If you have any questions about Pennsylvania Medigap plans or want to get a PA Medigap comparison, you can contact us online or call us at 877.506.3378.

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