Medicare’s Six-Month Medigap Window You Don’t Want to Miss

If you’re turning 65 or getting ready to retire and leave employer health coverage, you already have a lot on your to-do list. One Medicare deadline that’s easy to miss (and hard to fix later) is the six-month Medigap open enrollment window.

Unfortunately, I have seen friends miss this six-month window and for some, it has turned into years of stress and fewer choices.

The “6-Month Clock”

Think of Original Medicare as a block of Swiss cheese. Just as Swiss cheese is full of holes, Original Medicare coverage is also full of holes. Medigap tries to fill coverage holes of Original Medicare.

You get a one-time six-month window to enroll in Medigap. That six-month clock starts when your Medicare Part B coverage begins (as long as you’re 65 or older). During this window, insurers can’t deny you a Medigap policy because of pre-existing conditions, and they can’t charge you more for that reason, either.

After those six months, the rules change, and in most states, insurers can ask health questions, review medications, and either charge you more or deny coverage.

Why Missing It Can Get Expensive

The trap many people fall into is, “I’m healthy, I can just deal with this later.”

With Original Medicare Part B, you’ll usually pay 20% of the Medicare-approved cost after you meet the deductible. These costs include visiting the physician, tests, scans, outpatient therapies, and equipment.

A Real-Life Story About Missing the Six-Month Window

A friend of mine realized that her mother missed the six-month Medigap Open Enrollment period. Her mom was in good health, so she wasn’t too worried. But when she learned her mother would be responsible for the Part B 20% coinsurance, she started to help her mom with the Medigap application.

Then life happened.

After her mother went for a routine mammogram screening, the results flagged an abnormal finding. Her doctor ordered additional imaging (a breast MRI) and a biopsy. The testing confirmed breast cancer and treatment started immediately.

At that point, they decided not to apply for Medigap, since they were outside the six-month window and a recent cancer diagnosis could lead to a denial (underwriting often looks back several years). So they focused on the treatment.

Thankfully, the treatment went as well as one could hope. Two years after treatment ended, she applied for Medigap insurance.

But there was a surprise. Medical underwriting doesn’t just look at a recent diagnosis; it also looks at medications.

Her mother had osteopenia (low bone density, but not osteoporosis). Because some breast cancer treatments can accelerate bone loss, the oncologist had proactively prescribed denosumab (Prolia, often used to prevent or treat bone loss). Even though the doctor prescribed it as a prophylactic and her bone density hadn’t progressed during the cancer treatment, the private insurance company viewed it as a red flag and denied the application. Even a letter appealing the initial denial from her oncologist, confirming Prolia was prescribed as a prophylactic, did not change the insurer’s decision (insurers don’t have to overturn a denial).

The mother concluded she needed to wait until the oncologist stopped the Prolia injections and then wait long enough for a “clean” underwriting history, all while hoping no new medical issue cropped up.

“But I Thought Preexisting Conditions Were Protected Now?”

The Affordable Care Act (ACA) made numerous changes to our healthcare system, including prohibiting health insurance companies from denying coverage or charging you more based on a pre-existing condition.

But the ACA protections do not apply to Medigap (Medigap is private supplemental coverage).

Outside the six-month window and special situations, most states allow medical underwriting for Medigap policies.

If You Miss the Window, What Are Your Options?

If you missed the six-month Medigap open enrollment period, you still have some options.

1. Try Applying for Medigap Anyway

Even if you are outside the six-month open enrollment period, one option is to apply anyway. Many insurers approve applicants after they go through medical underwriting. Also, underwriting rules vary based on the insurer, so if one company says “no” a different company might say “yes.”

2. Stay on Original Medicare

Original Medicare allows you to keep broad provider access. But it’s important to remember you are responsible for the Part B 20% coinsurance after you meet the deductible and other out-of-pocket costs.

3. “Cautiously” Consider Medicare Advantage (Part C)

While there’s no medical underwriting and Medicare Advantage premiums are often lower than Original Medicare with Medigap, your doctor network may be smaller and your out-of-pocket costs for hospital and ongoing care can be higher than Original Medicare with Medigap, even though Medicare Advantage plans cap what you pay each year for Part A and Part B services.

Be “cautious” because it puts a private insurance company in charge of approving and denying coverage and procedures. And that’s often only after receiving prior authorization (common for higher-cost services).

There have been more and more reports of people on Medicare Advantage having insurers deny services that insurers should have approved, claims and procedures that Original Medicare would have automatically covered.

4. Look for Special Guaranteed-Issue Rights

There are specific life events that can create guaranteed-issue opportunities, including losing certain types of coverage (for example, certain plan changes or coverage loss events). Rules vary by state and plan, so Medicare.gov and State Health Insurance Assistance Programs (SHIPs) are two great resources to see what might apply to your specific situation.

A Final Thought

We all want to stay healthy and happy during retirement. And while you can’t control a surprise diagnosis, you can control if you sign up for Medigap during the window when it is usually easiest to secure.

A Few Questions to Think About

When will your Medicare Part B coverage start, and if you are still working, will your employer health coverage affect the timing?

Given your current health and your parents’ health, are you better off with Original Medicare + Medigap or Medicare Advantage and why?

Do you take any medications or are you undergoing any treatments that might make Medigap underwriting more difficult?

If you can’t afford Medigap or you’re denied, how will you manage out-of-pocket costs?