Medigap Underwriters Don’t Take Your Word on the Health Questions. They Pull Your Pharmacy Records, and the Prescription Answers for You.
She answered no to the blood thinner question and believed it. The insurer believed her pharmacy records instead, and those records remembered something she had long since forgotten.
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A 68-year-old in Ohio drops her Medicare Advantage plan after a bad prior-authorization fight and applies for Medigap Plan G to pair with Original Medicare. She has been in Advantage for three years and no longer has a federal trial right.
On the application, she answers “no” to a question about blood thinners. She has forgotten a 30-day Eliquis prescription filled two years earlier after an emergency-room visit. The carrier finds it anyway. It did not rely solely on her memory. It pulled her pharmacy history. Anyone applying for Medigap outside the one-time federal enrollment window may face medical underwriting in most states. Underwriting no longer runs on the honor system.
How Carriers Check the Answers
Many Medigap insurers obtain prescription-history reports when underwriting an application. One major provider is Milliman IntelliScript, a consumer reporting company whose data products are used in insurance underwriting. The report can show medications, dosage, fill dates, refill patterns and prescribing providers. How far an insurer looks back and how it treats a particular drug depend on that carrier’s underwriting rules.
A prescription does not prove a diagnosis. Eliquis can be prescribed for atrial fibrillation, a blood clot or short-term treatment after a medical event. Albuterol can point toward asthma or chronic obstructive pulmonary disease. The report nevertheless gives the insurer a reason to compare the medication with the applicant’s answers and investigate the condition behind it. Some medications or combinations can trigger an immediate decline under a carrier’s guidelines. Others prompt follow-up questions or medical-record requests. Either way, an answer that conflicts with the pharmacy file can close the application before the applicant gets much opportunity to explain.
What the Six-Month Window Buys
The federal Medigap open-enrollment period lasts six months, beginning the first month someone is both 65 or older and enrolled in Medicare Part B. It does not necessarily begin at 65; someone who delays Part B while working may start the window later.
During those six months, an insurer cannot deny a Medigap application or charge more because of health history. Afterward, medical underwriting may apply unless the applicant has a federal guaranteed-issue right or stronger protection under state law. That distinction catches Medicare Advantage members hardest. Leaving Advantage for Original Medicare can be simple. Buying a supplement to cap Original Medicare’s cost exposure may not be.
Without Medigap, the Part A hospital deductible is $1,736 in 2026, and skilled nursing care costs $217 a day from days 21 through 100. Original Medicare also has no annual out-of-pocket maximum (we mapped these surcharges, deductibles, and coverage gaps in a free Medicare guide).
State Protections Are Not All the Same
Where she lives can matter almost as much as what appears in her pharmacy file. New York and Connecticut provide unusually broad access to Medigap without medical underwriting. Other states offer narrower enrollment protections. California and Oregon, for example, have birthday rules that let many people who already own Medigap switch to a policy with equal or lesser benefits without new underwriting. Those rules generally do not give a Medicare Advantage member an unrestricted first chance to buy Medigap.
That is why “my state has a birthday rule” is not enough. The question is whether the rule protects someone in this applicant’s exact position.
Your Rights
IntelliScript reports are regulated by the Fair Credit Reporting Act (FCRA). If an insurer takes adverse action based partly or entirely on a consumer report, it must identify the reporting company and explain the applicant’s right to obtain a free copy within 60 days.
The applicant can dispute inaccurate, incomplete or unverifiable information. The reporting company generally must investigate within 30 days and correct or remove information it cannot verify. An accurate one-time prescription cannot be erased merely because it was temporary or has since been discontinued. The applicant can, however, obtain medical documentation explaining why it was prescribed and apply with a carrier whose guidelines treat that history differently.
Read the File First
Three steps can prevent a forgotten prescription from deciding the application:
- Request an IntelliScript consumer disclosure before applying and review every medication, date and prescriber.
- Correct genuine errors before submitting the application, and gather records explaining any accurate but temporary prescriptions.
- Confirm federal guaranteed-issue rights and state protections before leaving Medicare Advantage, then compare underwriting rules across carriers.
The health questions may appear on the application, but part of the answer key is already sitting in a pharmacy database. The applicant who reads it first gets to choose the carrier before the carrier chooses her.
Contact [email protected] for any questions or corrections.
Gerelyn Terzo is the author of dividend investing handbook "Dividend Investing Strategies: How to Have Your Cake & Eat It Too." A veteran financial journalist, she covers agri-finance for outlets like Global AgInvesting and the broader stock market and personal finance for 24/7 Wall Street. She began at CNBC and later helped launch Fox Business in New York. Gerelyn currently resides in Woodland Park, Colorado and dabbles in nature photography as a hobby.
