Goodsurance

Medicare Advantage

KFF: Nearly Three-Quarters of Medicare Advantage Enrollees Have a Condition That Could Block a Medigap Policy

A KFF analysis published the day before open enrollment opens finds that most people in Medicare Advantage plans carry diagnoses that Medigap insurers can use to deny or reprice coverage if those enrollees try to return to Original Medicare.

By the Goodsurance editorial teamOctober 14, 2026

A KFF analysis published October 13, 2026 found that 74 percent of people enrolled in Medicare Advantage plans carry at least one pre-existing medical condition that could allow a Medigap insurer to deny them a policy or charge higher premiums if they try to switch to Original Medicare.

Federal law does not require Medigap insurers to accept applicants with pre-existing conditions except during narrow guaranteed-issue windows. For most Medicare Advantage enrollees, that window is a brief trial period around when they first join Medicare. After it closes, nine in ten MA enrollees age 65 and older have no guaranteed right to purchase a Medigap supplement, the analysis found.

Open enrollment starts tomorrow. KFF finds nearly 3 in 4 Medicare Advantage enrollees have a pre-existing condition that could block them from buying Medigap if they switch back to Original Medicare.

As of 2023, roughly 20.9 million Medicare Advantage enrollees had at least one potentially deniable condition on record. The most commonly cited were peripheral vascular disease (25 percent of all MA enrollees), chronic kidney disease (24 percent), coronary artery disease (21 percent), and diabetes with related complications (21 percent).

The share of enrollees with at least one such condition rises sharply with age. Among enrollees 85 and older, nearly 88 percent had a condition that could trigger a denial. The figure also varies by state, ranging from 82 percent in Florida to 59 percent in Alaska.

Four states, Connecticut, Massachusetts, Maine, and New York, require Medigap insurers to offer coverage to all beneficiaries regardless of health history. In the remaining states, enrollees who decide during this fall's open enrollment to move back to Original Medicare face the possibility that a Medigap insurer could decline their application.

Medicare open enrollment runs October 15 through December 7, 2026. Coverage changes take effect January 1, 2027.

In plain words

Most people in Medicare Advantage plans have a health condition that has been recorded. If they leave Medicare Advantage and try to buy a Medigap plan, insurers in most states are allowed to say no because of those conditions. A KFF study found that about 3 out of 4 Medicare Advantage members face this risk. The older you are, the higher the chance. Among people 85 and older who are in Medicare Advantage, nearly 9 out of 10 have a condition that could cause a denial. Only four states, Connecticut, Massachusetts, Maine, and New York, require insurers to accept everyone no matter their health history. Medicare open enrollment runs from October 15 to December 7. Anyone thinking about switching plans should check what protections apply in their state before making a change.

Understand the basics first

Source: KFF
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