Tip for Insurer-specific

During your 6-month open enrollment, insurance companies CANNOT deny you or charge more due to pre-existing conditions

Tip for Insurer-specific

After open enrollment, you may face medical underwriting and could be denied coverage

Tip for Insurer-specific

Medigap Plan G is often the best value since Plan F is no longer available to new Medicare enrollees

Medicaremoderate

Medigap (Medicare Supplement) Application

Insurer-specific · Private insurance companies

Application for Medicare Supplement insurance. During the 6-month Open Enrollment Period (starting at age 65 with Part B), insurers cannot deny coverage or charge more for pre-existing conditions.

Form Details

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Where to Submit This Form

📬

Mail to the Medigap insurance company you have selected

Each insurance company has its own Medigap application.

🌐

Through the insurer's website (some companies offer online applications)

🏢

Through a licensed insurance agent or SHIP counselor

https://www.shiphelp.org/

SHIP provides free, unbiased Medicare counseling.

Filing Deadline

Medigap Open Enrollment Period: 6 months starting the month you turn 65 AND are enrolled in Part B. After this period, companies can use medical underwriting.

Required Attachments

📎 Completed application form
📎 Medicare Part A and Part B enrollment confirmation
📎 First premium payment
📎 Health questionnaire (only if applying outside your open enrollment period)

Processing Time

During open enrollment: guaranteed issue — no medical underwriting, approval within 1-2 weeks. Outside open enrollment: underwriting may take 2-4 weeks.

What Happens Next

If approved, your Medigap policy starts the first of the month after the application is accepted. You will receive your policy documents and insurance card.

Tips for This Form

✓ During your 6-month open enrollment, insurance companies CANNOT deny you or charge more due to pre-existing conditions
✓ After open enrollment, you may face medical underwriting and could be denied coverage
✓ Medigap Plan G is often the best value since Plan F is no longer available to new Medicare enrollees
✓ You cannot have both a Medigap policy and a Medicare Advantage plan at the same time

More Medicare Forms

Medicare Part B Enrollment

CMS-40B · CMS

Application for enrollment in Medicare Part B (medical insurance). Used during Initial Enrollment, General Enrollment, or Special Enrollment Periods.

Request for Employment Information

CMS-L564 · CMS

Employer verification of group health plan coverage dates. Required alongside CMS-40B when using a Special Enrollment Period after employer coverage ends.

Part A/B Special Enrollment (Exceptional Conditions)

CMS-10797 · CMS

Application for Medicare Part A and Part B during a Special Enrollment Period for exceptional conditions such as natural disasters or employer misinformation.

Part B Immunosuppressive Drug Coverage Enrollment

CMS-10798 · CMS

Application for Part B immunosuppressive drug coverage for individuals who lose Part B but need ongoing immunosuppressive drug coverage after a kidney transplant.

Medicare Advantage Enrollment

Plan-specific (CMS model template) · CMS

Model enrollment form for Medicare Advantage or Part D prescription drug plans. Plans customize the CMS template but must include all required elements.

Medicare Advantage Disenrollment

CMS model disenrollment form · CMS

Request to disenroll from a Medicare Advantage or Part D plan and return to Original Medicare. Available during applicable enrollment periods.

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