Medical Underwriting

Health questions before approval

Before the Affordable Care Act, most individual health insurance was medically underwritten. Today, ACA-compliant plans cannot use your health to decide eligibility or price. But many private plans sold outside the ACA rules still use underwriting.

During underwriting, an insurer reviews:

• Answers to health questions on your application.
• Prescription history, often pulled from pharmacy databases.
• Sometimes medical records or a phone interview.
• Height, weight and tobacco use.

Based on that review, the insurer may approve you at standard rates, approve you at a higher rate, approve you with an exclusion for certain conditions, or decline.

Why some people choose underwritten plans

Underwriting lets insurers offer lower premiums to healthier applicants. For self-employed people and early retirees above the subsidy line, where Marketplace premiums are paid in full, an underwritten plan can sometimes cost less and offer a broader PPO network. Underwritten plans can also be applied for year-round, not just during open enrollment.

Example

Two business partners, both 45, are shopping for 2027 coverage with incomes well above the subsidy line.

• Partner A is healthy, takes no medications and has no recent claims. She applies for a private underwritten PPO, gets approved at standard rates, and pays noticeably less than a full-price Marketplace plan.
• Partner B had heart surgery three years ago and takes ongoing medication. His underwritten application comes back with an exclusion for cardiac care. He chooses an ACA plan during open enrollment instead, where his heart care is covered without question.

Same age, same income, different best answer.

Things to know before applying

• Answer every question accurately. Misstatements can lead to denied claims or cancellation later.
• Read the approval terms. An approval may include exclusion riders or waiting periods.
• Keep your current coverage until approved. Do not cancel an existing plan until the new one is confirmed in writing.
• Check renewal terms. Some plans can raise rates at renewal based on group experience.

Marketplace vs private plans

ACA-compliant plans on and off the Marketplace use no medical underwriting. Your premium depends only on age, location, tobacco use and household size, and you are guaranteed acceptance during enrollment periods. Private underwritten plans trade that guarantee for the possibility of a lower price if you are healthy. For many people the right move is to compare both and choose based on health, budget and network needs.

Learn more in our guides on private vs Marketplace plans for the self-employed and short-term health insurance. Frank can help you understand whether an underwritten plan is realistic for you. Request a quote to compare.