HOW CAN I GET MEDIGAP OUTSIDE OF OPEN ENROLLMENT?
You can get Medicare Supplement insurance outside of an open enrollment period if you qualify for certain guaranteed issue rights. Read more to learn if you qualify for guaranteed issue Medigap.
Medigap plans (also called Medicare Supplements) are a solution to the gaps left behind by Original Medicare (Parts A and B). Medigap plans provide more comprehensive coverage than Original Medicare. In other words, they reduce or eliminate your out-of-pocket costs in exchange for a monthly premium (similar to traditional healthcare coverage).
Medicare Supplements are best purchased during the Initial Enrollment Period (IEP). This is a special period of time when you can purchase any plan you see fit without being subject to underwriting — the process in which an insurance company looks at your health and history to determine your overall risk (how likely and how often you’ll be using your coverage and subsequently costing the company money).
Based on the results of the underwriting process and your medical history and conditions, an insurance company has a right to deny you coverage, charge you a higher premium, or make you wait until your coverage kicks in.
For many, it’s impossible to qualify for or afford a Medigap plan if health conditions are taken into account. This is why choosing the right plan is so important during your IEP, when underwriting is not a factor.
However, you may have a guaranteed issue right to purchase a Medicare Supplement outside of an enrollment period — without undergoing the underwriting process.
WHAT ARE GUARANTEED ISSUE RIGHTS?
Guaranteed issue rights, also called Medigap protections, define situations in which insurance companies must offer certain Medicare Supplements to you in the same way they would during your IEP. That is, no underwriting and no chance they’ll deny you coverage.
When you qualify for guaranteed issue rights, insurance companies:
- Must offer you Medigap plans at the best available rates (based on your age, gender, location and tobacco use)
- Cannot deny you coverage
- Cannot make you have a waiting period for pre-existing conditions
Federal law guarantees issue rights (see how that works out?!). So insurance companies can’t skirt around your eligibility for a Medigap plan if you’re entitled to these rights — no ands, ifs, or buts.
WHEN DO YOU QUALIFY FOR GUARANTEED ISSUE MEDIGAP?
There’s no enrollment period to qualify for guaranteed issue rights to purchase a Medigap policy. Instead, these rights are triggered when certain events occur that would otherwise leave you without healthcare coverage through no fault of your own. For example, you wouldn’t qualify for guaranteed issue rights if you simply decide to stop paying your premium.
Click the links to below to jump to a scenario that fits your needs, or keep reading to learn more.
- Your Medicare Advantage plan leaves Medicare, changes service areas or you move.
- Your group healthcare coverage is ending.
- You move outside your Medicare SELECT service area.
- You switch from a Medicare Advantage or PACE plan within the first year.
- You dropped Medigap for Medicare Advantage or SELECT and you want to switch back after less than a year.
- You involuntarily lose Medigap coverage.
- Your current insurance company hasn’t followed government rules & regulations.
1. Your Medicare Advantage Plan Leaves Medicare, Changes Service Areas, or You Move From the Service Area
If you have a Medicare Advantage plan (Part C of Medicare), you qualify for guaranteed issue rights if:
- The Medicare Advantage plan leaves the Medicare program
- The Medicare Advantage plan is no longer available in your area
- You move away from the area serviced by the Medicare Advantage plan
You may apply for a Medigap plan up to 60 days before or 63 days after you lose coverage. Coverage under your Medigap plan would not begin until your Medicare Advantage coverage has ended, however.
You will not have guaranteed issue rights to switch to another Medicare Advantage plan. Instead, you must switch back to Original Medicare. This will then make you eligible for any A, B, C, F, K, or L Medigap plans offered in your state.
2. You Have Original Medicare and Group Coverage, and Your Group Coverage is Ending
If you lose healthcare coverage that pays after Original Medicare — such as employer coverage, COBRA, or retiree coverage — you have guaranteed issue rights to Medigap plans A, B, C, F, K, and L.
You qualify for guaranteed issue rights 63 days after the latest of:
- Your coverage ending
- The date on the notice informing you your coverage is ending
- The insurance company denies a claim (which is sometimes the only way you’ll know your coverage has ended)
- Copies of letters, notices, and claim denials
- Anything with your name written on it
- Postmarked envelopes used to send these forms as proof of mailing date
If you have COBRA coverage, you may either purchase a Medicare Supplement right away or wait until your COBRA coverage ends.
Depending on your state of residence, you may also have additional rights. It’s wise to check with your state’s Department of Insurance to know the full extent of your guaranteed issue rights in such a situation.
3. You Move From Your Medicare SELECT Service Area
Moving out of an area serviced by your Medicare SELECT policy will qualify you for guaranteed issue rights to purchase Medigap plans A, B, C, F, K, or L.
Your period of eligibility will begin 60 days before your coverage ends and up to 63 days after.
It’s also a good idea to contact your Medicare SELECT insurer in this situation as well, as alternative options may be available to you depending on your specific circumstances.
4. You Switch from a Medicare Advantage Plan Within the First Year
If you joined a Medicare Advantage plan or Program of All-Inclusive Care for the Elderly (PACE) when you were first eligible for Medicare Part A at 65 years old, the plan provides a “trial right” in your first year of coverage.
A trial right gives you exactly what you’d assume from the name — the right to trial a Medicare Advantage or PACE plan without any downside from switching within your first year of coverage. It’s a great opportunity to test the waters and figure out how best to manage your healthcare coverage under Medicare.
Your guaranteed issue right to purchase a Medicare Supplement begins 60 days before coverage would end from your Medicare Advantage plan and lasts until 63 days after it’s expired. Again, this right is only granted to you if you’re still within the first year of coverage by the Medicare Advantage plan.
5. You Dropped Medigap in Favor of a Medicare Advantage Plan or Medicare SELECT for the First Time, Have Had the Plan for Less Than a Year, and Want to Switch Back
You also have trial rights if you initially had Medigap coverage and dropped it in favor of a Medicare Advantage plan or Medicare SELECT for the first time and have had either plan for less than a year.
In this situation, you can switch back to the Medigap plan you initially dropped. If the plan is no longer offered by the same insurance company you had before, you can purchase a Medigap plan A, B, C, F, K, or L from any insurance company in your state 60 days before your coverage would end or 63 days after it already has.
6. You Involuntarily Lose Medigap Coverage
Involuntarily losing your Medigap coverage through no fault of your own isn’t something you’re penalized for. If your coverage ends for any reason beyond your own responsibility, such as your insurance provider going bankrupt, you have a guaranteed issue right to purchase an A, B, C, F, K, or L Medigap plan from any insurance company in your state.
As in most other cases, your guaranteed issue right lasts for 63 days following the end of your coverage.
7. You Leave a Medicare Advantage Plan or Medigap Policy Because the Company Hasn’t Followed Rules
The federal government strictly enforces rules and regulations for Medicare Supplements. If your insurance company commits fraud or otherwise misled you, you qualify for a guaranteed issue right and may change to a Medigap plan A, B, C, F, K, or L from any provider in your state within 63 days of your existing coverage ending.
HOW TO PROVE YOU QUALIFY FOR GUARANTEED ISSUE RIGHTS
Establishing a paper trail will serve you well when trying to prove a case for your guaranteed issue right to a Medigap policy. Unless your situation is simple, such as moving to an area your Medicare SELECT plan doesn’t service, you’ll likely need to provide proof you’re eligible for a guaranteed issue right.
The official Medicare website recommends keeping the following in the event you’re asked to include copies with your application for a Medigap plan:
Failure to adequately prove you had creditable coverage and subsequently qualify for guaranteed issue rights may mean you’re at the mercy of medical underwriting. The insurance company can deny you coverage or put you on the hook for higher premiums.
The age-old adage applies: it’s better to be safe than sorry.
EXERCISE YOUR GUARANTEED ISSUE RIGHTS FOR MEDIGAP COVERAGE
Understanding your guaranteed issue rights for Medigap coverage will protect you from the risk of falling into the gaps left behind by Original Medicare or being responsible for added costs of managing your healthcare.
Whether in your IEP, open enrollment, or exploring your options for coverage by a Medicare Supplement, learn how to find the best Medigap plan that matches your medical needs and budget.