Medicare—and healthcare in general—can be a very daunting world. According to the National Association of Insurance Commissioners, in 2016 there were 858 health insurance companies in the United States. It’s no wonder that choosing one specific company let alone a health care plan is challenging for many people. However, there are other important aspects to consider besides choosing the right coverage. If you wish to purchase Medicare Supplement Insurance, it is important to find out the best time to buy one in your state. Generally, the best time to enroll in a Medigap policy is during your Medicare open enrollment period. If you miss this six-month window, you can also buy Medigap if you have a guaranteed issue right. So, you’re probably asking by now, when is my open enrollment period? And what is my guaranteed issue right? Well, I am here to help you find the answer to those questions.
The Basics: When can I apply for Medigap?
First of all, a Medigap policy is private health insurance that helps supplement Original Medicare. This means it helps pay some of the health care costs that Original Medicare doesn’t cover, (in effect, the “gaps” in Medicare coverage) like copayments, coinsurance, and deductibles. Most people enroll in Medicare when they turn 65. This is called the open enrollment period (OPE). The OPE is a set window of time during which you can enroll in a Medicare health insurance plan. It begins three months before your 65th birthday—includes the month of your 65th birthday—and runs until three months after your birthday. During your six-month Medigap enrollment period, you have the right to buy any Medigap policy offered in your state, and you cannot be denied based on pre-existing condition. The six-month Medigap Open Enrollment Period begins on the first day of the month you’ve turned 65 or older, and already enrolled in Medicare Part B.
(Important: Once your Open Enrollment Period starts, it cannot be delayed or replaced.)
During open enrollment, you can buy any policy if you:
- are 65 or older
- are turning 65
- are under 65
- have group health coverage through an employer or union
Applying for Medigap after the open enrollment period
If you apply after your open enrollment period, there’s no guarantee that an insurance company will sell you a Medigap policy if you don’t meet their medical underwriting requirements, unless you are eligible due to one of the situations below:
- You are under 65 and eligible for Medicare because of a disability or End-Stage Renal Disease (ESRD)
- You have health problems
- You have a pre-existing condition
- You have other insurance
- You have guaranteed issue right
In addition, you may run into problems if you try to buy a Medigap policy outside a protected enrollment period. For instance, companies can refuse to sell you a policy or impose certain medical requirements. If a company does agree to sell you a policy, you may need to pay a higher monthly premium and be subject to a six-month waiting period before the Medigap will cover your pre-existing conditions.
On the other hand, Medicare.gov states that “if you apply during your Medigap open enrollment period, you can buy any Medigap policy the company sells, even if you have health problems for the same price as people with good health.” There are certain circumstances when you can buy outside your open enrollment period with the same protections you would have during the open enrollment period. These are called guarantee issue and trial rights.
Guaranteed issue rights
Also called Medigap protections, these are specific rights that customers have in certain situations. When you have a guaranteed issue right, insurance companies are lawfully required to sell or offer you a Medicare supplement insurance policy at the best available rate, regardless of your health status, and cannot deny your coverage even if you have pre-existing conditions. A guaranteed issue right also prevents companies from imposing a waiting period for coverage of pre-existing conditions.
You may have a guaranteed issue right if:
- You, through no fault of your own, lost a group health plan (GHP) that covered your Medicare cost-sharing (meaning it paid Secondary Medicaid)
- You joined a Medicare Advantage Plan when you first became eligible for Medicare and disenrolled within 12 months.
- Or, your previous Medigap policy, Medicare Advantage Plan, or PACE program ends its coverage or commits fraud.
In addition, guaranteed issue rights protect you from medical underwriting, which is when health insurance companies use your health history and data on pre-existing conditions to make determinations about whether or not they will cover you and how much they will charge you for coverage.
Advocates of medical underwriting say the process keeps individual health insurance premiums as low as possible. Critics, on the other hand, maintain it unfairly stops people with relatively minor and treatable pre-existing conditions from obtaining health insurance. In the United States, the Affordable Care Act (ACA) changed many of the rules associated with the way insurers qualify individuals looking for health insurance, preventing these from denying coverage to an individual, and from placing limitations on a policy for pre-existing medical conditions. However, this may change under the current Presidential administration.
Before you buy Medigap, we recommend that you check to see if your state offers additional protections. For instance, some states allow people to enroll in Medigap plans outside of the federally protected periods. Residents of New York and Connecticut can buy a policy throughout the whole year, not just during select times. These two states also require insurers to sell supplemental policies to Medicare beneficiaries under the age of 65.
Call your State Health Insurance Assistance Program (SHIP) or Department of Insurance to learn more about your right to purchase a Medigap policy in your state. Also, be sure to keep a copy of any letters, notices, postmarked envelopes and claim denials in case you need proof that you lost or ended health coverage. Medigap insurers may require these documents before they sell you a policy.