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Medigap eligibility rules for Americans under age 65 vary by state

Each state decides its own rules to determine whether disabled Medicare beneficiaries under age 65 are guaranteed enrollment in supplemental coverage.

Louise Norris | February 21, 2024

For Americans who become eligible for Medicare upon turning 65, enrollment in Medigap plans is guaranteed during a six-month federally mandated enrollment period. During this time, all available Medigap plans are guaranteed-issue, regardless of medical history.

But for almost 12% of the people enrolled in Medicare, eligibility is triggered by long-term disability or by a diagnosis of ALS or end-stage renal disease (ESRD, aka kidney failure), rather than age – and there are no federal rules guaranteeing access to Medigap plans for these enrollees. Members of Congress have introduced federal bills to mandate guaranteed access – among them, HR1394 in 2019 and HR1676 in 2021 (specific to beneficiaries with ESRD) – but these bills have thus far stalled.

Efforts to guarantee access to Medigap vary by state

States, meanwhile can create their own rules to ensure that disabled Medicare beneficiaries under age 65 can enroll in supplemental coverage, and the majority of the states have done so. But the solutions vary considerably from one state to another – ranging from access to a state-run high-risk pool all the way to a requirement that all Medigap plans be guaranteed issue with premiums that don’t exceed the rates charged to a 65-year-old.

This is an issue that at least a few state legislatures (or regulatory bodies) consider each year; Idaho, Indiana, Virginia, Oklahoma, Rhode Island, and Kentucky are recent examples of states where at least some Medigap plans have been made available to beneficiaries under age 65 due to legislation or regulatory changes.

But there have also been several states where legislative efforts to expand access to Medigap plans for people under 65 were not successful in recent years, including Arizona in 2021 and Texas in 2023.

You can click on a state on this map to see details about under-65 Medigap regulations. But here’s an at-a-glance overview:

Two states have no provisions – and no plans – geared to the under-65 population

These states have not enacted any provisions to ensure access to supplemental coverage for Medicare beneficiaries who are under age 65, and there do not appear to be any guaranteed-issue plans available for this population:

  • Nevada
  • Ohio (Legislation under consideration in 2024 would require Medigap insurers to make their plans available to under-65 beneficiaries, with premiums no higher than age-65 premiums.1)

12 states and DC have no coverage requirement for insurers, but some coverage is available

These states do not have regulations requiring Medigap insurers to offer plans to Medicare beneficiaries under the age of 65. But in each state, there is either a functioning high-risk pool that continues to offer coverage to Medicare beneficiaries under age 65, or there are at least some Medigap insurers that voluntarily offer coverage to beneficiaries under 65 (albeit typically with premiums that are much higher than the premiums for a person who is 65):

  • Alabama
  • Arizona
  • Washington, DC
  • Utah
  • West Virginia
  • Nebraska (Legislation introduced in 2023 and carried over into the 2024 session would require insurers to offer all Medigap plans to beneficiaries under age 65, with premiums no higher than the weighted average premiums for enrollees 65 and older.2)
  • Alaska (high-risk pool coverage is also an option)
  • Iowa (high-risk pool coverage is also an option; legislation under consideration in 2024 would create an annual 30-day window that begins on an applicant’s birthday, allowing guaranteed-issue access to all available Medigap plans, and the legislation applies equally to applicants under the age of 653 But previous efforts to implement an annual Medigap enrollment window in Iowa were unsuccessful.4)
  • New Mexico (high-risk pool coverage is also an option)
  • North Dakota (high-risk pool coverage is also an option)
  • South Carolina (high-risk pool coverage is also an option; legislation introduced in 2024 would make Medigap Plan A available5)
  • Washington (high-risk pool coverage is also an option)
  • Wyoming (high-risk pool coverage is also an option)

A note about high-risk pools: Before the Affordable Care Act did away with medical underwriting in the individual major medical insurance market, the majority of the states had high-risk pools that served as coverage of last resort for people with pre-existing conditions who didn’t have access to employer-sponsored health coverage. Many of them also offered Medicare supplement coverage for people under age 65 who weren’t able to enroll in private Medigap plans.

High-risk pool coverage is no longer necessary for people who aren’t Medicare-eligible, as individual major medical plans are now guaranteed-issue. But the ACA did not change anything about medical underwriting in the Medigap market. So several states that don’t have specific guaranteed-issue requirements for their Medigap plans have opted to keep their high-risk pools functional in order to serve this population.

Some of these high-risk pools are currently only open to Medicare beneficiaries who need supplemental coverage, although some continue to also offer coverage for people who don’t have other individual market (non-Medicare) coverage. New Mexico’s high-risk pool is an example of one that continues to offer coverage in both markets, with lower premiums for those who only need coverage to supplement Medicare.

12 states require insurers to offer at least one Medigap plan to those under age 65

In these states, insurers are required to offer some – but not all – of their Medigap plans to people under 65. State regulations vary in terms of the specific plans that have to be offered and whether the insurer can charge higher premiums for under-65 enrollees:

  • Arkansas
  • California (plans do not have to be offered to people with ESRD)
  • Connecticut
  • Maryland
  • New Jersey
  • North Carolina
  • Oklahoma
  • Texas (2023 legislation to make all plans guaranteed-issue at the same rates used for 65-year-olds was unsuccessful)
  • Michigan
  • Indiana (Additional legislation passed in 2024 — not yet signed into law as of February 2024 — would, as of 2025, make all plans available and prohibit higher premiums for Plans A, B, and D. For other plans, the under-65 premiums could be no more than 200% of the age-65 premiums.)6
  • Virginia (as of 2024, updated state law prohibits higher premiums for beneficiaries under age 65, and extends eligibility to those with ESRD)7
  • Rhode Island (effective July 2023; additional legislation under consideration in 2024 would require Medigap insurers in Rhode Island to make all policies available to beneficiaries under age 65, with premiums no higher than age-65 premiums8)

10 states make all plans guaranteed-issue, but under-65 premiums can be much higher

These states require Medigap insurers to offer all of their plans to any newly eligible Medicare beneficiary, regardless of age. But insurers are allowed to charge significantly higher premiums when an enrollee is under age 65:

14 states make all plans guaranteed-issue, include restrictions on premiums

In these states, Medigap insurers have to make all of their plans available to all newly eligible Medicare beneficiaries, regardless of age. And there are rating restrictions that either prevent insurers from charging higher premiums for enrollees under age 65, or limit the additional premiums that can apply to this population:

  • Hawaii (rates for those under 65 are the same as age-65 rates)
  • Idaho (rates capped at 150% of age-65 rates; this took effect in 2018)
  • Illinois (rates capped at highest rate the insurer charges over-65 enrollees)
  • Kansas (under-65 rates are the same as age-65 rates)
  • Kentucky (effective in 2024; under-65 rates not more than weighted average for 65+ rates)
  • Maine (rates don’t vary by age, including rates for under-65 enrollees)
  • Massachusetts (rates don’t vary by age, including rates for under-65 enrollees. But Medigap insurers can reject applicants with ESRD)
  • Minnesota (rates don’t vary by age, including rates for under-65 enrollees)
  • Mississippi (rates capped at 150% of age-65 rates)
  • Missouri (rates are capped at the “weighted average aged premium rate” that applies to people age 65+)
  • New York (premiums do not vary based on age)
  • Oregon (under-65 rates are the same as age-65 rates)
  • Pennsylvania (under-65 rates are the same as age-65 rates)
  • South Dakota (rates can’t exceed the rates for a 75-year-old)

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

  1. Ohio HB400. BillTrack50. Introduced February 2024. 
  2. Nebraska Legislative Bill 32. BillTrack50. Carried over from 2023 session to 2024 session. 
  3. Iowa SF2081” BillTrack50. Accessed February 27, 2024. 
  4. Iowa H.F.228 and Iowa H.F.462. BillTrack50. Accessed January 2024 
  5. South Carolina Senate Bill 952. BillTrack50. Introduced January 2024. 
  6. Indiana Senate Bill 215 and Indiana House Bill 1346. BillTrack50. Passed February 2024. 
  7. Medicare Supplement Policies for Certain Individuals Under Age 65: Scope and Application of § 38.2-3610 (HB 1640/SB 1409) Frequently Asked Questions. Virginia State Corporation Commission. Accessed January 2024. 
  8. Rhode Island H7433” and “Rhode Island S2392” BillTrack50. Introduced February 2024. 
  9. Georgia HB1098 and Georgia SB409. BillTrack50. Introduced January 2024. 
  10. Vermont H366. BillTrack50. Introduced February 2024. 
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