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Medicare enrollees have an annual opportunity to review and adjust their Medicare coverage each year, but that flexibility doesn’t apply to Medicare supplement plans – commonly referred to as Medigap. While Medicare Advantage and Medicare Part D have an annual open enrollment period (October 15 – December 7), federal rules only give Medicare beneficiaries one guaranteed-issue Medigap open enrollment period in their lifetime.
Medigap plans help to pay down costs that Original Medicare doesn’t cover – costs such as deductibles, copays, and coinsurance. Depending on your medical situation, you could need more or less coverage at different times in your life. Unfortunately, having only one Medigap open enrollment period does not give enrollees the flexibility to change plans, at least not affordably.
The truth is that you may or may not be able to change Medigap plans when you need to. That’s because insurance companies can use medical underwriting when you apply for a Medigap plan outside of the Medicare open enrollment period.
Medigap open enrollment starts the day your Medicare Part B coverage begins and lasts six months. This generally applies to Medicare beneficiaries 65 and older – although some states allow Medicare beneficiaries under 65 to sign up for Medigap plans, too (in that case, the beneficiary will also have another guaranteed-issue open enrollment window for Medigap when they turn 65, under federal rules).
This enrollment period is the one time that qualifying Medicare beneficiaries can sign up for a Medicare supplement plan without medical underwriting. Put simply, it is a time when insurance companies cannot charge you higher rates for any pre-existing conditions you have. In addition, carriers can’t make you wait for their plan’s benefits to kick in.
Signing up for Medigap outside of that window could cost you a lot more. In some cases, insurance carriers could deny you coverage altogether.
You may qualify for a special Medigap enrollment period if you have guaranteed issue rights. In these cases, insurance companies cannot charge you more based on your medical conditions, put a waiting period on your coverage, and deny you coverage.
The Centers for Medicare and Medicaid has established a list of seven situations that require insurance companies to allow you to sign up for or change a Medigap plan without medical underwriting. This list of events is somewhat limited, but you may have even more options depending on what state you live in.
As of 2023, twelve states offer guaranteed issue rights that go above and beyond what the federal government does (this applies to annual enrollment or plan change opportunities; more than half the states go above and beyond federal requirements in terms of making guaranteed-issue Medigap plans available to beneficiaries under age 65).
Of those dozen states, six have implemented a “birthday rule” that allows Medigap enrollees to switch Medigap plans without medical underwriting around the time of their birthday, and Kentucky will join them in 2024. (The other six states have other windows, either year-round, or a specific time of the year, or related to the anniversary of when the person’s current policy was purchased.) To qualify for a “birthday rule” plan change, you need to already be enrolled in a Medigap plan.
While Medigap is an excellent option for people on Original Medicare, some policyholders may feel that they are locked into Medigap plans with high rates. Guaranteed issue rights can help, but the situations outlined by CMS are limited to very specific situations that apply to relatively few policyholders.
The states that have created annual windows during which enrollees have at least some level of guaranteed-issue Medigap rights are helping to give Medicare beneficiaries the option to periodically review their Medigap options, even if they have pre-existing medical conditions.
The number of states offering “birthday rule” plan change windows has increased in recent years. Kentucky is the latest state to join this list, with a plan change opportunity that starts in 2024.
Legislation (HF228) was introduced in Iowa in 2023 to would create a birthday rule for Iowa Medigap enrollees, but it was subsequently replaced by HF462, which would instead allow Medigap enrollees the opportunity to switch to a new plan during the month of March (each Medigap insurer would have to make at least one plan guaranteed issue, without premium increases or exclusions, during that window).
Lawmakers in other states are likely to introduce similar legislation as time goes by. As more states enact “birthday rules” or similar provisions, more Medicare beneficiaries will have the opportunity to shop around for plans. This will increase the market competition for Medigap plans in those states and could hopefully drive down rates.
Keep an eye out for more “birthday rules” in the future.
Tanya Feke M.D. is a licensed, board-certified family physician. As a practicing primary care physician and an urgent care physician for nearly ten years, she saw first-hand how Medicare impacted her patients. In recent years, her career path has shifted to consultant work with a focus on utilization review and medical necessity compliance. She currently works as a physician advisor at R1 RCM, Inc., where she performs case reviews for hospitals nationwide.
Dr. Feke is an expert in the field, having Medicare experience on the frontlines with both patients and hospital systems. To educate the public about ongoing issues with the program, she authored Medicare Essentials: A Physician Insider Reveals the Fine Print. She has been frequently referenced as a Medicare expert in the media and is a contributor to multiple online publications. As founder of Diagnosis Life, LLC, she also posts regular content about health and wellness to her site at diagnosislife.com.