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), enrollees get just one 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 sign up for a Medigap plan outside of the Medicare open enrollment period.
All enrollees get a single 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.
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.
Some enrollees may qualify for Medigap special enrollment
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 2022, eleven 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).
A ‘birthday rule’ in five states allows users to switch Medigap plans
Of those eleven states, five have implemented a “birthday rule” that allows Medigap enrollees to switch Medigap plans without medical underwriting around the time of their birthday (the other six 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, you need to already be on a Medigap plan.
- California: You have 60 days from the first day of your birth month to change to another Medigap plan with the same level or a lower level of benefits. You can also change insurance carriers during this time. This is an updated birthday rule that took effect on January 1, 2020. Prior to that the special enrollment period was only 30 days long.
- Idaho: You have 63 days from your birthday to change to another Medigap plan with the same level or a lower level of benefits. You can also change insurance carriers. This birthday rule starts on March 1, 2022.
- Illinois: You have 45 days from your birthday to change to another Medigap plan with the same level or a lower level of benefits. This only applies to plans with your current insurance carrier. To qualify for this birthday rule, you must be 65 to 75 years old. This birthday rule took effect on January 1, 2022.
- Oregon: You have 30 days from the first day of your birth month to change to another Medigap plan with the same level or a lower level of benefits. You can also change insurance carriers. This birthday rule took effect on January 1, 2013.
- Nevada: You have 60 days from the first day of your birth month to change to another Medigap plan with the same level or a lower level of benefits. You can also change insurance carriers. This birthday rule took effect on January 1, 2022.
Are ‘birthday rules’ likely in more states?
Life is not predictable and your medical needs may change over time. What you can afford may change too. You deserve the opportunity to find an affordable plan that works for you.
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. (It would be more impactful if all policyholders had these rights – and every year.)
These states are being proactive for your health. As more of them enact these “birthday rules,” 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 authoredMedicare 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.