Guaranteed issue is a right granted to Medicare beneficiaries and applies to Medicare Supplement Insurance (Medigap plans). All states and the federal government enforce this essential right, which protects Medicare beneficiaries from medical underwriting.
- Medigap protections (guaranteed-issue rights) protect beneficiaries from being denied insurance due to a pre-existing condition.
- Protection is for a limited period.
- In some circumstances, a beneficiary may have their Medigap protections restored.
- Some states grant additional protections not required by the federal government.
Unlike regular health insurance, which was reformed by the Affordable Care Act (Obamacare), supplemental Medicare insurance companies can use your health history and data on pre-existing conditions to make their coverage determination. In other words, they can turn you down or make you pay more due to a pre-existing condition.
The process Medicare supplement companies use to approve or disapprove your application is called medical underwriting. However, there are two situations that allow you to apply for coverage without going through medical underwriting.
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The first situation is when you’re first eligible for Medicare Part B and you’re also enrolled in Medicare Part A. this is your individual open enrollment period (OEP). It starts as soon as your Part B benefits begin and ends six months later.
The second situation is when you exercise a trial right or when you lose health insurance through a situation outside of your control. This might be because you stop working, and lose your employer group coverage, or because you move. These situations, like your OEP, trigger your guaranteed issue rights, and you can’t be turned down, and you won’t be asked health questions.
What is the Guaranteed Issue Period for Medicare Supplements?
When you turn age 65, or first enroll in Medicare Part B (whichever comes later), your one-time-only period to buy any Medigap plan you want, without question, begins. This is a six-month period of time, during which you have guaranteed issue rights. These rights allow you to choose your supplement, and the company you want to buy it from, without fear of being rejected based on your health or age.
After your six-month open enrollment period has ended, all bets are off. That does not mean you won’t be able to get a Medicare supplement policy, it simply means that there’s no guarantee that your application will be accepted.
When you have a guaranteed issue right, the insurance company you choose:
- Must sell you a Medigap policy
- Must cover all your pre-existing health conditions
- Can’t charge you more for a Medigap policy because of past or present health problems
Without your guaranteed issue right, Medigap insurance companies can and will ask you health questions on their application, just like you would answer when applying for life insurance. To get coverage, you must be able to pass medical underwriting.
You also have a guaranteed issue right when you have other health insurance that changes in some way, like when you retire and no longer have coverage under your employer’s group health plan. Another common scenario is when you have a “trial right” to try Medicare Advantage and later change your mind.
Can I buy a Medigap policy if I lose coverage through my employer?
In most cases, yes. You typically retain your guaranteed issue right to buy a Medigap plan if you were covered by your employer’s group health plan, but then lose this coverage. However, you will need to prove that you had coverage and when it ended. Make sure you keep a copy of any letters, notices, emails, and/or claim denials that have your name on them as proof of your coverage. Use the postmarked envelope these papers come in as proof of when it was mailed (i.e., termination). The insurance company you choose may require you to send a copy of these documents with your application to prove you have a guaranteed issue right.
What other situations give me a Guaranteed Issue Right?
You have a guaranteed issue right in these situations:
- You have a Medicare Advantage plan and the plan is leaving Medicare or stops giving care in your area
- You have a Medicare Advantage plan and move out of the plan’s service area.
- You have Original Medicare and an employer group health plan (or union coverage) that pays after Medicare pays and that plan is ending.
- You have Original Medicare and a Medicare SELECT policy and you move out of the Medicare SELECT plan’s service area.
- You have Medicare due to a disability and you’re turning age 65.
- You joined a Medicare Advantage Plan or Programs of All-inclusive Care for the Elderly (PACE) when you were first eligible for Medicare Part A at 65, and you decide to go back to Original Medicare within the first year. (Trial Right)
- You canceled a Medigap plan to join a Medicare Advantage plan (or to switch to a Medicare SELECT policy) for the first time and you want to switch back within the first year. (Trial Right)
- Your Medicare supplement insurance coverage ends through no fault of your own (e.g., the company goes out of business).
- You leave a Medicare Advantage plan because the plan hasn’t followed the rules or it misled you.
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How else can I get guaranteed-issue rights?
Some states, including California, Oregon, Washington State, and Missouri allow additional situations to qualify you for guaranteed-issue rights.
What are pre-existing conditions?
Pre-existing conditions are health conditions that existed before the start of a Medicare supplement policy. They may limit your coverage, be excluded from coverage, or even prevent you from being approved for a policy. It’s important to note that the exact definition and relevant limitations or exclusions vary with each insurance company. Ak your insurance agent to help you review the official plan documents to understand how a carrier handles pre-existing conditions.
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