by Russell Noga | Updated May 18th, 2023
23% of the 65.1 million Original Medicare Beneficiaries have Medigap policies as of 2023. If you’re not one of them, you might consider enrolling in Medigap as soon as possible. Original Medicare only covers around 80% of your inpatient and outpatient medical expenses, and Medigap picks up the outstanding 20%.
As a result, you get better predictability of your annual healthcare expenses. In some cases, you might not have to pay anything other than your Medigap premium each month to get full coverage.
Medigap policies are available from private healthcare insurers like:
And many more.
But who regulates Medicare supplement plans?
While private insurers offer the policies, the Federal government is responsible for regulating the coverage these plans provide. As a result, Medigap plans offered by insurers come with standardized benefits that all insurers must provide to beneficiaries, depending on their chosen plan.
Medicare Supplement Plans - Key Takeaways
- The Medigap market varies widely from state to state, with 3% of beneficiaries in Hawaii and 51% of all beneficiaries living in Kansas.
- Federal law offers limited protection for consumers over the age of 65 looking to enroll in a Medigap scheme with a private healthcare insurer.
- A one-time, six-month open enrollment period begins on the applicant’s 65th birthday.
- Each state has the flexibility to institute a consumer protection policy for Medigap plans going beyond the minimum required Federal standards for coverage. For instance, 28 states require healthcare insurers to issue Medigap policies to eligible beneficiaries whose employer changed their retirement healthcare coverage benefits.
- Four states (CT, ME, MA, & NY) require annual or continuous guaranteed issue protections for all beneficiaries enrolled in Original Medicare aged 65 and older, regardless of their medical history. Guaranteed issue protections prevent insurers from denying Medigap policies to eligible applicants, including individuals with pre-existing health conditions, such as heart disease and diabetes.
- In all other states and Washington D.C., people switching from Medicare Advantage plans to Original Medicare may be denied Medigap policies by healthcare insurers due to pre-existing health conditions, with few exceptions. For example, if they move to a new state or are currently in the Medicare Advantage trial period.
Protections to Consumers for Medigap Policies
Typically, Medigap supplemental insurance plans are regulated by the state. However, Federal requirements, guidelines, and consumer protections are also subject to minimum standards in the benefits they offer.
For instance, Federal law requires the standardization of benefits provided in Medigap plans by healthcare insurers. This rule makes it easier for prospective beneficiaries to compare the premiums and benefits across all Medigap plans from all private healthcare insurers.
Guaranteed Issue Periods
Federal law also requires private Medigap insurers to off beneficiaries “guaranteed issue” policies to applicants aged 65 and older within the first six months of enrolling in Original Medicare Part B. During these enrollment periods, private insurers cannot refuse a Medigap policy to any applicant, regardless of factors like their gender, health status, or if they have a pre-existing healthcare condition.
Furthermore, during these open enrollment periods, private Medigap insurers cannot use medical underwriting processes to set premium rates for Medigap plans. However, private insurers can implement a six-month waiting period in some states to activate benefits and coverage for new Medigap beneficiaries with pre-existing health conditions.
These rules apply, provided the beneficiary had at least six months of prior creditable continuous coverage. Some states also have the flexibility to implement consumer protection rights going beyond the minimum Federal guidelines and standards.
Other consumer protections imposed on Medigap policies by Federal law include “guaranteed renewability,” limits on broker commissions to discourage policy “churning” of policies, minimum medical loss ratios, and rules preventing the sale of Medigap policies to applicants with duplicate health policies.
Guaranteed Issue Protections for Medigap Plans
Federal law provides consumers with guaranteed issue protections on Medigap policies during the one-time, six-month Medigap open enrollment period for new beneficiaries aged 65 and older when they enroll in Original Medicare Part B and in specific qualifying events.
These circumstances include when Original Medicare beneficiaries lose supplemental coverage involuntarily. For example, when the beneficiary loses coverage from their Medicare Advantage plan due to discontinuance in their service area or if an employer cancels their medical coverage.
Beneficiaries enrolled in Medicare Advantage plans have Federal guaranteed issue rights when moving to new areas where they can’t access a Medicare Advantage plan. People 65 and older who meet these qualifying criteria have 63 days to apply for a Medigap policy under the Federal guaranteed issue protections.
Federal law requires private insurers to sell Medigap policies with guaranteed issue rights during “trial” periods in the year for those enrolled in Medicare Advantage plans. An example is the first-year beneficiaries enrolling in Original Medicare Parts A & B.
During this trial period, beneficiaries can enroll in a Medicare Advantage plan. If they decide to leave in the first year, they have guaranteed issue rights to enroll in a Medigap plan under Federal law. Other trial periods apply to Medicare beneficiaries canceling Medigap policies to enroll in Medicare Advantage plans.
These beneficiaries get time-limited guaranteed issue rights on purchasing a Medigap policy if they decide to disenroll from a Medicare Advantage Plan in the first year to obtain coverage under Original Medicare.
States also have the flexibility to institute Medigap consumer protections going beyond the minimum Federal standards; examples would be extending the guaranteed issue requirements beyond the Medigap open enrollment period. Or they may add other qualifying criteria or events requiring private healthcare insurers to issue Medigap policies.
6-Month Medigap Open Enrollment Period
Typically, after a beneficiary is enrolled in Medicare Part B for over six months, they don’t have any Federal guaranteed issue protections when applying for their Medigap policy, except for specified qualifying events discussed earlier.
So, older adults enrolled in Original Medicare who miss their open enrollment period will likely be subject to a medical underwriting process, and private insurers may potentially deny them a Medigap policy due to their pre-existing health conditions.
We can help if you’re in this situation, give us a call today at 1-888-891-0229.
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Frequently Asked Questions
Who oversees Medicare Supplement insurance policies?
Medicare Supplement policies, also known as Medigap policies, are regulated by both federal and state laws. The Centers for Medicare & Medicaid Services (CMS) is the federal agency that oversees Medicare, while individual state insurance departments regulate Medigap policies sold in their states.
What are the federal laws regarding Medicare Supplement plans?
Federal law guarantees certain rights when it comes to Medicare Supplement plans. This includes the right to buy a Medigap policy during your Medigap open enrollment period, and protection against unethical sales practices.
How do state laws affect Medicare Supplement plans?
State laws can affect the availability and pricing of Medigap policies. For instance, some states require insurers to offer at least one type of Medigap policy to people under 65 who are on Medicare, while other states don’t.
When can I enroll in a Medicare Supplement plan?
The best time to enroll in a Medicare Supplement plan is during your six-month Medigap open enrollment period. This period begins on the first day of the month when you’re both 65 or older and enrolled in Medicare Part B.
Are there penalties for late enrollment in a Medigap policy?
There’s no late enrollment penalty for Medigap, but if you wait until after your Medigap open enrollment period to buy a policy, the insurance company may charge you a higher premium or deny you coverage based on your health status.
Can I switch Medicare Supplement plans anytime?
Yes, you can apply to switch to a different Medigap policy at any time, but if you apply after your Medigap open enrollment period, the insurer can use medical underwriting to decide whether to accept your application and what to charge you.
Will Medigap plans be changing in 2024?
Medicare Supplement Plans in 2024 will remain the same with no new plan letters being added. All coverage within each letter currently will be the same for 2024.
Do all insurance companies offer the same Medigap policies?
The coverage offered by each standardized Medigap policy (Plan A through N) is the same no matter which insurance company sells it, but not all insurance companies offer every Medigap plan.
What are the protections against misleading marketing of Medigap policies?
Both federal and state laws protect consumers from misleading marketing practices. Insurers are prohibited from misleading you about the benefits and coverage of a Medigap policy.
Can an insurance company cancel my Medigap policy if I get sick?
If you pay your premiums on time, your Medigap policy is guaranteed renewable. This means the insurance company can’t cancel your Medigap policy as long as you pay the premium.
Where can I report a problem with a Medicare Supplement insurance company?
If you have a complaint about a Medigap policy or insurance company, you can contact your state insurance department or the State Health Insurance Assistance Program (SHIP) in your state.
Find the Right Medicare Plan for You
When it comes to choosing the best Medicare Supplement plan to fit your needs, it can get a bit overwhelming.
Which plan letter is right for me?
How do I make sure I’m not paying too much?
What about yearly rate increases?
Whether it’s a Medigap plan, or you have questions about Medicare Advantage or Medicare Part D, we can help.
Call us today at 1-888-891-0229 and one of our knowledgeable, licensed insurance agents will walk you through it the easiest way possible.
Russell Noga is the CEO of Medisupps.com, an online Medicare Agency and resource center helping Medicare beneficiaries learn about Medicare, Medigap and Part D drug plans, and Medicare Advantage plans since 2009. Russell is licensed in all 50 states and has been featured as a keynote speaker, and author of several publications, along with hosting the very popular Medisupps.com Youtube channel.