Guaranteed acceptance into
Medi Gap – Supplemental plans.

There are certain times when you can enroll in a Medi-Gap – Supplemental plans without Medical Health Underwriting questions.   These times are called Guaranteed Acceptance – Issue.

Medi Gap is not like Medicare Advantage, where if you enroll when you turn 65 or at AEP Annual Open Enrollment, there are no health questions asked, or ACA under 65 Health Care Reform, where no questions are asked if you enroll at Open Enrollment or a Special Enrollment.

The basic most common time, is when you turn 65.

See below of a summary of the times, then check with us or the actual documents we’ve linked to for the exact rules.  Also, check out our “child pages” for more details on the more common guaranteed enrollment times

What is a better choice for Me?

Medi-Gap or Medicare Advantage?

What are the Guaranteed Issue Rules for when you are
new to Medicare as you’ve #turned 65?

Or just enrolled in Part B?

Here’s Blue Shield rule from their Guaranteed Issue Guide:

New to Medicare A & B Guaranteed issue

 

When’s the best time to buy a Medi Gap policy?

The best time to buy a Medigap policy is during your Medigap Guaranteed Issue Open Enrollment Period. This period lasts for 6 months and begins on the first day of the month in which you’re both 65 or older and enrolled in Medicare Part B.  Publication 02110 Page 14 & 45

 

Blue Shield Authorized Agent
No extra charge to you 

#Get Quotes & Enroll with Blue Shield 

Blue Shield Logo & Enroll

#Birthday Rule GI Guaranteed Issue right for plan A, F, G or N.

 

An individual shall be entitled to an annual open enrollment period lasting 60 days or morecommencing with the individual’s birthday, during which time that person may purchase any Medicare supplement coverage that offers benefits equal to or lesser than those provided by the previous coverage.

 

The application may be submitted 90 days in advance, for Blue Cross, but the effective date would be for the month after the clients birthday unless their birth date was on the 1st.  CA Health Care Advocates  * excerpt of email from BC 6.2.2020

During this open enrollment period, an issuer that falls under this paragraph shall not deny or condition the issuance or effectiveness of Medicare supplement coverage
  • nor discriminate in the pricing of coverage, because of health status,
  • claims experience,
  • receipt of health care, or
  • medical condition of the individual

Blue Cross Innovative F or G or Blue Shield Plan F or G Extra,  count the same as F or G and don’t require underwriting.  CA Health Care Advocates *# *

Blue Shield – Birthday Rule

Typical Guidelines

Guaranteed Issue Guide

Guaranteed Issue Guide - Birthday Rule

Excerpt of CA Law – Birthday Rule 

if, at the time of the open enrollment period, the individual is covered under another Medicare supplement policy, certificate, or contract. An issuer that offers Medicare supplement contracts shall notify an enrollee of their rights under this subdivision at least 30 and no more than 60 days before the beginning of the open enrollment period, and on any notice related to a benefit modification or premium adjustment.  1358.11. (h) (1)    *  SB 407  Effective 7.1.2020? 

Steve talks about the Birthday Rule –

Right to change to equal or lessor plan – 60 days – Innovative & Extra don’t count for making you do underwriting

birthday rule video

Transfer Application

No need to fill out Health Questions

 

When you fill out the transfer application under the birthday rule, whether ONLINE or Paper, check off the equal or lesser plan that you want.

which medi gap plan do you want?

Then put down the rule – situation # for the Insurance Company that you are using.

Birthday rule guaranteed #

When you get to the Statement of Health, you don’t have to fill out any questions.

Don't have to fill out medical questions

 

While these pictures are from the Blue Shield application, the general principles apply to all Insurance Companies.

Guaranteed Issue Rights for Medi-Gap
when you enroll beyond age 65 for Part B as you had
Qualifying #Employer Coverage

 

Termination of Employment or Retirement Plan

You have the right to purchase a Medigap policy for 6 months if your, your spouse’s or a family member’s current employment or retirement plan coverage terminatesor you lose your eligibility due to divorce or death of a spouse or family member. The 6-month period to apply for a Medigap policy starts on the date you receive notice that your health benefits will end. If you do not receive advance notice, the 6-month period starts the date the benefits end or the date of your first denied claim. This protection of California law applies whether your group health benefits were primary or secondary to Medicare.

Loss of COBRA or Cal Cobra

You are also entitled to this protection when you become eligible for COBRA  (Our webpage on COBRA)  or have used up all your COBRA benefits. It does not apply if you stop paying COBRA premiums before you use all your benefits. COBRA benefits are always secondary to Medicare benefits unless you have ESRD and are in a 30-month coordination period. For more information on COBRA, see Medicare & Other Health Insurance.  CA HealthCare Advocates *

COBRA and Medicare are VERY VERY confusing.  Double check with us on your specific situation!!!

 

Guaranteed Issue Loss of Employer Coverage
 
You received notice of termination, or your coverage was terminated from any employer-sponsored health plan, including an employer-sponsored retiree health plan. This includes termination for loss of eligibility due to divorce or death of a spouse.
 
 
You enrolled in an employer-sponsored health plan that supplements Medicare, [§419 (e) Welfare Benefit Plans ] and either of the following apply:
• The plan either terminates or ceases to provide all of those supplemental health benefits to you;
or
• The employer no longer provides you with insurance that covers all of the payment for the 20% coinsurance.
Why is there Both situation 4 and 11?
I asked and was told # 11 applies to §419 (e) Welfare Benefit Plans 

Employer loss of Coverage Guaranteed Issue

CA Insurance Code  §10192.11

 

(e)

(1) An individual enrolled in Medicare Part B is entitled to open enrollment described in this section for six months following:

(A) Receipt of a notice of termination or, if no notice is received, the effective date of termination from any employer-sponsored health plan including an employer-sponsored retiree health plan.

(B) Receipt of a notice of loss of eligibility due to the divorce or death of a spouse or, if no notice is received, the effective date of loss of eligibility due to the divorce or death of a spouse, from any employer-sponsored health plan including an employer-sponsored retiree health plan.

(C) Termination of health care services for a military retiree or the retiree’s Medicare eligible spouse or dependent as a result of a military base closure or loss of access to health care services because the base no longer offers services or because the individual relocates.

(2) For purposes of this subdivision, “employer-sponsored retiree health plan” includes any coverage for medical expenses, including, but not limited to, coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) and the California Continuation Benefits Replacement Act (Cal-COBRA), that is directly or indirectly sponsored or established by an employer for employees or retirees, their spouses, dependents, or other included insureds.

Be careful and double check – COBRA might not get you out of the Part B Late Enrollment Penalty!

Resources & Links
 
Technical Memo:
Interaction between COBRA and Medigap Guaranteed Issue Requirements in Situations Involving Termination of Employer Group Coverage
.
Medicare.Gov  *  Next Page  *  All Federal Guaranteed Issue Rights  *  Federal Rights in HTML Matrix  *

#Guaranteed Acceptance Guide
Blue Shield CALIFORNIA
Blue Cross CA

This is just a summary of the most common ways you can get a Medi Gap plan without having to answer health questions.

Get more detail at:

On some pages you can Scroll down for our cut & paste of the ACTUAL CA Law

#Understanding Medicare Advantage Plans (PDF) #12026

Watch Video

Video understanding medicare advantage mapd

Insurance Companies get a fee from the Federal Government, when you enroll in an MAPD plan.

That's why the premium is very low or ZERO!

Medi Gap plan – guaranteed issue
if your Medicare Advantage Plan offers #less benefits or raises premium

 

Cost Sharing Rule – Excerpt from Blue Shield
Cost Sharing Rule - Excerpt from Blue Shield
 
 

CA Insurance Code §10192.12 (D) (i) The Medicare Advantage plan in which the individual is enrolled reduces any of its benefits or increases the amount of cost sharing or premium or discontinues for other than good cause relating to quality of care its relationship or contract under the plan with a provider who is currently furnishing services to the individual. An individual shall be eligible under this subparagraph for a Medicare supplement policy issued by the same issuer through which the individual was enrolled at the time the reduction, increase, or discontinuance described above occurs or, commencing January 1, 2007, for one issued by a subsidiary of the parent company of that issuer or by a network that contracts with the parent company of that issuer. If no Medicare supplement policy is available to the individual from the same issuer, a subsidiary of the parent company of the issuer, or a network that contracts with the parent company of the issuer, the individual shall be eligible for a Medicare supplement policy pursuant to paragraph (1) of subdivision (e) issued by any issuer, if the Medicare Advantage plan in which the individual is enrolled does any of the following:

(I) Increases the premium by 15 percent or more.

(II) Increases physician, hospital, or drug copayments by 15 percent or more.

(III) Reduces any benefits under the plan.

(IV) Discontinues, for other than good cause relating to quality of care, its relationship or contract under the plan with a provider who is currently furnishing services to the individual.

(ii) Enrollment in a Medicare supplement policy from an issuer unaffiliated with the issuer of the Medicare Advantage plan in which the individual is enrolled shall be permitted only during the annual election period for a Medicare Advantage plan, except where the Medicare Advantage plan has discontinued its relationship with a provider currently furnishing services to the individual. Nothing in this section shall be construed to authorize an individual to enroll in a group Medicare supplement policy if the individual does not meet the eligibility requirements for the group.

 

I don’t see that the Federal Law has this rule.

AARP – Have us or your agent review bullet points 7 & 8 in confidential agent manual.

What are the #Trial Right rules & guarantees about if you get a
Medicare Advantage Plan MAPD and
then you would rather switch to Originial Medicare A-Hospital & B- Doctor Visits and a Medi-Gap plan?

 

There is a 12 month trial period (free-look) in which you can test drive an MAPD.  This trial period can be  either when you first turn 65, or you drop a Medi-Gap plan to enroll in a MAPD Plan.

Sometimes, there might be a “Underwriting Holiday” where you can change to the Insurance Company celebrating the Holiday, regardless of how long it’s been!

Trial Rights MAPD to Medi Gap

 

Publication 02110  Choosing a Medi-Gap Policy

 

Blue Shield Guaranteed Trial Right

 

Blue Shield Guaranteed Issue Rights

CA Health Care Advocates *  Medicare & You – See link in Side Panel

 

FAQ’s

What if you are past the 12 month period – but less than 2 years?

Email us and we can send you the information for the unnamed company below.

I don’t like the unnamed company or just want to know how I can get a Medi-Gap plan.

There might be other guaranteed reasons for you.  See our webpage on that.

I don’t have a guaranteed reason, what kind of underwriting is there?

I have Medicare and I’m #under 65,

What Medi Gap or Medicare Advantage Plans can I get?

 

If you are under 65 and have Medicare   due to a disability, SSDI, SSI? you can get Part D Rx, Medicare Advantage and Medi Gap plans, guaranteed issue, no medical questions asked, in California by enrolling when you are first eligible or in the case of Part D & Medicare Advantage, at Open Enrollment 10.15  to 12.7 each year.  Other states may differ, learn more CA Healthline 1.4.2016.

When you turn 65, that gives you an additional time to enroll in a Medicare Supplement plan at LOWER rates.

See Medicare and You # 10050 and each Insurance Companies Web Page (see menu above) for details, brochures, enrollment forms and rates.

Please  email us, [email protected]   if you want more personalized attention.

 

FAQ’s, Resources & Links

Guaranteed Issue times & reasons for Medicare Supplements

Special Enrollment times for Medicare Advantage

See menu above for more.

What are the Medical #Underwriting Questions for a Medi-Gap policy
if I’m not in a guaranteed issue period, like just turning 65?

 

Check the paper applications below and review the questions:

 

InsuBuy International Medical Coverage –
Instant Quotes & Enrollment

Travel Policies

Coverage for Travel - $50k Emergency under Medicare Medi Gap or MAPD Advantage may not be enough!

CA Insurance Code §10192.11 (h) open enrollmenbirthday Rule

(h) (1) An individual shall be entitled to an annual open enrollment period lasting 30 days or more, commencing with the individual’s birthday, during which time that person may purchase any Medicare supplement policy that offers benefits equal to or lesser than those provided by the previous coverage. During this open enrollment period, no issuer that falls under this provision shall deny or condition the issuance or effectiveness of Medicare supplement coverage, nor discriminate in the pricing of coverage, because of health status, claims experience, receipt of health care, or medical condition of the individual if, at the time of the open enrollment period, the individual is covered under another Medicare supplement policy or contract. An issuer shall notify a policyholder of his or her rights under this subdivision at least 30 and no more than 60 days before the beginning of the open enrollment period.,

CA Health Advocates   More

CA Insurance Code §10192.12

(a)

(1) With respect to the guaranteed issue of a Medicare supplement policy, eligible persons are those individuals described in subdivision (b) who seek to enroll under the policy during the period specified in subdivision (c), and who submit evidence of the date of termination or disenrollment or enrollment in Medicare Part D with the application for a Medicare supplement policy.

(2) With respect to eligible persons, an issuer shall not take any of the following actions:

(A) Deny or condition the issuance or effectiveness of a Medicare supplement policy described in subdivision (e) that is offered and is available for issuance to new enrollees by the issuer.

(B) Discriminate in the pricing of that Medicare supplement policy because of health status, claims experience, receipt of health care, or medical condition.

(C) Impose an exclusion of benefits based on a preexisting condition under that Medicare supplement policy.

(b) An eligible person is an individual described in any of the following paragraphs:

(1) The individual is enrolled under an employee welfare benefit plan that provides health benefits that supplement the benefits under Medicare and either of the following applies:

(A) The plan either terminates or ceases to provide all of those supplemental health benefits to the individual.

(B) The employer no longer provides the individual with insurance that covers all of the payment for the 20-percent coinsurance.

Definitions  leginfo.legislature.ca.gov

(g) “Employee welfare benefit plan” means a plan, fund, or program of employee benefits as defined in Section 1002 of Title 29 of the United States Code (Employee Retirement Income Security Act).   erisa

law.cornell.edu/uscode/text/29/1002

(1)  The terms “employee welfare benefit plan” and “welfare plan” mean any plan, fund, or program which was heretofore or is hereafter established or maintained by an employer or by an employee organization, or by both, to the extent that such plan, fund, or program was established or is maintained for the purpose of providing for its participants or their beneficiaries, through the purchase of insurance or otherwise, (A) medical, surgical, or hospital care or benefits, or benefits in the event of sickness, accident, disability, death or unemployment, or vacation benefits, apprenticeship or other training programs, or day care centers, scholarship funds, or prepaid legal services, or (B) any benefit described in section 186(c) of this title (other than pensions on retirement or death, and insurance to provide such pensions).

(2) The individual is enrolled with a Medicare Advantage organization under a Medicare Advantage plan under Medicare Part C, and any of the following circumstances apply:

(A) The certification of the organization or plan has been terminated.

(B) The organization has terminated or otherwise discontinued providing the plan in the area in which the individual resides.

Health Net Guide Rev. 7.2015 # 5 on page 6

medicare advocacy.org/when-a-medicare-advantage-plan-does-not-renew-its-contract

(C) The individual is no longer eligible to elect the plan because of a change in the individual’s place of residence or other change in circumstances specified by the secretary. Those changes in circumstances shall not include termination of the individual’s enrollment on the basis described in Section 1851(g)(3)(B) of the federal Social Security Act where the individual has not paid premiums on a timely basis or has engaged in disruptive behavior as specified in standards under Section 1856 of the federal Social Security Act, or the plan is terminated for all individuals within a residence area.

(D)

(i) The Medicare Advantage plan in which the individual is enrolled reduces any of its benefits or increases the amount of cost sharing or premium or discontinues for other than good cause relating to quality of care its relationship or contract under the plan with a provider who is currently furnishing services to the individual. An individual shall be eligible under this subparagraph for a Medicare supplement policy issued by the same issuer through which the individual was enrolled at the time the reduction, increase, or discontinuance described above occurs or, commencing January 1, 2007, for one issued by a subsidiary of the parent company of that issuer or by a network that contracts with the parent company of that issuer. If no Medicare supplement policy is available to the individual from the same issuer, a subsidiary of the parent company of the issuer, or a network that contracts with the parent company of the issuer, the individual shall be eligible for a Medicare supplement policy pursuant to paragraph (1) of subdivision (e) issued by any issuer, if the Medicare Advantage plan in which the individual is enrolled does any of the following:

(I) Increases the premium by 15 percent or more.

(II) Increases physician, hospital, or drug copayments by 15 percent or more.

(III) Reduces any benefits under the plan.

(IV) Discontinues, for other than good cause relating to quality of care, its relationship or contract under the plan with a provider who is currently furnishing services to the individual.

(ii) Enrollment in a Medicare supplement policy from an issuer unaffiliated with the issuer of the Medicare Advantage plan in which the individual is enrolled shall be permitted only during the annual election period for a Medicare Advantage plan, except where the Medicare Advantage plan has discontinued its relationship with a provider currently furnishing services to the individual. Nothing in this section shall be construed to authorize an individual to enroll in a group Medicare supplement policy if the individual does not meet the eligibility requirements for the group.

See our new page on the cost sharing rule

(E) The individual demonstrates, in accordance with guidelines established by the secretary, either of the following:

(i) The organization offering the plan substantially violated a material provision of the organization’s contract under this article in relation to the individual, including the failure to provide on a timely basis medically necessary care for which benefits are available under the plan or the failure to provide the covered care in accordance with applicable quality standards.

(ii) The organization, or agent or other entity acting on the organization’s behalf, materially misrepresented the plan’s provisions in marketing the plan to the individual.

(F) The individual meets other exceptional conditions as the secretary may provide.

(3) The individual is 65 years of age or older, is enrolled with a Program of All-Inclusive Care for the Elderly (PACE) provider under Section 1894 of the federal Social Security Act, and circumstances similar to those described in paragraph (2) exist that would permit discontinuance of the individual’s enrollment with the provider, if the individual were enrolled in a Medicare Advantage plan.

(4) The individual meets both of the following conditions:

(A) The individual is enrolled with any of the following:

(i) An eligible organization under a contract under Section 1876 of the federal Social Security Act (Medicare cost).

(ii) A similar organization operating under demonstration project authority, effective for periods before April 1, 1999.

(iii) An organization under an agreement under Section 1833(a)(1)(A) of the federal Social Security Act (health care prepayment plan).

(iv) An organization under a Medicare Select policy.

(B) The enrollment ceases under the same circumstances that would permit discontinuance of an individual’s election of coverage under paragraph (2) or (3).

(5) The individual is enrolled under a Medicare supplement policy, and the enrollment ceases because of any of the following circumstances:

(A) The insolvency of the issuer or bankruptcy of the nonissuer organization, or other involuntary termination of coverage or enrollment under the policy.

(B) The issuer of the policy substantially violated a material provision of the policy.

(C) The issuer, or an agent or other entity acting on the issuer’s behalf, materially misrepresented the policy’s provisions in marketing the policy to the individual.

(6) The individual meets both of the following conditions:

(A) The individual was enrolled under a Medicare supplement policy and terminates enrollment and subsequently enrolls, for the first time, with any Medicare Advantage organization under a Medicare Advantage plan under Medicare Part C, any eligible organization under a contract under Section 1876 of the federal Social Security Act (Medicare cost), any similar organization operating under demonstration project authority, any PACE provider under Section 1894 of the federal Social Security Act, or a Medicare Select policy.

(B) The subsequent enrollment under subparagraph (A) is terminated by the individual during any period within the first 12 months of the subsequent enrollment (during which the enrollee is permitted to terminate the subsequent enrollment under Section 1851(e) of the federal Social Security Act).

(7) The individual upon first becoming eligible for benefits under Medicare Part A at 65 years of age enrolls in a Medicare Advantage plan under Medicare Part C or with a PACE provider under Section 1894 of the federal Social Security Act, and disenrolls from the plan or program not later than 12 months after the effective date of enrollment.

Some companies are more liberal and offer two years. More detail

(8) The individual while enrolled under a Medicare supplement policy that covers outpatient prescription drugs enrolls in a Medicare Part D plan during the initial enrollment period terminates enrollment in the Medicare supplement policy, and submits evidence of enrollment in Medicare Part D along with the application for a policy described in paragraph (4) of subdivision (e).

(c)

(1) In the case of an individual described in paragraph (1) of subdivision (b), the guaranteed issue period begins on the later of the following two dates and ends on the date that is 63 days after the date the applicable coverage terminates:

(A) The date the individual receives a notice of termination or cessation of all supplemental health benefits or, if no notice is received, the date of the notice denying a claim because of a termination or cessation of benefits.

(B) The date that the applicable coverage terminates or ceases.

(2) In the case of an individual described in paragraphs (2), (3), (4), (6), and (7) of subdivision (b) whose enrollment is terminated involuntarily, the guaranteed issue period begins on the date that the individual receives a notice of termination and ends 63 days after the date the applicable coverage is terminated.

(3) In the case of an individual described in subparagraph (A) of paragraph (5) of subdivision (b), the guaranteed issue period begins on the earlier of the following two dates and ends on the date that is 63 days after the date the coverage is terminated:

(A) The date that the individual receives a notice of termination, a notice of the issuer’s bankruptcy or insolvency, or other similar notice if any.

(B) The date that the applicable coverage is terminated.

(4) In the case of an individual described in paragraph (2), (3), (6), or (7) of, or in subparagraph (B) or (C) of paragraph (5) of, subdivision (b) who disenrolls voluntarily, the guaranteed issue period begins on the date that is 60 days before the effective date of the disenrollment and ends on the date that is 63 days after the effective date of the disenrollment.

(5) In the case of an individual described in paragraph (8) of subdivision (b), the guaranteed issue period begins on the date the individual receives notice pursuant to Section 1882(v)(2)(B) of the federal Social Security Act from the Medicare supplement issuer during the 60-day period immediately preceding the initial enrollment period for Medicare Part D and ends on the date that is 63 days after the effective date of the individual’s coverage under Medicare Part D.

(6) In the case of an individual described in subdivision (b) who is not included in this subdivision, the guaranteed issue period begins on the effective date of disenrollment and ends on the date that is 63 days after the effective date of disenrollment.

(d)

(1) In the case of an individual described in paragraph (6) of subdivision (b), or deemed to be so described pursuant to this paragraph, whose enrollment with an organization or provider described in subparagraph (A) of paragraph (6) of subdivision (b) is involuntarily terminated within the first 12 months of enrollment and who, without an intervening enrollment, enrolls with another such organization or provider, the subsequent enrollment shall be deemed to be an initial enrollment described in paragraph (6) of subdivision (b).

(2) In the case of an individual described in paragraph (7) of subdivision (b), or deemed to be so described pursuant to this paragraph, whose enrollment with a plan or in a program described in paragraph (7) of subdivision (b) is involuntarily terminated within the first 12 months of enrollment and who, without an intervening enrollment, enrolls in another such plan or program, the subsequent enrollment shall be deemed to be an initial enrollment described in paragraph (7) of subdivision (b).

(3) For purposes of paragraphs (6) and (7) of subdivision (b), an enrollment of an individual with an organization or provider described in subparagraph (A) of paragraph (6) of subdivision (b), or with a plan or in a program described in paragraph (7) of subdivision (b) shall not be deemed to be an initial enrollment under this paragraph after the two-year period beginning on the date on which the individual first enrolled with such an organization, provider, plan, or program.

(e)

(1) Under paragraphs (1), (2), (3), (4), and (5) of subdivision (b), an eligible individual is entitled to a Medicare supplement policy that has a benefit package classified as Plan A, B, C, F (including a high deductible Plan F), K, L, M, or N offered by any issuer.

(2)

(A) Under paragraph (6) of subdivision (b), an eligible individual is entitled to the same Medicare supplement policy in which he or she was most recently enrolled, if available from the same issuer. If that policy is not available, the eligible individual is entitled to a Medicare supplement policy that has a benefit package classified as Plan A, B, C, F (including a high deductible Plan F), K, L, M, or N offered by any issuer.

(B) On and after January 1, 2006, an eligible individual described in this paragraph who was most recently enrolled in a Medicare supplement policy with an outpatient prescription drug benefit is entitled to a Medicare supplement policy that is available from the same issuer but without an outpatient prescription drug benefit or, at the election of the individual, has a benefit package classified as a Plan A, B, C, F (including high deductible Plan F), K, L, M, or N that is offered by any issuer.

(3) Under paragraph (7) of subdivision (b), an eligible individual is entitled to any Medicare supplement policy offered by any issuer.

(4) Under paragraph (8) of subdivision (b), an eligible individual is entitled to a Medicare supplement policy that has a benefit package classified as Plan A, B, C, F (including a high deductible Plan F), K, L, M, or N and that is offered and is available for issuance to a new enrollee by the same issuer that issued the individual’s Medicare supplement policy with outpatient prescription drug coverage.

(f)

(1) At the time of an event described in subdivision (b) by which an individual loses coverage or benefits due to the termination of a contract or agreement, policy, or plan, the organization that terminates the contract or agreement, the issuer terminating the policy, or the administrator of the plan being terminated, respectively, shall notify the individual of his or her rights under this section and of the obligations of issuers of Medicare supplement policies under subdivision (a). The notice shall be communicated contemporaneously with the notification of termination.

(2) At the time of an event described in subdivision (b) by which an individual ceases enrollment under a contract or agreement, policy, or plan, the organization that offers the contract or agreement, regardless of the basis for the cessation of enrollment, the issuer offering the policy, or the administrator of the plan, respectively, shall notify the individual of his or her rights under this section, and of the obligations of issuers of Medicare supplement policies under subdivision (a). The notice shall be communicated within 10 working days of the date the issuer received notification of disenrollment.

(g) An issuer shall refund any unearned premium that an insured paid in advance and shall terminate coverage upon the request of an insured.

(Amended by Stats. 2012, Ch. 162, Sec. 113. Effective January 1, 2013.)

12 comments on “Guaranteed Acceptance – Medi-Gap – Supplemental Plans

  1. 4 comments on “Under 65 disabled & Medicare Qualified”

    1. Joan W says:

      I have been trying to get a Medicare supplement for two years. NO one will give me one. I get denied for anything, for an H. Pylori infection. Every company I apply with denies me. I was born in 1957 and have Medicare but no company will give me a supplement. They all want to give me prescription drug plan while denying the medical plan. I live in California.

      Reply
      • How about Medicare Advantage at the next Open Enrollment? Medicare Advantage is guaranteed issue, while Medicare Supplements where you can go to any doctor or hospital that accepts Medicare is not. Check out our page on when Supplements are guaranteed issue. See also the subpage where if you take a Medicare Advantage Plan and don’t like it, you can then get a supplement. Let’s talk privately about some companies that have an unofficial practice of being more liberal…

        Please note that Medicare Supplements are not like Obama Care, there is no right to guaranteed issue, any time. Even Obama Care has certain open enrollment periods. See our page on Medical Loss Ratio, the Insurance Companies take in a small premium…from lots of people, but have to be able to pay all claims from all policy holders. See also the new page – under construction we are building on Donald Care. It appears that many of our leaders don’t understand medical underwriting and the law of large numbers.

        Reply
    2. Todd M says:

      Hi. I’m looking for the best price on a Pre-65 Plan N supplement. We have Anthem at $249/month. My wife is on Social Security Disability. Birthdate: 10/25/1954. The price for Anthem started at $174 and after six months they raised it to $249.

      Any possibilities we should look into?

      Todd M

      Reply
      • I’ve responded to you privately. Use the menu above to check out other companies for Medi-Gap… but there may be a problem with Guaranteed Issue. In October there is Medicare Advantage.

  2. 12 comments on “MAPD Trial Period – Come back to Medicare and Medi-Gap”

    1. Anonymous says:

      I enrolled in a Medi-Gap plan, last year when I turned 65.

      If I enroll in a Medicare Advantage plan, can we go back to our Medi Gap plan anytime in 2020 or do we have to wait for Open Enrollment, 10.15 to 12.7 annually?

      Reply
      • Thank you for your question. It’s helps us build our website and make sure it’s understandable to our visitors. We’ve reorganized this page to make it more clear. If you cancel the MAPD plan within 12 months, you can go back to your Medi Gap plan.

        If you stay in the MAPD plan longer than a year, you would have to meet underwriting – health questions to get a Medi Gap policy. There might be some Insurance Companies more liberal, but the law doesn’t require it.

        Reply
      • The Open Enrollment Period is only for MAPD and Part D Rx guaranteed sign up, switching plans or going back to original medicare, Parts A & B.

        After the 1st year, that’s when you can get out of a MAPD plan.

        Again, if you are in a MAPD plan longer than a year, it’s not guaranteed issue to get your Medi Gap plan back

        Reply
    2. Ted W says:

      If I understand it, this benefit – Right to get a Medi Gap Plan occurs because there is a “trial” period for MA in certain cases.

      However, those cases don’t seem to include the case in which MA was obtained upon returning from overseas.

      What am I missing?

      Reply
    3. Anonymous says:

      Do I understand correctly that a MAPD plan that was guaranteed issued, as I was living overseas and returned to USA as we discussed in this Q & A https://tinyurl.com/MAPD-Guaranteed-Issue can be reverted to original Medicare + Medigap also on a guaranteed issue basis after a year?

      Reply
      • Yes. That’s what this whole page is about. See above for details and explanation. If you have further questions, just use the “reply” button.

        Reply
  3. 20 comments on “Medical Questions – Underwriting – If not in Guaranteed Issue Period?”

    1. Anonymous says:

      I have Plan F Medi Gap and applied for Plan G to save premium. So what if the Part B Deductible is higher. It wasn’t my birthday. What RIGHT does the Insurance Company have to deny the transfer because I had an alleged pre-existing condition a nothing squamous cell skin cancer. It’s hard to find someone who has not had a skin cancer

      Reply
      • 1st off, when I ask my higher ups at any of the Medi Gap Insurance Carriers about health underwriting, I get a blank stare, as most everyone gets a Medi Gap policy or change at a Guaranteed Issue date – period.

        Thus, I can’t get underwriting guidelines from anyone. Here’s an excerpt from a well known carrier, prior to ACA/Obamacare when asking health questions and pre X clauses where outlawed for under 65. Conversely, there is a mandate and only certain times one can enroll.

        There are exclusions for tons of stuff. Insurance Companies need to collect $1 to pay claims of 80 cents. It’s called MRL Medical Loss Ratio and is written into ACA/Obamcare. It was pretty much the way it was before.

        Underwriting Manual

        Reply
      • Insurance underwriters evaluate the risk and exposures of potential clients. They decide how much coverage the client should receive, how much they should pay for it, or whether even to accept the risk and insure them. Underwriting involves measuring risk exposure and determining the premium that needs to be charged to insure that risk. The function of the underwriter is to protect the company’s book of business from risks that they feel will make a loss and issue insurance policies at a premium that is commensurate with the exposure presented by a risk.

        Each insurance company has its own set of underwriting guidelines to help the underwriter determine whether or not the company should accept the risk. The information used to evaluate the risk of an applicant for insurance will depend on the type of coverage involved. For example, in underwriting automobile coverage, an individual’s driving record is critical. However, the type of automobile is actually far more critical. As part of the underwriting process for life or health insurance, medical underwriting may be used to examine the applicant’s health status (other factors may be considered as well, such as age & occupation). The factors that insurers use to classify risks are generally objective, clearly related to the likely cost of providing coverage, practical to administer, consistent with applicable law, and designed to protect the long-term viability of the insurance program.[3]

        The underwriters may decline the risk or may provide a quotation in which the premiums have been loaded (including the amount needed to generate a profit, in addition to covering expenses[4]) or in which various exclusions have been stipulated, which restrict the circumstances under which a claim would be paid. Depending on the type of insurance product (line of business), insurance companies use automated underwriting systems to encode these rules, and reduce the amount of manual work in processing quotations and policy issuance. This is especially the case for certain simpler life or personal lines (auto, homeowners) insurance. Some insurance companies, however, rely on agents to underwrite for them. This arrangement allows an insurer to operate in a market closer to its clients without having to establish a physical presence.

        Two major categories of exclusion in insurance underwriting are moral hazard and correlated losses.[5] With a moral hazard, the consequences of the customer’s actions are insured, making the customer more likely to take costly actions. For example, bedbugs are typically excluded from homeowners’ insurance to avoid paying for the consequence of recklessly bringing in a used mattress.[5] Insured events are generally those outside the control of the customer, for example (typical in life insurance) death by automobile accident, contrasted with death by suicide. Correlated losses are those that can affect a large number of customers at the same time, thus potentially bankrupting the insurance company. This is why typical homeowner’s policies cover damage from fire or falling trees (usually affecting an individual house), but not floods or earthquakes (which affect many houses at the same time).[5] https://en.wikipedia.org/wiki/Underwriting#Insurance_underwriting

        Reply
      • Here’s our webpage on the rate review process. That is, the CA Department of Insurance reviews the rates and underwriting guidelines to make sure they are actuarially sound.

        Reply
      • COST OF TREATMENT FOR SQUAMOUS CELL CARCINOMA OF THE HEAD AND NECK IN THE UNITED STATES

        Average per patient cost of care for SCCHN in the US was estimated to be $20,876.

        Higher costs resulted for patients that present with advanced cancers.

        The estimated cost of treating a patient with Stage IV lip SCC ($19,274) was four times that of Stage 0 lip SCC ($5,062).

        The site with the lowest cost of treatment was lip ($7,261) while the highest cost was associated with hypopharyngeal SCC ($28,584).

        The cost per patient for palliative care ranged from $2,052 for lip SCC (28% of total cost of care) to $7,172 for sinonasal SCC (30% of total cost of care).

        The lifetime cost of managing annual incident SCCHN cases was estimated to approximate $976 million.

        CONCLUSION: This study found that tumor stage and location are useful predictors of increased treatment costs. The results suggest that prevention and early detection are critical in reducing the treatment costs of SCCHNhttps://onlinelibrary.wiley.com/doi/abs/10.1046/j.1524-4733.2001.40202-73.x

        Reply
    2. Anonymous says:

      I’m living outside the USA, if I apply for a Medigap plan and am subject to underwriting, how much extra would coverage cost and what are the underwriting requirements?

      Reply
      • The requirements or at least the questions are in the respective insurance company applications.

        The price – premium is the same for those who enroll during a SEP or Guaranteed Enrollment Period. You can get those rates on our webpages for each company by using the site map, menu above or the link above to Blue Cross and Blue Shield affiliate sites.

        Reply
    3. Anonymous says:

      I don’t ever want to deal with underwriting because even though I’m a healthy person, the insurance companies
      may look at the info in the MIB and think I am not.

      So it sounds like I should get a regular Plan F at the get go when starting Medicare in June.

      Is that what you would recommend?

      Reply
      • How healthy are you, related to the questions on the applications above?

        Have your reviewed your MIB Medical Information Bureau File? https://www.mib.com/request_your_record.html

        MIB shouldn’t have anything that isn’t being asked in the applications. There’s a law somewhere that says Insurance Companies cannot deny you based only on the MIB file. They can only use it to indicate things that need to be investigated further.

        If you want the Medi Gap plan with the highest benefits Plan F and don’t want to worry about underwriting, yes.

        Reply
  4. 6 comments on “Turn Age 65 or newly enrolled in Part B”

    1. Anonymous says:

      GEP General Enrollment Period Timetable and Guaranteed Issue Availability

      Hello – I just signed up for Medicare Part B using the current GEP. Since I relied on Cobra coverage, I will be subject to a penalty

      Am I entitled to a guaranteed issue Medigap policy, and how soon before July do I have to obtain the policy?

      Thanks!

      Reply
      • Yes, under situation # 1 above, you are entitled to guaranteed issue Medi Gap as it says 65 and enrolled in Part B!

        I grant you, I don’t like the wording… but I’ve checked with the carriers and have actually had coverage issued.

        I suggest you enroll, as soon as you get confirmation that Part B has been approved!

        See our Medi Gap Pages for Blue Cross and Blue Shield, two separate companies in CA

        There is no extra charge for our expertise. You can enroll online or we can help you in a Zoom meeting.

        Reply
    2. Anonymous says:

      From what I understand, the door is closing on signing up for F

      Reply
      • If you mean when can you enroll, guaranteed issue from the month that you turn 65, you have six months. See Blue Shield Guaranteed Issue document above or here.

        If you mean the new rules under MACRA that starts in 2020 for those who are newly eligible. You would be OK as you turn 65 in 2018.

        Reply
    3. Anonymous says:

      1 Is it true that one has to sign up for a Medigap plan within 6 months of starting Medicare?

      2 I will be starting in June, [that’s when I turn 65] so can I wait until November to sign up for a Medi-gap plan ? (to save money?)

      Reply
      • 1 Yes, see above for details

        2 Yes, if I’m counting on my fingers correctly. Your six months would start in June.

        I do not recommend that you wait. If this is your plan, you might be better off finding another agent to help you. Purposely waiting can only lead to a malpractice claim and a major hurt to your pocket book. If one knew when they were going to have a claim or be in an accident, they just wouldn’t leave the house that day.

        Will your next question be, how long can you wait to sign up for Part B?

        3 months after the month you turn 65. That would save you $134/month.

        If you are on a budget, how about Hi F? You pay the first 2k of bills, not paid by Medicare A or B and you save around $100/month on premium. Get quotes and enroll online.

        Reply
  5. 13 comments on “Loss of Employer Coverage”

    1. Steve Shorr says:

      Please note the rules for Medi Gap and Medicare Advantage are and or can be different! Be sure to double check

      Simple explanation from my wholesaler on the rule for MAPD and Part D Rx

      There is an SEP – Special Enrollment Period that is always in place for loss of an employer group plan.

      It allows you to get signed up on a plan for up to 63 days after the plan is terminated. So it isn’t something you can wait around a long time on but you do have 63 days from the end of the group plan to utilize that s e p for your client.

      If it happens to be past that time frame then you need to utilize AEP to get them on board right away for a 1-1 effective date

      https://www.medicare.gov/Pubs/pdf/11219-Understanding-Medicare-Part-C-D.pdf#page=8

      Reply
    2. Anonymous says:

      Are Medigap policies written during the 8-month Special Enrollment Period issued subject to the same terms as terms, with regard to pre-existing conditions, as those written during the Initial Enrollment Period?

      Reply
      • The waiver of Pre X would be the same. Situation # 4 above says the enrollment period is 6 months. It gets QUITE confusing with different rules for different enrollments… Part B Outpatient, Part D Rx, Medicare Advantage, etc. One has to check each option with a fine tooth comb!

        See links above to enroll online with Blue Cross and Blue Shield.

        Here’s our scheduler to set a zoom meeting with screen sharing. https://steveshorr.com/intro/set-a-meeting/

        Reply
    3. Andrea B says:

      I already have Medicare A and want part B. I am covered by a federal employee health plan (FEHB). Medicare (SSA) says I need to have a form filled out by my company president to verify employment- my W2 and tax form indicating coverage is not enough. Online it says my Medicare part B won’t start until July.

      Reply
    4. Anonymous says:

      This is utterly confusing. It says six month period of eligibility but that you must apply within 63 days of termination? Makes no sense to me.

      Reply
      • Right. Please send a copy of your termination notice and if at all possible, all documents from your Employer’s Health Plan. Don’t hold back. We need to see if your under situation 4 or 11.

        Did the plan supplement Medicare or not?

        Reply
    5. Anonymous says:

      If one gets terminated from their spouses retiree benefits plan when the spouse passes away is there a guaranteed enrollment period into Medi Gap and how does it work?

      Reply
      • Yes. See situation # 4 above.

        Reply
    6. Ted W says:

      If you cancel your Part B, then you to reinstate Part B later will you have guaranteed issue rights for Medi Gap?

      Reply
      • Good POINT!

        Excerpt from Medicare Medi Gap Guide # 02110 * Medicare.Gov *

        It’s also important to understand that your Medigap rights may depend on when you choose to enroll in Medicare Part B. If you’re 65 or older, your Medigap Open Enrollment Period begins when you enroll in Part B and it can’t be changed or repeated.

        In most cases, it makes sense to enroll in Part B and purchase a Medigap policy when you’re first eligible for Medicare, because you might otherwise have to pay a Part B late enrollment penalty and you might miss your Medigap Open Enrollment Period. However, there are exceptions if you have employer coverage.

        From prior conversations and emails, you’ve stated that you have an application pending for Part B, but have not been enrolled. I’d check and see if you can get the application cancelled, as if you never asked to be enrolled in Part B.

        Either you or I can write to HICAP – CA Advocates and see what light they can put on the subject.

        Reply
        • This may be a question to learn when you got Part B and if you can get guaranteed issue at a later date…

          Reply
  6. 15 comments on “Birthday Rule”

    1. Anonymous says:

      Just confirming: CA birthday rule for Plan C Medicare Advantage customers does not apply.

      Changes can be made only during end-of-year period.

      Reply
    2. Anonymous says:

      When is an application submitted?

      Received?

      By agent?

      Wrong Department of the Insurance Company?

      Reply
    3. Anonymous says:

      I’m transferring from Plan F to Plan G under the birthday rule to save premium. How come the Insurance Company called and asked about tobacco usage? It’s guaranteed issue isn’t it?

      Reply
      • My initial thought is that if you are currently on a Medi Gap plan and paying the Tobacco Rate, that the new plan would have the tobacco rate too. Just because you change would not eliminate that surcharge. Let me see if I can find a citation. That’s one reason I prefer email for complex questions. So I can get the CORRECT answer and not some off the cuff answer. Even “Quick Questions” generally don’t have simple or quick answers.

        CA Insurance Code 10192.11. (h) (1) … annual open enrollment period … During this open enrollment period, no issuer that falls under this provision shall deny or condition the issuance or effectiveness of Medicare supplement coverage, nor discriminate in the pricing of coverage, because of health status, claims experience, receipt of health care, or medical condition of the individual if, at the time of the open enrollment period, the individual is covered under another Medicare supplement policy or contract.

        So, is tobacco usage protected under health status?

        Resource Brokerage.com Central States Indemnity agent underwriting guide – CA requires Tobacco usage question even in Open Enrollment or Guaranteed Issue

        Alisprotect.com says tobacco rates don’t apply

        (24)(36) “Health status” means the determination bya carrier ofthe past, present, or expected risk of an individual or the employer due to the health conditions of THE INDIVIDUAL OR the employees of the employer.
        (24.5) (37) “Health-status-related factor” means any of the following factors:

        (a) Health status;
        (b) Medical condition, including both physical and mental illnesses;
        (c) Claims experience;
        (d) Receipt of health care; Ch. 217 Insurance 913
        (e) Medical history;
        (f) Genetic information;
        (g) Evidence of insurability, including conditions arising out of acts of domestic violence; and
        (h) Disability. Colorado.Gov

        One might also check with https://cahealthadvocates.org/ for their research, which isn’t answered on their website

        d. Tobacco Use – If a carrier reflects tobacco usage in the calculation of rates, then it shall do so according to the following requirements:

        (3) Any rate adjustment attributable to an individual (and all similarly situated individuals) based upon tobacco usage shall be applied to that individual (and all similarly situated individuals), and shall not be distributed to the entire group; and,

        h. Health status and claims experience may not be used as case characteristics. A health questionnaire, requesting reasonable information, may be used to obtain information about the health status of group enrollees. However, the health questionnaire may not be used in any way to determine the premium rate or any rating factor that is used in the determination of the premium rate that is charged to the group, except as provided in Subparagraph (d) of this paragraph. Colorado Secretary of State

        UHC Confidential Agent Manual 2017

        Members who have smoked tobacco cigarettes or used any tobacco product at any time within the past 12 months will pay the tobacco rate. Non-tobacco rates apply to all applicants who meet open enrollment or guaranteed issue requirements.

        Obamacare/ACA doesn’t allow health questions, but it does allow tobacco usage to be surcharged 50%. CA though doesn’t allow the surcharge. Our Website

        Reply
    4. Anonymous says:

      If I sign up for a Hi-F Medicare Supplement plan now, can I easily switch to a regular Plan F later?

      Reply
      • The birthday rule above allows you to change from one plan to another of the same or lesser value on your birthday. So, no, since plan F is greater than Hi F. (Summary of Benefits) (Background Q & A) Some companies like UHC – AARP may be more liberal. We can check when your actually ready to change.

        If you are healthy when you want to make a change, you can do that anytime. Click here for typical underwriting questions.

        Reply
  7. Humana was my supplementary insurance [Medi Gap]

    I have Medicare part A and B- I received a letter from Humana last week stating that are no longer providing the plan I had with them. I’m in Iowa.

    I still have my drug coverage with them however. I need to find a new supplemental insurance

  8. I lost employer coverage MAPD and was not informed of my right to purchase a Medi Gap plan. Would that be a material violation under item # 13 of the Blue Shield listing?

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