When Can You Get a Medigap Plan With No Health Questions?

Guaranteed Issue 

• California has several situations where you may be able to buy or change a Medicare Supplement / Medigap plan without medical underwriting. The two most common questions I get are:
  • “Can I use the California Birthday Rule?” and
  • “What happens if my Medi-Cal changes?”
• What to email me [email protected] :
  • your date of birth,
  • Medicare Part A and Part B effective dates,
  • current plan name,
  • Zip Code & county, and
  • any notice you received from Medi-Cal, Medicare Advantage, or your insurance company.

New to Medicare Part B —

Medigap Open Enrollment

Generally, this is the easiest time to buy a Medicare Supplement plan without medical underwriting.

You may qualify if:

• You are age 65 or older and newly enrolled in Medicare Part B; or
• You are under age 65, qualify for Medicare because of disability, and are newly enrolled in Medicare Part B.

When to apply

• Age 65 or older: California law provides a six-month Medigap open enrollment period beginning with the first month in which you are both age 65 or older and enrolled in Medicare Part B.
• Under age 65 due to disability: California provides a six-month open enrollment period after enrollment in Medicare Part B. If Medicare eligibility is determined retroactively, the six-month period can begin after notice of eligibility.

What guaranteed acceptance means

• The insurance company generally cannot deny your application because of your health.
• The company cannot charge you more because of your health status, claims history, or medical condition during the applicable open enrollment period.
• The exact Medigap plans available can depend on your age, when you first became eligible for Medicare, and the plans offered by that insurance company.

Information you may need

• Medicare Part A and Part B effective dates.
• Your Medicare Beneficiary Identifier (MBI).
• If under age 65, information about your current insurance coverage may also be requested.

Sources:

• California Insurance Code §10192.11 •
• Medicare.gov — Medigap Open Enrollment •
• Blue Shield Guaranteed Acceptance Guide — MSP17149_1025

California Medigap Birthday Rule

You may qualify if:

• You already have a Medicare Supplement / Medigap policy; and
• You want to change to another Medigap policy with benefits equal to or less than the benefits in your current plan.

When to apply

• California law provides an annual open enrollment period lasting at least 60 days beginning on your birthday.
• Some insurance companies may allow you to submit the application before the protected Birthday Rule period begins.

What this means

• You may change insurance companies without medical underwriting if the replacement plan has equal or lesser benefits.
• The company cannot deny the application or charge you more because of your health during the protected period.
• Extra or innovative benefits such as dental or vision benefits generally are not used to decide whether one standardized Medigap plan has greater benefits than another.

What you may need

• Proof of your current Medicare Supplement plan.
• Your current Medigap ID card or other coverage documentation.
• Your date of birth and requested effective date.

Sources:

• California Insurance Code §10192.11(h) •
• California Health Advocates — California Birthday Rule •
• Blue Shield carrier example — MSP17149_1025

Employer or Retiree Health Coverage Is Ending

See also my web page — Medicare & Employer Coverage.

You may qualify if:

• You are enrolled in Medicare Part B and employer-sponsored health coverage is ending.
• This can include employer-sponsored retiree health coverage.
• It can include loss of eligibility because of divorce or death of a spouse.
• California law’s definition of employer-sponsored retiree health coverage also includes COBRA and Cal-COBRA coverage.

When to apply

• California provides a six-month Medigap open enrollment period following the applicable notice of termination or loss of eligibility — or the effective date if no notice was received.

Documentation

• Keep the employer, retiree plan, COBRA, or Cal-COBRA termination notice.
• If coverage is ending because of divorce or death, keep the notice showing the loss of eligibility and effective date.
• The exact documentation requested can vary by Medigap insurance company.
• COBRA and Medicare can be complicated.
  • See my web page — COBRA and Cal-COBRA.

Sources:

• California Insurance Code §10192.11(e) •
• California Health Advocates — California Medigap Rights •
• Blue Shield carrier example — MSP17149_1025

Medi-Cal Ends or Changes to a Share of Cost

See also my web page — Medi-Cal Share of Cost.

You may qualify if:

• You are enrolled in Medicare Part B; and
• Because of an increase in income or assets, you are notified that you are no longer eligible for Medi-Cal; or
• You become eligible for Medi-Cal only with a Share of Cost.

Important Share of Cost rule

• If you have a Medi-Cal Share of Cost, California law requires you to certify when applying that you have not met the Share of Cost.

When to apply

• California provides a special Medigap open enrollment right when Medi-Cal eligibility is lost or a Share of Cost is imposed because of an increase in income or assets.
• California Health Advocates states that there is a six-month period when a Share of Cost is first imposed or changes.
• Do not wait. Have the insurance company verify the applicable deadline using your actual Medi-Cal Notice of Action.

Documentation

• Keep the Medi-Cal Notice of Action showing the reason for the change.
• Keep the notice date, effective date, and Share of Cost amount.
• Do not discard the notice after the Medi-Cal change takes effect.

Sources:

• California Insurance Code §10192.11(i) •
• California Health Advocates — Medigap & Medi-Cal •
• Blue Shield carrier example — MSP17149_1025

Medicare Advantage Plan Ends, Leaves Your Area, or You Move

You may qualify if:

• Your Medicare Advantage plan terminates or stops offering coverage where you live; or
• You become ineligible for the plan because you move outside its service area; or
• Another qualifying involuntary termination applies.

When to apply

• The normal federal guaranteed-issue period generally begins before or when the Medicare Advantage coverage ends.
• California adds an additional 60-day open enrollment period after the federal period for people whose Medicare Advantage coverage is terminated. This can extend the protected period to 123 days after the MA coverage ends.

Documentation

• Keep the Medicare Advantage termination or service-area notice.
• Keep documentation showing your coverage termination date.
• If you moved, keep the notice showing that the new residence is outside the plan’s service area.

Sources:

• California Insurance Code §10192.11(g) •
  •  §10192.12 •
• California Health Advocates — Other California Medigap Rights •
• Blue Shield carrier example — MSP17149_1025
•  insure me kevin.com/how-to-switch-from-medicare-advantage-to-a-medicare-supplement-plan  

You Tried Medicare Advantage, but didn’t like it

You May Have a Medigap Trial Right

Trial Right #1 — Medicare Advantage when first eligible for Medicare

• You joined a Medicare Advantage plan or PACE when first eligible for Medicare at age 65.
• You decide within the first 12 months that you want to return to Original Medicare.
• You may have a guaranteed right to buy a Medicare Supplement policy.

Trial Right #2 — You dropped Medigap to try Medicare Advantage

• You had a Medigap policy and dropped it to join Medicare Advantage for the first time.
• You decide within the first 12 months that you want to return to Original Medicare.
• You generally have a right to return to your former Medigap policy if it is still available from that company.
• If your former policy is no longer available, other guaranteed-issue Medigap choices may be available.

Documentation

• Keep proof of your former Medigap coverage.
• Keep the Medicare Advantage effective date and disenrollment documentation.

Sources:

• Medicare.gov — Medigap Trial Rights •
• California Insurance Code §10192.12 •
  • 42 CFR § 422.62(c) establishes the age-65 trial enrollment period. 
• Blue Shield carrier example — MSP17149_1025
• Part D SEP 42 CFR § 423.38(c)(5).- It grants a Part D Special Enrollment Period to someone leaving an MA-PD plan and returning to Original Medicare under § 422.62(c).  

Medicare Advantage Benefits, Premiums, Copays, or Treating Provider Change

California provides additional Medigap protections in certain situations, including:

• A Medicare Advantage plan reduces benefits.
• A Medicare Advantage plan increases premium or cost-sharing.
• A Medicare Advantage plan ends its relationship with a provider who is currently furnishing services to you, for reasons other than quality of care.

Important — this rule has additional conditions

• Your Medigap rights can depend on whether the Medicare Advantage company, its parent company, subsidiary, or affiliated network offers a Medicare Supplement plan.
• Where no affiliated Medigap is available, California law provides additional rights for specified premium or copay increases, benefit reductions, and termination of a treating provider.
• Enrollment with an unrelated Medigap company is generally limited to the Medicare Annual Election Period, October 15th to December 7th, except for the specified treating-provider situation.

Do not cancel your Medicare Advantage plan based only on this summary. Have the specific Annual Notice of Change, premium notice, or provider termination notice reviewed first.

Documentation

• Annual Notice of Change.
• Premium or copayment increase notice.
• Benefit reduction notice.
• Notice showing termination of a provider currently treating you.

Sources:

• California Insurance Code §10192.12(b)(2)(D) •
• California Health Advocates — Guaranteed Issue •
• Blue Shield carrier example — MSP17149_1025

Other Medigap Guaranteed-Issue Situations

Federal and California law provide additional guaranteed-issue rights that are less common.

• Your Medicare Supplement insurer becomes insolvent or your Medigap coverage is otherwise involuntarily terminated.
• Your Medigap company substantially violates an important provision of the policy.
• The company or its representative materially misrepresented the Medigap policy when it was sold.
• Certain Medicare Cost, PACE, Medicare SELECT, or other Medicare health-plan coverage terminates.
• Certain employer plans stop providing benefits that supplement Medicare.
• Certain other exceptional circumstances recognized under Medicare law may apply.

If your coverage is ending unexpectedly, keep every termination letter and notice. A document that looks unimportant may establish the date and reason needed to prove guaranteed-issue eligibility.

Sources:

• California Insurance Code §10192.12 •
• California Health Advocates — Guaranteed Issue •
• Choosing a Medigap Policy — CMS Product #02110

What If I Don’t Have a Guaranteed-Acceptance Right?

• You can still apply for a Medicare Supplement plan.
• Outside an open enrollment or guaranteed-issue period, an insurance company may require medical underwriting.
• Different insurance companies may have different health questions and underwriting requirements.
  • Email us, [email protected] for a sample application
• One company may accept an applicant another company will not.
• Before answering health questions, first check whether one of the California or federal protections above applies.

If you qualify for a guaranteed-issue or protected open enrollment period, your health generally cannot be used to deny the Medigap coverage protected by that rule.

Email Steve — Do I qualify for guaranteed acceptance?

Sources:

• Medicare.gov — Applying for Medigap •
• California Health Advocates — Your Rights to Buy a Medigap Policy
• Nearly Three-Quarters of Medicare Advantage Enrollees Could be Denied a Medigap Policy Due to a Pre-Existing Condition  Kff.org 

Insurance Company Guaranteed-Acceptance Guidelines

The California and federal rules above apply broadly, but each insurance company has its own application, documentation procedures, plan availability, and underwriting instructions.

• Blue Shield of California — Guaranteed Acceptance Guide MSP17149_1025 — I use this guide frequently because it is relatively easy to review by situation.
• Anthem Blue Cross — email Steve for current guaranteed-acceptance guidelines.
• AARP / UnitedHealthcare — email Steve for the current company guidelines.

Important: A company’s underwriting guide does not replace California or federal law. It shows how that company currently handles applications and documentation for the applicable rules.