Eligibility And Enrollment For Supplement Plans (Medigap)

Medicare health plans

Medigap policies supplement your original Medicare coverage, so in order to purchase one, you must be enrolled in Medicare Part A and Part B. As a supplemental plan only covers one person, you and your spouse must each buy separate policies. There are several ways to be eligible for a Medigap policy:

Eligibility When You Turn 65 (Initial Enrollment)

Adding supplemental insurance to your Medicare is easiest within six months of your initial enrollment in Part B of Medicare. During this time, the insurance provider cannot refuse to sell you a policy, you do not have to go through ‘underwriting, and the insurer cannot charge you more for any pre-existing conditions.

Pre-existing Conditions

If you have pre-existing conditions, but had a prior insurance that provided for at least six months ‘creditable coverage’ (= at least as good as Medicare), you may be able to avoid or at least shorten any waiting periods you will otherwise have.

Most insurers have a 6 months “pre-existing condition waiting period”, before expenses related to a condition are covered, that has been diagnosed or treated within the past six months before the start of coverage. Good news is, Medicare will still pay for these costs to the extend they are included in the Medicare covered services. However, for as long as your Medigap plan does not pay, you are the one responsible for any co-payments or coinsurance.

Medigap Eligibility Of Disabled Persons

When you have Medicare and are under the age of 65, typically because you are disabled or have End Stage Renal Disease, you may not be able to enroll in a Medigap plan of your choice, or even any supplement plan, until you turn 65. Federal law does not require insurance providers to sell these policies to persons on Medicare under 65 years of age. However, 29 states currently do. Click here to check in which states insurers are required to sell Medigap policies to persons under 65, and more information about eligibility for persons on Medicare under the age of 65.

Medigap For Persons On Medicaid

If you receive Medicaid, you do not need and are not allowed to have coverage by a supplement plan.

Medigap And Medicare Advantage Plans

You cannot have Medigap and an advantage plan at the same time. This means the coverage for your advantage plan must end before the Medigap plan goes into effect. If you forget to cancel your advantage plan after you enroll in Medigap, you will have to pay both premiums, but your supplemental plan provider won’t pay any deductibles, co-payments, or coinsurance as long as you are covered under the advantage plan.

Eligibility Outside Of The ‘Initial Enrollment Period’

If you apply for Medigap coverage after you first became eligible for Medicare, an insurance company does not have to sell you a policy if you don’t meet their medical underwriting requirements, unless you meet the following situation:

You have a ‘guaranteed issue right’ – this means the insurer needs to sell you a policy. This protection applies when you are eligible (you have Part A and B) and your current health care coverage changes in some way. This may for example be the case when you lose the other health care coverage, e.g. because the Medicare advantage or SELECT plan you had, stopped serving your area, or you moved away.

If an insurance company denies you Medigap coverage, you may contact your State Health Insurance Assistance Program (SHIP) or your State Insurance Department. You can find contact information for your state here.

By: Joseph Rosario

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