To be eligible to enroll in a Medigap insurance plan, a patient must be enrolled in both Medicare Part A and Part B, and reside in the plan’s service area.
The best time to enroll in a Medigap insurance plan is usually during a patient's "Medigap Open Enrollment Period," which begins on the first day of the month they enrolled in Medicare Part B and are aged 65 or older. This enrollment period lasts for six months. During this time, they have guaranteed issue right to enroll in any Medigap plan that’s available in their county, regardless of their health status. Outside of this enrollment period, they may be subject to medical underwriting, where they can be denied coverage or charged a higher monthly premium due to pre-existing health issues. In addition, most states have no yearly enrollment period for Medigap coverage like with Part D.
Medigap Guaranteed Issue Qualifying Events
There are special situations where a patient can enroll in a Medigap policy outside their Open Enrollment Period and plans are required by law to accept their enrollment. In these cases, plans are also not allowed to charge a higher monthly premium due to the patient's health history.
Patients in all states and US territories have a guaranteed issue right (an insurance company can’t refuse to sell the patient a Medigap policy or charge a higher premium) in these situations:
•They joined a Medicare Advantage Plan or Programs of All-inclusive Care for the Elderly (PACE) when they were first eligible for Medicare Part A at 65, and within the first year of joining, they decide they want to switch to Original Medicare. (Trial Right)
• They dropped a Medigap policy to join a Medicare Advantage Plan for the first time, they've been in the plan less than a year, and want to switch back. (Trial Right)
•They have Original Medicare and an employer group health plan (including retiree or COBRA coverage) or union coverage that pays after Medicare pays and that plan is ending.
• They're in a Medicare Advantage Plan, and their plan is leaving Medicare or stops giving care in their area, or they move out of the plan's service area.
• They have Original Medicare and a Medicare SELECT policy. They move out of the Medicare SELECT policy's service area.
• Their Medigap insurance company goes bankrupt and they lose their coverage, or their Medigap policy coverage otherwise ends through no fault of their own.
• They leave a Medicare Advantage Plan or drop a Medigap policy because the company hasn't followed the rules, or it misled them.
In most of these situations, the patient would need to apply for a Medigap policy no later than 63 calendar days after their coverage ends to be eligible for guaranteed issue rights.
More detailed information regarding these qualifying events can be found here.
Tip: For patients who currently have a Medicare Advantage plan and want to switch back to Original Medicare with a Medigap policy, it is best to apply for a Medigap policy before their coverage ends. The Medigap insurer can sell it in this situation as long as the patient is leaving the plan. They should ask that the new policy take effect no later than when their Medicare Advantage enrollment ends so there will be no gaps in coverage.
State-Specific Guaranteed Issue Rights
Three states (Connecticut, Massachusetts, and New York) have continuous guaranteed issue protections for Medigap for all patients in traditional Medicare ages 65 and older, regardless of medical history.
California and Oregon have “birthday rules” that allow patients already on a Medigap policy a 30-day window following their birthday each year when they can switch, without medical underwriting, to another Medigap plan with the same or lesser benefits.
Similarly, Missouri has an "anniversary rule" for patients who already have Medigap policies. Patients have a 60-day window every year (30 days before until 30 days after the anniversary of their Medigap policy issue date) to switch to a different Medigap plan of the same "type." For example, if a patient has Medigap Plan N through one company, they can switch to a different Plan N through a different company.
In Illinois, Blue Cross Blue Shield of Illinois and Health Alliance provide ongoing guaranteed issue rights for all beneficiaries ages 65 or older.
In Maine, Medigap insurers must offer guaranteed-issue protection, at least for Plan A (a type of Medigap plan), during one month of their choosing each year.