Even though Medicare is a Federal program, some states have different terms for Open Enrollment, Guaranteed Issue Rights, excess charges, disability, etc. Below, we’ll highlight what states have their own unique guidelines.
State Specific Medicare Open Enrollments
Guaranteed Issue rights are in place to ensure you can obtain a Medigap policy. Companies must offer you an option, even if you have pre-existing health conditions. For example, Susan lives with COPD, Guarantee Issue rights allow her to get a policy without fear of denial!
Some states allow the “Birthday Rule,” which allows a 30-day timeframe for you to change your Medigap plan after your birthday every year. Also, you can change plans without underwriting as long as the policy benefits are equal to or less than your current plan.
The “anniversary rule” allows you to change plans within 60 days of your Initial Enrollment anniversary in a Medigap policy.
Here are some states with specific rules:
- California – California Medigap rules abide by the birthday rule. The birthday rule in California allows you to change policies within a 60-day window. The birthday rule begins 30 days before your birthday and ends 30 days after.
- Oregon – The birthday rule also applies to the state of Oregon.
- Connecticut – Connecticut is a guaranteed year-round state, permitting you to make changes to your policy throughout the year.
- Maine – Those in Maine have an extension on the standard Medicare Advantage “trial right.” In other states, you have only one year to switch to a supplement when you try an Advantage plan. But, in Maine, you can “try” the Advantage plan for three years, and you have 90 days after dropping the policy to switch to a supplement with Guaranteed Issue rights.
- Vermont – In Vermont, you can enroll in a Medigap plan without underwriting throughout the year.
Also, you may need Medicare documents for Guarantee Issue rights. However, documents might not be necessary for Medigap Open Enrollment Period rights.
Guaranteed Issue States for Medicare Supplements
There are several differences between Open Enrollment vs. Guarantee Issue rights; mostly, during Open Enrollment, you have more plan options.
These States Offer Guaranteed Issue rights ANNUALLY:
- Missouri – If you have a Medigap policy, you can switch plans within 60 days of your enrollment anniversary.
- New York – You can enroll in a Medigap policy without underwriting throughout the year.
- Washington – Allows Medigap enrollees to change Medigap plans (except for Plan A) at any point.
What States Do Not Allow Medicare Excess Charges
If you’re looking at purchasing a Medigap policy, you may find that some of the plans cover excess charges. When a doctor doesn’t accept Medicare, excess charges may occur; doctors can only charge 15% above the threshold.
States that DON’T ALLOW excess charges:
- Connecticut
- Pennsylvania
- Massachusetts
- Rhode Island
- Minnesota
- Vermont
- New York
- Ohio
State Specific Guidelines for Voluntary Group Termination
Voluntary group termination means you decide to end your group insurance plan. Sometimes, people pay more for their group insurance than they would pay for Medicare. If this is your current situation, group termination may be beneficial to your pocketbook.
Generally, choosing to leave your healthcare coverage will not land you in a Guaranteed Issue situation. However, there may be exceptions to the rule.
If the Employer-Sponsored Plan is Primary to Medicare
Many states within the U.S. have Guaranteed Issue rights for voluntary group termination. There are typically concrete terms in which you can take advantage of this process, however. If your employer’s health care policy is the primary form of insurance, and Medicare is secondary.
Below are the states in which the employer plan IS PRIMARY:
- Alaska
- Maine
- Colorado
- Montana
- Idaho
- Nevada
- Illinois
- New Jersey
- Indiana
- Ohio
- Iowa
- Pennsylvania
- Kansas
In the following states, you CAN use Guaranteed Issue rights to change from employer to Medigap coverage:
This change may only take effect when your employer’s policy reduces health benefits.
In the state of Wisconsin, if the annual premium of your employer plan is over 125% of the Basic Annual Premium for your gender and age, then you may qualify for Guaranteed Issue.
No Conditions – You may decide to cancel your group health insurance and make Medicare primary.
Also, many states allow you to make this switch without any conditions or stipulations.
The states listed below have NO REQUIREMENTS for switching primary insurers:
States that Offer Under 65 Plans for those on Disability
You may have Medicare coverage before turning 65 due to a disability or ESRD. If you have Medicare because of a disability or ESRD, you may not be able to buy the policy you’d like until you turn 65.
Federal law doesn’t require carriers to sell Medigap to people under 65. Still, some states require companies to sell Medigap, even if under 65. States that don’t require under 65 Medigap plans, may still have some options.
These states DON’T require Medigap options for those under 65:
- Arkansas
- Kentucky
- New Jersey
- California
- Louisiana
- New York
- Colorado
- Maine
- North Carolina
- Connecticut
- Maryland
- Oklahoma
- Delaware
- Massachusetts
- Oregon
- Florida
- Michigan
- Pennsylvania
- Georgia
- Minnesota
- South Dakota
- Hawaii
- Mississippi
- Tennessee
- Illinois
- Missouri
- Texas
- Idaho
- Montana
- Vermont
- Kansas
- New Hampshire
- Wisconsin
If you live in one of these states, you’ll want to understand the Medicare Advantage enrollment periods. Some coverage is better than none.
How to Get Help with Medicare State Specific Rules
If you’re moving or considering dual residency, it’s beneficial to understand the rights you’ll have in your new state. Medicare is different in each state, familiarizing yourself with the rules can save you both time and money. Also, some states are more expensive for Medigap than others. Our agents teach you everything you need to know. Let us help find you the best options in your state. If you miss your Medigap enrollment periods, a Medicare Advantage enrollment period may be an option for you. Can’t call us right now? Just fill out the online rate comparison form and discover your rates now!
I switched to Anthem Medigap because prescription coverage was free and the plan offered extra coverage at no additional cost. Well nothing is free friends, what they did not tell me was that they have a separate company that acts as a go-between, that is between me and my doctor that must preapprove of all procedures that my doctor recommended. About 1/2 of my procedures were denied and I had to pay for them myself or just skip them. I have been skipping them.
Hi Warren! It sounds like you got mixed information from whoever you purchased the plan through… a Medigap plan does not cover prescriptions drugs. To get prescription drug coverage, you would add Medicare Part D to your Medigap plan. Unfortunately, we’ve never heard of a separate company acting as a go-between. If you would like to enroll in a plan that fits your healthcare needs, give us a call.
Hi Warren, Sounds like you have a Medicare Advantage plan not Medigap..
Warren, it does not sound like you enrolled in a Medigap plan. There are no preapproval requirements or go betweens in a Medigap plan. If a service is a Medicare covered service, then the Medigap plan pays its share. Period! No if ands or buts. Now keep in mind, Medicare only covers medically necessary services. If Medicare pays, then Medigap pays. No Medigap plans sold after 2010 will cover prescription drugs. Some companies may offer you a discount card, but that is NOT a drug plan. And no Medigap plans offer additional coverage for non Medicare services. Medigap plans may offer added benefits, such as Silver Sneakers, but these added benefits can not be insurance benefits.
Great response Peter! You’re 100% correct!