Medicare is a federal health insurance program available in all 50 states and the U.S. territories.
Whether you’re enrolling because you have:
- turned 65
- under 65 and disabled
- have end-stage renal disease (ESRD)
- amyotrophic lateral sclerosis (ALS)
Knowing the rules and guidelines for what coverage is available to you and what type of Medicare plans are offered in your state is key to getting the best care you can.
Although Medicare is a federal program, some states have different rules when it comes to Guaranteed Issue, Open Enrollment, excess charges and disability.
It’s important to understand how these rules can affect you and your Medicare coverage. You should re-examine these rules if you relocate to another state or a U.S. territory, as your coverage options may change in your new location.
State Specific Medicare Rules
Year Around Guaranteed Issue, Birthday & Anniversary Rules
- In New York and Connecticut, plans for Medigap are guaranteed issue year-round.
- The birthday rule – a 30-day window allowing Medigap enrollees to switch plans following their birthday each year – is in place in California and Oregon. This rule allows for change without underwriting to a plan with the same or lesser benefits.
- Maine allows Medigap enrollees to switch at any time of the year.
- Missouri’s Anniversary Guaranteed Issue Period lets anyone with a Medigap plan to switch within a 60-day window of their enrollment anniversary in a Medigap plan.
- Washington allows enrollees to switch from any Medigap to any other Medigap except Plan A at any time of the year.
Some insurers have specific rules for the Medigap Guaranteed Issue coverage
For example, Aetna Companies, Bankers Fidelity, Gerber, GPM, Manhattan Life and Mutual of Omaha have no pre-existing waiting period. Check with your carrier of choice to find out what their guidelines are for Medigap coverage.
State Specific Medicare Rules for Excess Charges
Medicare Part B Excess Charges refers to the amount a doctor who does not accept Medicare assignments is allowed to charge over and above what Medicare designates a treatment should cost. Part B coverage is for doctor’s office visits and procedures.
Doctors are limited to charging 15% above what any particular procedure costs according to Medicare guidelines.
A Medigap plan can shield you from excess charges, as long as the plan you choose includes that coverage. Ask your Medigap provider about which plan would work best for you.
There are a variety of plans to choose from, and getting help navigating the choices is the best way to ensure that you are properly covered for fees, copays and other expenses that is not paid for by Medicare Parts A & B.
States that do not allow excess charges by care providers:
State Specific Medicare Rules for Disability
If you are enrolled in Medicare because of disability, end-stage renal disease, or amyotrophic lateral sclerosis and you are under the age of 65, your eligibility for Medicare Supplement coverage is dependent on the state where you live. Not all states offer Medigap coverage plans for those under 65.
There are some insurance companies that will sell Medigap plans to those under 65, despite the fact that it is not required by the government.
However, these companies can deny you coverage – or charge you more – for a preexisting condition, so make sure you understand your rights based on the state where you live.
If you are covered by Medicaid in addition to Medicare, your supplemental coverage for your disability most likely won’t work with your Medicaid coverage.
Be sure to look into a Medicare Part D Prescription Drug plan, because your Medigap plan will not pay for medication.
The states that do not offer Medigap plans for disabled Medicare recipients under the age of 65 are:
- New Mexico
- North Dakota
- Rhode Island
- South Carolina
- West Virginia
If you’re a teacher in Connecticut, find out what you need to know about the TRB health plan changes here.
Finding the right coverage available in your state and understanding the limitations and options for Medigap coverage, whether you are 65 and older or disabled, will make managing your health care much simpler and less costly. Give us a call, or complete our rate comparison form here.