As a Medicare beneficiary, do you ever wonder if Medicare is the same in every state? If Medicare is a federal program, surely it must be equal across the board, in all 50 states, right?
The truth is that each state has specific rules in place regarding coverage options. Even though Medicare is a Federal program, each state has different terms for Open Enrollment, Guaranteed Issue Rights, excess charges, and other rules.
Being completely aware of these rules can help you better understand how Medicare works, especially if you end up moving.
State Specific Medicare Open Enrollments
For example, Susan lives with COPD, Guarantee Issue rights allow her to get coverage without fear of denial!
Some states allow the “Birthday Rule,” which allows a 30-day timeframe for you to change your Medigap plan directly after your birthday every year. Also, you can change plans without underwriting as long as the policy benefits are equal or less than your current coverage.
The “anniversary rule” authorizes 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, instead of the typical 30-day timeframe. The birthday rule begins 30 days before your birthday and ends 30 days after your birthday.
- 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. However, 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.
Additionally, you may need Medicare documents for Guarantee Issue rights. However, documents might not be necessary for 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 throughout the year.
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:
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:
If the Employer-Sponsored Plan’s Benefits are Reduced Substantially
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 your primary insurance Medicare.
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 or any Medigap until you turn 65.
Federal law doesn’t require carriers to sell Medigap to people under 65. However, some states require companies to sell Medigap, even if under 65.
These states DON’T require Medigap options to those under 65:
- New Jersey
- New York
- North Carolina
- South Dakota
- New Hampshire
Medicare is different in each state, familiarizing yourself with Medicare rules can save you both time and money. However, you don’t have to do it by yourself.
Here at MedicareFAQ, we have an entire group that helps with educating you about the complexities of Medicare. Let us do the legwork and help find you the best options in your state.
If you’re a teacher in Connecticut, you can find out what you need to know about the TRB health plan changes.
Do you need more information on guidelines in your state? Contact MedicareFAQ today at the number above. Our team of experts can help you find the right coverage!
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