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Is Medicare Different in Each State


Even though Medicare is a federal program, states can implement various rules if they meet the basic Medicare regulations. Most states across the country have implemented rules to ease the requirements for seniors to make changes to their Medigap plans. Below, we will highlight unique Medicare rules and their applicable states.

What Makes Medicare Different State-to-State?

State-specific rules allow Medicare to differ in each state. These rules include annual birthday rules, guaranteed issue rights, disability plan requirements, excess charges, and more.

Established by state governments, these regulations give more options to seniors when it comes to Medicare Supplement policies outside of initial enrollment.

State Specific Medicare Open Enrollments

Guaranteed Issue Rights and Open Enrollment Periods

Guaranteed issue rights are protections for Medicare enrollees in certain situations. These rights prevent insurance companies from denying enrollment in certain Medigap policies when beneficiaries meet specific criteria.

To utilize guaranteed issue rights, beneficiaries must abide by MACRA when selecting their plan. At this time, only those who enrolled in Part A before January 1, 2020, can be guaranteed issue to Plan F or Plan C.

Like guaranteed issue rights, Open Enrollment Periods allow beneficiaries to enroll in a Medigap plan with no underwriting health questions. Those who receive Medicare after January 1, 2020, must abide by MACRA when in an open enrollment period. Thus, individuals who enrolled in Medicare prior to January 1, 2020, may enroll in any Medigap plan they wish.

State-Specific Medigap Rules

The following states offer residents annual rules that allow policyholders to change their Medigap plans with no health underwriting questions.

Birthday Rule

California – The California birthday rule allows beneficiaries to change Medigap plans during a 91-day open enrollment window.

Idaho – The Idaho birthday rule is a 63-day guaranteed issue period beginning on the beneficiary’s birthday.

Illinois – The Illinois birthday rule extends an open enrollment period to Medigap policyholders in a specific age range during a 45-day window.

Nevada – The Nevada birthday rule is a 61-day open enrollment period for Medigap beneficiaries residing in the state.

Oregon –The Oregon birthday rule offers policyholders a 31-day open enrollment period.

No Health Underwriting Year-Round

Connecticut

New York

*Vermont – Mutual of Omaha and UnitedHealthcare only

Washington

Annual Guaranteed Issue

Missouri – Policyholders may change from like-to-like benefits during a 62-day period beginning 30 days before the annual policy anniversary and ending 30 days after.

Maine – Open Enrollment only in the month of June

State Specific Medigap Plans

Medigap plans are standardized nationwide. However, three states offer distinct types of Medigap plans. These states are Wisconsin, Massachusetts, and Minnesota. Rather than the traditional letter plans, these unique states provide more variety in coverage.

Wisconsin offers three customizable Medigap plans. The three plans available in Wisconsin are:

  • Basic Plan
  • 25% Cost-Sharing Plan
  • 50% Cost-Sharing Plan

In addition to these plans, the state also offers riders to provide policyholders with extra individualized coverage as well as the High Deductible F plan.

Massachusetts offers three Medigap Plans. These plans are:

  • Core Plan
  • Supplement 1
  • Supplement 1A

These plans offer the basic Medicare benefits and additional coverage, with Supplement 1 being the most comprehensive.

Minnesota offers two unique plans to beneficiaries. These plans include:

  • Basic Plan
  • Extended Basic Plan

Both plans provide basic Medicare benefits, foreign travel, and additional benefits to policyholders. The plans are similar. However, the Extended plan offers more benefits.

States That Do Not Allow Medicare Excess Charges

When enrolling in a Medigap plan, you will notice that some plans cover excess charges and others do not. This can make or break a plan for some beneficiaries. In these states, policyholders will not need to worry about excess charges as they are not permitted.

Connecticut

Massachusetts

Minnesota

New York

Pennsylvania

Ohio

Rhode Island

Vermont

State-Specific Employer Coverage Rules

When combining employer coverage and Medicare, each state has different rules regarding who pays first and how you can utilize the coverage.

Voluntary Group Termination

Voluntary group termination means you choose to drop your group insurance plan. Sometimes, people pay more for their group coverage than for Medicare. If this is your current situation, group termination may benefit your wallet.

Generally, choosing to leave your health care coverage will not land you in a guaranteed issue situation. However, your location may provide an exception to this rule. You CAN use guaranteed issue rights to change from employer coverage to Medigap coverage in the following states.

Alaska

Arkansas

California

Colorado

Florida

Idaho

Illinois

Indiana

Iowa

Kansas

Louisiana

Maine

Missouri

Montana

Nevada

New Jersey

New Mexico

Ohio

Oklahoma

Pennsylvania

South Dakota

Texas

Virginia

West Virginia

Wisconsin

Medigap Plans for Those Under 65 on Disability

If you have Medicare coverage before turning 65 due to a disability, ESRD, or ALS, you may not be able to enroll in a Medigap policy until you turn 65.

Federal law does not require carriers to sell Medigap to people under 65. Still, some states require companies to sell Medigap, even if the beneficiary hasn’t had their 65th birthday yet. Those living in states that don’t require carriers to provide a Medigap plan option to those under 65 may still have some options. The following states DO NOT require Medigap options for those under 65:

Alabama

Alaska

Arizona

Arkansas

Idaho

Indiana

Iowa

Nebraska

Nevada

New Mexico

North Dakota

Ohio

Rhode Island

South Carolina

Utah

Virginia

Washington

West Virginia

Wyoming

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, so familiarizing yourself with the rules can save you a headache.

Remember, Medigap costs vary from state to state as well. Our agents can teach you everything you need to know and help you find the best options in your state. Can't call? Just fill out the online rate form and discover your rates now!

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Jagger Esch

Jagger Esch is the Medicare expert for MedicareFAQ and the founder, president, and CEO of Elite Insurance Partners and MedicareFAQ.com. Since the inception of his first company in 2012, he has been dedicated to helping those eligible for Medicare by providing them with resources to educate themselves on all their Medicare options. He is featured in many publications as well as writes regularly for other expert columns regarding Medicare.

13 thoughts on “Is Medicare Different in Each State

  1. 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.

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