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Is Medicare Different in Each State

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 rules.

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 for a birthday rule, which is a timeframe for you to change your Medigap plan around your birthday every year. Also, you can change plans without underwriting as long as the policy benefits are equal to or less than those on your current plan. Birthday rules vary by state.

The anniversary rule allows you to change plans within 60 days of your Initial Enrollment anniversary in a Medigap policy.

State Specific Medicare Open Enrollments

Here are some states with specific rules:

  • California – Medigap in California allows for a birthday rule. The California birthday rule allows you to change policies within a 90-day window. The birthday rule begins 30 days before your birthday and ends 60 days after.
  • Oregon – The Oregon birthday rule begins on your birthday and ends 30 days after.
  • Idaho – Medigap plans in Idaho will include a birthday rule of 63 days, beginning on the beneficiary’s date of birth. It allows beneficiaries to switch to a policy with another carrier.
  • Illinois – Illinois will allow for a birthday rule, beginning on the beneficiary’s date of birth like Idaho’s, but only lasting 45 days. In this state, you are only allowed to switch to a plan with the same carrier as your original plan.
  • Nevada – Like the previous two states, 2022 will bring in Nevada’s new birthday rule. It offers an opportunity to switch policies using the same carrier. Nevada’s birthday rule window lasts at least 60 days, beginning the first day of the beneficiary’s birthday month.
  • New York – New York State provides a year-round open enrollment period for Medigap beneficiaries. If you have a Medicare Supplement plan in New York, you can change to another policy of your choice at any time.
  • Connecticut – Connecticut is another state with open enrollment year-round, 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, certain carriers allow beneficiaries to 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.
  • 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:

State Specific Rules 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:

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:

Which States Offer Medigap Plans to Those Under 65 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:

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!

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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 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.

9 thoughts on “Is Medicare Different in Each State

  1. I’m an insurance agent and I was researching what different guarantee issue rules apply in different states. I am licensed in 17 states and was specifically looking at New Jersey. I found this to be a terrific resource. For some reason, I thought Massachusettes also had some guarantee provisions. California birthday rule allows someone on an existing Medicare supplement plan to apply within 60 days following their birthday. One carrier allows them to apply 30 days prior and make an effective date the 1st of the month in which they have a birthday. One carrier allows submission on the 1st of the month for that effective date. All other carriers that I know of won’t make the new policy effective until after their birthday, but there’s a 60-day window following the birthday.

    1. Hi Paul! That’s great information, thank you for sharing! So happy you found the article to be a good resource for you.

  2. In Florida, if I am 65, and covered under an employer-retiree GROUP Medicare Advantage Plan PPO. Can I choose to opt-out and still have guarantee issue rights to enroll in Medigap Plan G and a PDP? If yes, would I have to opt-out during my former employers annual open enrollment period?
    Also, is there somewhere I can find this in writing? I have been searching for days.
    Thank you!

  3. 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.

    1. 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.

  4. 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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