Guaranteed Issue

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back to Your Rights to Buy a Medigap Policy

During guaranteed-issue periods, companies must sell you one of the required Medigap policies at the best price for your age, without a waiting period or health screening. Guaranteed-issue periods are generally shorter than open enrollment periods and do not include as many choices.

You can usually apply for a guaranteed-issued Medigap policy as early as 60 days before your current benefits end to avoid a gap in coverage. In most cases, you must also apply for one of these plans no later than 63 days after your coverage ends as a result of one of the events described below. When you submit your application, you are typically required to provide evidence of the date your coverage ends or ended.

You have the right to purchase certain Medigap plans following the 7 events listed below, which apply to Medicare beneficiaries of all ages. For most of the events, you are only guaranteed the right to buy plans A, B, C, F (including F with a high deductible), K, L, M or N.

1. Termination of Employer-Sponsored Retiree Plan

You have the right to purchase certain Medigap plans when your employer-sponsored retiree plan (including COBRA coverage) that is supplementing Medicare involuntarily terminates. This federal right does not apply if the terminating health plan provided primary benefits or if you stopped paying your premium for the retiree plan or COBRA coverage. California law is broader and provides more protection for its residents in this situation.

2. Reduction of Employer-Sponsored Retiree Benefits or Loss of Eligibility

You have the right to purchase certain Medigap plans if your employer-sponsored retiree plan stops providing supplemental benefits to Medicare, but continues providing other benefits, you lose eligibility due to divorce or death of a spouse or family member, or your retiree plan stops paying the Medicare Part B 20% coinsurance for services.

3. Increased Premium, Increased Cost-Sharing, Reduction of Benefits or Termination of Provider in Your Medicare Advantage Plan

You have the right to buy a Medigap plan but only from the same Medicare Advantage (MA) organization in which you are enrolled, if it sells one, or from the parent company or network that contracts with the MA plan. If the MA plan you belong to doesn’t sell a Medigap policy, you still have the right to buy a Medigap from any other company IF your MA plan increased your premium or copayments by 15% or more, reduced your benefits, or terminated its relationship with your medical provider who was treating you.

You have 63 days to purchase one of the guaranteed issue Medigap policies from the time you are notified of any reduced benefits, increased premium or cost-sharing, or that your plan is no longer contracting with one of your medical providers. Yet you can only use this right during certain periods when you’re allowed to disenroll from your MA plan. (See our section on MA plan enrollment and disenrollment).

Since MA plans may not reduce their benefits or increase premiums or cost-sharing during the plan year, you will only be notified of any reduction in benefits or increase in premiums or cost-sharing for the new plan year during the Annual Election Period (AEP) which allows you to disenroll from your Medicare Advantage plan. The AEP is October 15 – December 7 each year.  If you disenroll during this period, the effective date of your disenrollment will be January 1 of the following year. See our Summary of Enrollment Periods for more information on when you can enroll into and disenroll from MA plans.

An MA plan may, however, discontinue its contract with a provider anytime during the year. This means, even though you may have a guaranteed issue right to buy a Medigap when a provider no longer has a contract with your MA plan, you may not have a corresponding right to disenroll from that MA plan.

4. Moving Out of Medicare Advantage (MA) Plan or PACE Organization Service Area

You have the right to purchase certain Medigap plans if you move out of the area of your Medicare Advantage (MA) plan or Program for All-Inclusive Care for the Elderly (PACE) organization. You have the right to buy a Medigap policy even when MA plans and PACE organizations are available in your new area.

5. Medicare Plan Fraud, Loss of Contract, Misrepresentation or Failure to Meet Contractual Obligations

You have the right to purchase certain Medigap plans if your Medicare Advantage (MA) plan, Medicare SELECT Plan, PACE provider or any other health plan under contract with Medicare:

  • Commits fraud
  • Ends or loses its contract with Medicare
  • Misrepresents the plan you bought
  • Has failed to meet its contractual obligations to Medicare beneficiaries, as determined by the federal government

6. Medicare Trial Period #1

You have the right to purchase certain Medigap plans during Medicare Trial Period #1: You joined a Medicare Advantage (MA) plan or Program for All-Inclusive Care for the Elderly (PACE) organization when you first became eligible for Medicare at age 65, and you want to switch to a Medigap policy during your first 12 months in the MA plan or PACE organization.

Note: If you were previously in an MA plan or PACE organization, you are not eligible for this guaranteed-issue right.

7. Medicare Trial Period #2

You have the right to purchase certain Medigap plans during Medicare Trial Period #2: You switch from a Medigap policy to an MA plan, PACE organization, Medicare SELECT plan, or any other health care organization contracting with Medicare, for the first time since becoming eligible for Medicare, and you disenroll from that plan within the first 12 months. You have the option to return to your previous Medigap policy if it is still available. If it is not available, you can choose plans A, B, C, F, K, L, M or N from any company.

Note: If you were previously in an MA plan, PACE organization, Medicare SELECT plan or any other health care organization contracting with Medicare, you are not eligible for this guaranteed-issue right.

See also:

back to Your Rights to Buy a Medigap Policy

Updated Dec 19, 2011

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