Q&A: Does California Law Allow Health Screening for Medigaps?

Q&A: Does California Law Allow Health Screening for Medigaps?

Recently someone wrote to us with a Medigap question inquiring about a woman, Claire, who is almost 65 and who has been in remission from cancer for over 6 years. She asked, “If Claire takes a Medicare Advantage (MA) plan now as a way to save money on premiums, can she change her mind later and be able to switch to a Medigap plan without a health screening?” This is a good question, and a good opportunity to review one’s rights. Below is our response, which may be applicable to you if you are considering your rights to purchase a Medigap policy without a health screening.

First of all, yes, Claire will be able to switch to a Medigap plan without a health screening as long as she does so within the first 12 months of being in the MA plan. This is a Special Election Period (SEP) referred to as a “Trial Period.” It begins when she turns 65 and is first enrolled in Medicare Part A,  and ends when she disenrolls from the MA plan or one year later, whichever is earlier. Leaving her MA plan within these first 12 months triggers her guaranteed issue right to purchase any Medigap plan currently being sold.

After this 12 month period ends, however, Claire will have NO right to a Medigap policy without a health screening, unless she has other events that trigger a guaranteed issue right.  For example, if her MA plan stops providing Medicare benefits or she moves out of the plan’s service area, she will have a right to purchase a Medigap without a health screening.

If Claire stays in the MA plan AFTER the first 12 months, she has to wait until the following Annual Election Period (AEP – October 15 through December 7 of each year) to make changes.  She should carefully consider her treatment needs, the doctors and hospitals she might use, and the MA plan’s network of providers and facilities when making her choice. She should also understand the cost-sharing she will have each time she gets health care services in an MA plan and how those out-of-pocket costs compare to those of a Medigap.

Even if Claire does not have a guaranteed issue right to buy a Medigap, she can apply for a Medigap policy but she would probably be subject to health screening.  Insurance companies may consider her health conditions before deciding whether to cover her.  If they do cover her, they may charge a higher premium based on her health condition and age.

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Karen Fletcher
Our blogger Karen J. Fletcher is CHA's publications consultant. She provides technical expertise, writing and research on Medicare, health disparities and other health care issues. With a Masters in Public Health from UC Berkeley, she serves in health advocacy as a trainer and consultant. See her current articles.

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