What Is Guaranteed Issue for Medicare Supplement?

Medicare Supplement (Medigap) plans help cover costs Original Medicare (Parts A and B) does not, such as deductibles, copayments, and coinsurance. Offered by private insurance companies, these plans work with your Original Medicare benefits. A key concept for obtaining these plans is “guaranteed issue.” This right allows individuals in specific circumstances to acquire a Medigap policy without medical underwriting. This protection is valuable outside initial enrollment periods when health conditions might otherwise impact eligibility or cost.

Understanding Guaranteed Issue

Guaranteed issue refers to specific situations where private insurance companies offering Medigap plans cannot deny coverage, charge higher premiums, or impose waiting periods for pre-existing conditions based on health status. This differs from standard insurance underwriting, where health history can lead to denial, increased costs, or delayed coverage. These rights provide a safety net, ensuring access to supplemental coverage for individuals experiencing certain life events or changes in health coverage.

When a guaranteed issue right applies, insurers are mandated to sell you a Medigap policy at the best available rate, meaning they cannot factor your health problems into the premium calculation. This protection covers all pre-existing health conditions without a waiting period, provided there hasn’t been a significant break in prior creditable coverage. While the Medigap Open Enrollment Period offers guaranteed acceptance without medical underwriting, guaranteed issue rights provide opportunities outside this initial window. These rights are federal protections, but some states may offer additional guaranteed issue periods or expanded protections.

Specific Guaranteed Issue Rights

Several scenarios trigger guaranteed issue rights, each with specific timeframes. A common timeframe is a 63-day window, typically beginning from the date your prior coverage ends, you receive notification of termination, or a claim denial signifies the end of coverage. Acting within this window is essential to preserve your right.

Loss of Group or Medicare Advantage Coverage

One common trigger is the involuntary loss of employer-sponsored group health coverage that supplemented Medicare, including COBRA. If this coverage ends, you have a guaranteed issue right to enroll in a Medigap plan. You can apply as early as 60 days before your employer coverage ends and up to 63 days after it terminates.

Individuals losing coverage from a Medicare Advantage (MA) Plan also qualify for guaranteed issue. This occurs if your MA plan leaves the Medicare program, stops serving your area, or you move out of its service area. In such cases, you have a guaranteed issue right to switch back to Original Medicare and purchase a Medigap policy. The application window spans 60 days before and up to 63 days after your MA Plan coverage ends.

Trial Rights

Another scenario involves “trial rights.” If you enrolled in a Medicare Advantage Plan when first eligible for Medicare at age 65, you have a 12-month trial period to switch back to Original Medicare and enroll in a Medigap plan without medical underwriting. A similar trial right exists if you dropped a Medigap policy to join an MA Plan for the first time and decide to switch back within 12 months. In this case, you can often return to your previous Medigap policy if available; if not, you can choose from certain standardized plans.

Other Qualifying Events

Guaranteed issue rights also apply in other situations:
Your Medicare SELECT policy requires network providers, and you move out of its service area.
Your Medigap insurance company goes bankrupt or your policy is terminated through no fault of your own.
You leave a Medicare Advantage plan or drop a Medigap plan because the company misled you or did not follow Medicare’s rules.

Applying for a Guaranteed Issue Policy

The application process for a Medigap policy is streamlined once you qualify for a guaranteed issue right. First, identify which Medigap plans are available in your area and offered under guaranteed issue. While many plans are available, some situations may limit the specific plans you can select, often including plans A, B, C, D, F, G, K, or L. Plans C and F are generally only available to individuals eligible for Medicare before January 1, 2020.

After selecting a plan, contact insurance companies offering Medigap policies in your state to inquire about their offerings and application procedures. During a guaranteed issue period, insurers cannot ask health questions on your application, as eligibility is based on the qualifying event, not medical history.

You will need to provide proof of your qualifying event. This typically involves documentation like a letter from your previous insurer confirming coverage termination or a notice from your Medicare Advantage plan regarding its withdrawal. Submitting this documentation with your application within the specified timeframe is crucial. It is advisable to apply as early as 60 days before your current coverage ends to prevent any gaps.

Upon successful application, the policy’s effective date typically aligns with the end of your previous coverage. You will begin paying monthly premiums for your Medigap policy, in addition to your Medicare Part B premium. Compare policy prices among different companies, as premiums for the same standardized plan can vary.