Many people believe that the Affordable Care Act prevents insurance companies from factoring in pre-existing conditions when applying for a policy. However, this protection doesn’t extend to insurance plans outside of the ACA.
Medicare beneficiaries, however, have specific protections known as Guaranteed Issue Rights or “GI Rights.” In this article, we’ll explore when these rights apply and how the rules sometimes vary across different states.
When Do You Have GI Rights for Medicare?
When discussing Guaranteed Issue (GI) Rights in the context of Medicare, we’re primarily referring to Medicare Supplement plans, also known as Medigap plans. While Medicare Parts A, B, C, and D always benefit from GI Rights, ensuring no one can be denied access, Medigap plans do not have the same level of protection.
Having Guaranteed Issue Rights means that no insurance company can reject your application for a Medigap plan. There are about ten different Medigap plans: Plans A, B, C, D, F, G, K, L, M, and N. However, Plans C and F are only available to Medicare beneficiaries who turned 65 before 2020.
There are seven specific situations where you will have GI Rights for a Medigap policy.
1. You Turn 65
When you first become eligible for Medicare at age 65, you have Guaranteed Issue (GI) Rights for any Medigap plan. This entitlement lasts for a 6-month open enrollment period starting on the first day of the month of your 65th birthday. For instance, if your birthday is on July 2, your open enrollment period starts on July 1 and ends on December 31. To ensure your Medicare coverage begins promptly, it’s advisable to apply about three months before your birthday month.
2. You Lose Creditable Coverage
It’s quite common for individuals to continue working past the age of 65, and contrary to popular belief, you are not required to enroll in Medicare at that age. As long as you have other creditable coverage, you can delay Medicare enrollment without facing penalties.
If you decide to end your employer’s coverage (or coverage from your spouse’s employer), you can enroll in Medicare without penalties and still retain GI Rights for a Medigap plan. This enrollment period starts 60 days before your creditable coverage ends and extends 63 days past the termination date. In rare cases, this period can extend up to 12 months, such as when you are not notified of your plan’s termination.
3. You Enrolled in Medicare SELECT and Moved
A Medicare SELECT plan combines elements of both Medigap and Medicare Advantage plans. It functions like a typical Medigap plan as long as you use the plan’s network of providers. However, if you seek services outside the network, you will incur higher costs. Unlike Medicare SELECT, traditional Medigap plans do not have network restrictions.
If you are enrolled in a Medicare SELECT plan and move outside its service area, you have GI Rights to switch to a Medigap plan within 63 days of your move.
4. Your Current Medicare Supplement Ends
GI Rights are also available if your Medicare Supplement plan ends through no fault of your own. This protection does not apply if your coverage is terminated because of missed premium payments. However, if your plan ends due to circumstances like the company going bankrupt, you have GI Rights to obtain another Medigap policy within 63 days of the termination date.
5. You Are in Your Trial Right Period
If you enrolled in Medicare Advantage either at age 65 or for the first time later, you have a 12-month Trial Right period. During this initial year, you can decide to switch back to Original Medicare and obtain a Medigap plan. If you had a Medigap plan before, you must return to the same plan with the same carrier. If you were not previously enrolled in a Medigap plan, you can choose from various insurance companies.
6. Your Current Medicare Advantage Plan Leaves the Service Area
Medicare Advantage plans operate on annual contracts, which means their availability can change yearly. If your Medicare Advantage plan leaves your service area, you have the right to switch back to a Medigap plan within 63 days of losing coverage.
7. You Were Misled by the Insurance Carrier
No matter what type of Medicare health plan you have, if your insurance carrier misled you or violated Medicare rules, you have GI Rights. In such cases, you have 63 days to change your plan.
Unique Guaranteed Issue Rights
While the general rules for GI Rights apply in most states, some states offer more flexibility in changing Medigap plans.
For instance, five states have implemented a Birthday Rule, allowing policyholders to change their Medigap plan annually on their birthday. These states include California, Idaho, Illinois, Nevada, and Oregon. Beneficiaries can select a policy with the same or fewer benefits than their current plan.
Maine offers an open enrollment period every June. Missouri allows changes to Medigap plans on the anniversary date of the current plan. Additionally, Connecticut, New York, Vermont, and Washington provide GI Rights year-round. However, certain limitations apply in all these scenarios.
If you are in good health and do not have chronic conditions, you can switch your supplement plan at any time by passing medical underwriting. To determine if GI Rights apply to your situation, contact the team at Carolina Senior Benefits.
