Guaranteed Issue
Your most valuable – and short lived – right.
The most important thing to know about your ability to be accepted to a plan regardless of your health status is that it is not a permanent right. It is limited to specified enrollment periods.
This overview of Medicare guaranteed issue rights is offered as a service and is not intended to be definitive. I encourage you to visit Medicare.gov and download the “Medicare and You” booklet. It is an excellent reference guide and must reading for every Medicare participant. You can download the 2024 booklet here.
1. Guaranteed Issue for Medigap Plans
When you enroll in Medicare Part B, a six-month open enrollment period begins for Medicare Supplement (Medigap) plans. This is a one-time open enrollment period that does not repeat every year.Â
During this initial period:
- Insurers cannot refuse to sell you any Medigap policy they offer in your state.
- Plans cannot exclude coverage for preexisting health conditions and cannot charge more based on your health history.
- A new Medigap policy is guaranteed to be renewable regardless of your health status. This means the plan can’t cancel your policy if you stay enrolled and pay the premium.
Outside of this limited period:
- You are not guaranteed acceptance into the plan.
- You will very likely be required to undergo medical underwriting, and the insurance company is allowed to deny you a policy if you don’t meet its medical underwriting requirements.Â
- You may have to pay more for a policy.
- Fewer policy options may be available to you.
Important: There are exceptions to this limitation on guaranteed issue policies, such as if your plan leaves Medicare or if you move out of your plan’s service area. Please get in touch with me for more information on this subject.
2. Guaranteed Issue for Medicare Advantage Plans
Medicare Advantage beneficiaries also have guaranteed issue protections during their initial enrollment period. Generally, if you’re eligible for Original Medicare (Part A and Part B), you can’t be denied enrollment into a Medicare Advantage plan.
Medicare Advantage plan participants have additional guaranteed issue rights under certain circumstances:
- During the first year of enrollment in a Medicare Advantage plan, participants have a Trial Right, in which they may switch from Medicare Advantage to Original Medicare and obtain a Medigap policy. Federal law permits 63 days guaranteed issue days after you leave your Medicare Advantage plan. in which to enroll in a Medigap plan.
- An individual may enroll in a different plan following changes in residence or employment that forced them to change plans.
- Participants also have “no-fault rights” that allow a beneficiary guaranteed issue if an insurer no longer offers an enrollee’s plan or the beneficiary has been misled by a carrier or agent. Some states have additional open enrollment rights.
Important: While Medicare Advantage plans may not deny coverage based on preexisting conditions, they can have additional eligibility criteria or restrictions, such as specific chronic conditions for certain Special Needs Plans (SNPs).
Other rights and limitations may apply depending on your state and the insurance company policy. Please get in touch with me for more information on this subject.
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