Supplemental Insurance Eligibility

Medigap, also known as Medicare supplemental insurance, is a health insurance policy sold by private companies to fill in the various “gaps” in Original Medicare plans. Medicare supplemental policies help pay for costs your Original Medicare coverage will not pay. When you sign up, plans cover what would otherwise come out of your pocket. Medicare supplemental policies are relatively simple regarding eligibility on a basic level. There are some exceptions to the basics, however.

Who is eligible?

You are eligible if you are 65 years or older, enrolled in Medicare Part A and Part B, and enrolled in a policy in your area. You are required to play your monthly Part B premium and your Medigap premium.

Are there other eligible conditions?

You can also be eligible for a Medigap policy if under 65 if you have a disability or have End Stage Renal Disease. You also might have to wait until you turn 65 as policies vary from state to state. Federal laws have no requirement that insurance companies sell those under 65, even those eligible for Medicare, a Medigap policy. Some states, however, do require insurers to issue policies for people eligible for Medicare and under the age of 65.

When is the open enrollment period?

In the six months following your 65th birthday, you are in the Medigap open enrollment period. Even if you already had Medicare Part B before the age of 65, you still get a Medigap open enrollment period after you turn 65. This period is important. During these six months you can buy any Medigap policy—even policies that cover prescription drugs. Insurance companies cannot refuse to sell you a Medigap policy due to a disability or health problem. If you have a disability or health problem, the insurance companies cannot charge you a higher premium than they charge others who are 65 years old. When you purchase your Medigap policy within the open enrollment period, the insurance company has to shorten the waiting period for pre-existing conditions by the amount of creditable coverage you have. For instance, if you had Medicare before you turned 65 years old, you would have no pre-existing condition waiting period because Medicare is creditable coverage.

Enrolling during this open enrollment period is important. If you wait, you will not necessarily lose the possibility of getting a Medigap policy. You might because the insurance companies will not always be required to sell you a plan. If they do sell you a plan when you are outside the open enrollment period, the cost might be significantly higher. Be aware when you are in this open enrollment period.

Are there certain state requirements?

These states require Medigap insurers to offer a limited Medigap open enrollment period of those under 65 who have Medicare Part B. The states include; California, Connecticut, Kansas, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Mississippi, New Hampshire, New Jersey, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, South Dakota, Texas, Washington and Wisconsin. Rules will vary from state to state so be sure to contact your state for details. These states all require companies to have at least one Medigap policy available to those under 65.

As noted the rules do vary. Connecticut requires that companies during open enrollment or guarantee issue make Medigap Plans A and B available to those on Medicare but under 65 years of age. Maryland requires companies offer both Medigap Plans A and C. California requires adherence to the state laws without necessarily mandating specific lettered Medigap policies.

Even in states where companies are not required to sell Medigap policies to Medicare Part B members, insurance companies sometimes choose to sell policies to those under the age of 65. Be aware that these policies might cost you more. If your state does have the open enrollment period for those under the age of 65 you will still get the six month open enrollment when you turn 65.

What if I already have a Medicare Plan?

You cannot sign up for a new Medigap policy if you are part of a Medicare Advantage Plan. If, when you join for the first time, you are not happy with your Medicare health plan you have special rights to buy a Medigap policy if you return to Original Medicare within 12 months of your initially joining.

If you did have a Medigap policy before joining your Medicare health plan it is possible you can get that same policy back—provided the company you bought it from still sells that particular Medigap policy. Even if you are able to go back to that same policy if it included drug coverage you will not be able to get that part of the policy back. You might be able, however, to join a Medicare Prescription Drug Plan (Medicare Part D). If you joined a Medicare health plan when you first became eligible for Medicare coverage you can choose from any Medigap plan.

It is important to emphasize that you cannot have prescription drug coverage through both a Medigap policy and a Medicare drug plan. Also important is the fact that you cannot use a Medigap plan to pay for copayments, deductibles and premiums in a Medicare Advantage Plan like you would if you had Original Medicare.