Medicare Supplement Plan Denial: Can this Happen?
With any health insurance plan, the worry about being denied coverage is justifiable. That goes even more for health plans that supplement Medicare. Can you be denied access to a Medicare Supplement insurance policy (also called Medigap)? That depends on your circumstances, where you live, if you are replacing certain coverage, and whether you’re currently within your Medicare Open Enrollment period.
Buying During the Open Enrollment Period
The first important thing to know is that if you buy Medicare Supplement insurance during your Open Enrollment period, you cannot be denied, even if pre-existing medical conditions exist.2 That Open Enrollment period takes place during the six months following your 65th birthday, and upon enrollment in Medicare Part B (which covers some doctors’ and preventative health services, some supplies, and outpatient care). Some states offer an Open Enrollment period to applicants under age 65 eligible for Medicare due to disability. If you miss that window and do not qualify under the situations above, you may be denied Medicare supplement coverage.
What Is a Guaranteed Issue Right?
Also important to know is that the U.S. government has laid down a series of Guaranteed Issue Rights (also called Medigap Protections) under which insurance companies must sell Medicare Supplement insurance to you regardless of health status, receipt of health care, or medical conditions. That means as long as your circumstances reflect one of the situations below, you cannot be turned down for health related circumstances. In addition, the policy must cover your pre-existing conditions, and cannot be more expensive than it would for someone who lacks those pre-existing conditions. Some states offer expanded Guaranteed Issue protections.
Guaranteed Issue Rights Scenarios from Medicare.gov1
| Situation |
You can buy… |
When to apply |
|
You are in a Medicare Advantage Plan, and your plan is leaving Medicare or stops giving care in your area, or you move out of the plan's service area.
|
Medigap Plan A, B, C, F, K, or L that is sold in your state by any insurance company.
You only have this right if you switch to Original Medicare rather than joining another Medicare Advantage Plan.
|
As early as 60 calendar days before the date your health care coverage will end, but no later than 63 calendar days after your health care coverage ends. Medigap coverage can't start until your Medicare Advantage Plan coverage ends.
|
|
You have Original Medicare and an employer group health plan (including retiree or COBRA coverage) or union coverage that pays after Medicare pays and that plan is ending.
Note: In this situation, you may have additional rights under state law.
|
Medigap Plan A, B, C, F, K, or L that is sold in your state by any insurance company.
If you have COBRA coverage, you can either buy a Medigap policy right away or wait until the COBRA coverage ends.
|
No later than 63 calendar days after the latest of these 3 dates:
- Date the coverage ends
- Date on the notice you get telling you that coverage is ending (if you get one)
- Date on a claim denial, if this is the only way you know that your coverage ended
|
|
You have Original Medicare and a Medicare SELECT policy. You move out of the Medicare SELECT policy's service area.
You can keep your Medigap policy, or you may want to switch to another Medigap policy.
|
Medigap Plan A, B, C, F, K, or L that is sold by any insurance company in your state or the state you are moving to.
|
As early as 60 calendar days before the date your health care coverage will end, but no later than 63 calendar days after your health care coverage ends.
|
|
(Trial Right) You joined a Medicare Advantage Plan or Programs of All-inclusive Care for the Elderly (PACE) when you were first eligible for Medicare Part A at 65, and within the first year of joining, you decide you want to switch to Original Medicare.
|
Any Medigap policy that is sold in your state by any insurance company.
|
As early as 60 calendar days before the date your coverage will end, but no later than 63 calendar days after your coverage ends.
Note: Your rights may last for an extra 12 months under certain circumstances.
|
|
(Trial Right) You dropped a Medigap policy to join a Medicare Advantage Plan (or to switch to a Medicare SELECT policy) for the first time; you have been in the plan less than a year, and you want to switch back.
|
The Medigap policy you had before you joined the Medicare Advantage Plan or Medicare SELECT policy, if the same insurance company you had before still sells it.
If your former Medigap policy isn't available, you can buy a Medigap Plan A, B, C, F, K or L that is sold in your state by any insurance company.
|
As early as 60 calendar days before the date your coverage will end, but no later than 63 calendar days after your coverage ends.
Note: Your rights may last for an extra 12 months under certain circumstances.
|
|
Your Medigap insurance company goes bankrupt and you lose your coverage, or your Medigap policy coverage otherwise ends through no fault of your own.
|
Medigap Plan A, B, C, F, K, or L that is sold in your state by any insurance company.
|
No later than 63 calendar days from the date your coverage ends.
|
|
You leave a Medicare Advantage Plan or drop a Medigap policy because the company hasn't followed the rules, or it misled you.
|
Medigap Plan A, B, C, F, K, or L that is sold in your state by any insurance company.
|
No later than 63 calendar days from the date your coverage end
Note: You must demonstrate the violations to Medicare.
|
State-Specific Coverage
Finally, as of 2018, insurers in the states of Connecticut, Maine, and New York are bound by state law to sell Medicare supplement insurance to all state residents ages 65 or older, regardless of pre-existing conditions, for either the entire year or one month per year.3 If you live in one of those states and are nearing or over the age of 65, check with your insurance Agent on when you are eligible to buy Medicare supplement insurance.
Your style is your choice. Shouldn't your doctor and your coverage be, too?
Learn more about Medicare Supplement insurance options.
Sources:
1 Medicare.gov, Your rights to buy a Medigap policy
2 Medicare.gov, When can I buy Medigap?
3 kff.org, In All But Four States, Seniors on Medicare Can Be Denied a Medigap Policy Due to Pre-existing Conditions, Except During Specified Windows of Opportunity
Author: By the Globe Life Staff
Globe Life articles are researched, written, and edited by multiple members of the Globe Life staff including, Marketing Specialists, Content Writers, Product Experts, as well as Legal & Compliance Professionals.