Medigap protections, also known as guaranteed issue rights, are rules that help to protect personal rights to coverage. These rights prohibit insurance companies from denying coverage or overcharging for policies due to pre-existing health conditions. It is important to understand what these rights are and how they may impact coverage.
What Are Medicare Guaranteed Issue Rights?
Guaranteed issue rights are rights that have qualified individuals for Medicare in certain situations. In these situations, insurance companies have to offer some types of Medigap policies. There are three requirements for insurance companies responding to guaranteed issue rights:
- They must sell a qualified individual a Medigap policy.
- They cannot discriminate against pre-existing conditions.
- They must not charge more because of current or previous health problems.
In qualified situations, the insurance company has to offer a policy that provides for an individual’s health needs. When does this apply, though?
When Are Some Situations Where You Have Guaranteed Issue Rights?
The most common time guaranteed issue rights are granted is:
- When someone’s health insurance changes for reasons outside their control. For example, if they lose their health coverage from an employer, they may then gain guaranteed issue rights.
- Most people have a trial right. They can try a Medicare Advantage Plan (Medicare Part C) and if they are dissatisfied during the trial period, then they can buy a Medigap policy in lieu of Part C.
Here are some additional examples of when Medigap Guaranteed Issue Rights may apply.
In the case of an existing plan change:
Imagine that a person is in a Medicare Advantage plan, but the plan itself is leaving Medicare. Because of the changes in coverage, the person attains Medigap guaranteed issue rights. Another time when this may apply, is when the current Advantage Plan stops providing care in a certain area. In this case, a person will need to change plans to retain coverage, so Medigap guaranteed issue rights protect them. People also need protection when they move out of one coverage area to a new coverage area. Guaranteed issue rights come into play to allow them to move to a Medigap plan.
In the case of group health insurance ending:
Beneficiaries with Original Medicare and an employer group health plan (which helps cover costs not covered under Original Medicare) may qualify for guaranteed issue rights if their plan is ending. Plans can end when a beneficiary retires or when COBRA insurance coverage ends. Sometimes union insurance benefits, that pay for coverage after Medicare, expire. There are many examples of group health insurance ending, so keep in mind that the end of this type of coverage often comes with guaranteed issue rights.
In the case when someone with Medicare SELECT relocates:
If one has Medicare SELECT coverage and they are moving out of the area where that policy applies, they may qualify for guaranteed issue rights.
In the case of an existing provider closing:
Though not common, it is possible for a Medigap insurance company to shutter its doors or file for bankruptcy. In this situation, beneficiaries may lose coverage. When coverage ends with the company for this or another reason that is not the fault of the beneficiary, the door is opened for guaranteed issue rights.
In the case of switching to Original Medicare from other coverage:
If someone made the decision to use a Medicare Advantage Plan or the PACE program (Program of All-Inclusive Care for the Elderly) when they were first eligible for Medicare, but now want to switch to Original Medicare, they may be given a right to coverage. This often happens when individuals are 65 and joined Medicare the first year, they were eligible.
In the case of fraud from an existing company:
In some situations, people are issued a guaranteed right if they choose to leave a Medigap policy or a Medicare Advantage Plan because the company was not honest. Companies may have been dishonest or failed to follow the rules. If fraud or dishonesty can be proven, then the affected people may be able to make a switch protected by guaranteed issue rights.
How to Prove a Need to Switch
If someone has lost their health coverage, they may need to prove they have a guaranteed issue right. There are a few key things they need to do. They should gather any letters, notices, emails, or claims denials relevant to their loss of coverage that they may have. These documents should ideally have the relevant individual’s name and date on them. The names and dates are important because these documents can be proof that coverage has been terminated. Envelopes from insurance providers with postmarks still on them are also valuable as evidence. The envelopes are solid proof of when the documents were mailed.
Is it Possible to Get into a Medigap Plan Before the End of an Ongoing Advantage Plan?
If a Medicare Advantage Plan beneficiary wishes to move into Original Medicare, they can apply to make the switch to a Medigap plan before the end of their current coverage.
Can You Buy Medigap Without Guaranteed Issue Rights?
In some situations, you may not have guaranteed issue rights. In some situations, you may still be able to buy a Medigap policy after the open enrollment period ends. Medigap providers may refuse to sell you a policy if you have pre-existing conditions or charge you higher rates. Also, some may require you to wait six months before covering that condition.
If you are unsure if you have coverage or the right to make changes to your policy, reach out to your current policy provider or seek out a new provider who may be able to answer your questions for you.