KNOW YOUR MEDIGAP RIGHTS UNDER FEDERAL LAW
In a recent column, I discussed the pros and cons of various Medicare options, including Medicare Advantage plans.
I also referred to the situation in which an individual signed up for Original Medicare with a Medigap option and switched to a Medicare Advantage plan. If that person then wanted to switch back to original Medicare, he/ she may have certain guaranteed issue rights under federal law, also known as “Medigap protections.”
Where guaranteed issue rights apply, insurance companies:
Must sell you a Medigap policy.
Must cover your preexisting health conditions.
Cannot charge you more for a Medigap policy because of past or present health problems.
In the following situations, an insurance company can’t refuse to sell you a Medigap policy. These are known as guaranteed issue rights.
You are in a Medicare Advantage plan, and your plan is leaving Medicare; the plan stops providing care in your area; or you move out of the plan’s service area.
You have Original Medicare, and an employer group health plan (including retiree or COBRA coverage) or union coverage that provided supplemental coverage after Medicare coverage, and that plan is ending.
You have Original Medicare and a Medicare SELECT policy (this is a type of Medigap policy that necessitates the use of hospitals and doctors within its network), and you moved out of the Medicare SELECT policy’s service area.
You joined a Medicare Advantage plan or program of all-inclusive care for the elderly (PACE) when you were first eligible for Medicare at 65, and within the first year of joining you decided to switch to Original Medicare.
You dropped a Medigap policy to join a Medicare Advantage plan, or to switch to a Medicare SELECT policy for the first time. If you have been in the plan for less than a year, you are allowed to switch back.
Your Medigap insurance company goes bankrupt and as a result, you lose your coverage; or your Medigap policy coverage ends for another reason through no fault of your own.
You leave a Medicare Advantage plan or drop a Medigap policy because the company either hasn’t followed the rules or has misled you.
If you have a Medicare Advantage plan but are planning to return to Original Medicare, consistent with these guaranteed issue rights, you can apply for a Medigap policy before your coverage ends. The Medigap insurer can sell it to you as long as you’re leaving the plan. Ask that the new policy take effect no later than when your Medicare Advantage enrollment ends to ensure continuous coverage.
If you have switched to a Medicare Advantage plan, it is important for you to understand these guaranteed issue rights. If you do decide to terminate your Medicare Advantage Plan and the guaranteed issue rights are not applicable, then you may not be able to obtain a Medigap policy, or the cost may be much higher than it would have been if you had enrolled in a Medigap plan when you were first eligible to do so.
If you have lost your health care coverage for reasons relating to any of these guaranteed issue rights, in order to prove that you have the right to buy a Medigap policy, you should keep these items and include a copy of these papers with your Medigap application:
A copy of any letters, notices, emails and/or claim denials with your name on them to prove you have lost coverage.
The postmarked envelope these papers come in as proof of when it was mailed.