Basic Facts About Medigap Policies

Open Enrollment
Guarantee Issue
Suspension of Medigap Policy
30-day Free Look
Waiting Periods, Limitations, and Exclusions
Renewability
Common Exclusions
Midterm Cancellation
Outline of Coverage

Open Enrollment

Medicare supplement and Medicare select insurance companies must make coverage available to you, regardless of your age, for 6 months beginning with the date you enroll in Medicare Part B. This 6-month period is called the open-enrollment period. Insurance companies may not deny or condition the issuance of a policy on your health status, claims experience, receipt of health care, or medical condition. The policy may still have waiting periods before preexisting health conditions are covered.

In addition, if you are under age 65 and eligible for Medicare due to disability or end stage renal disease, you are entitled to a 6-month open enrollment period upon reaching age 65.

Medicare cost and Medicare Advantage insurance plans accept applicants who live in the plan's geographic service area, have Medicare Part A and Part B, and do not have permanent kidney failure.

Guaranteed Issue

In addition to the open-enrollment period, you have the right to enroll in a Medicare supplement or Medicare select policy regardless of your health status if your other health coverage terminates. The insurance company must offer you one of these Medigap policies if:

• Your Medicare Advantage or Medicare cost plan stops participating in Medicare or providing care in your service area; or
• You move outside the plan's geographic service area; or
• You leave the health plan because it failed to meet its contract obligations to you; or
• Your employer group health plan ends some or all of your coverage; or
• Your Medicare supplemental insurance company ends your Medigap or Medicare select policy, and you are not at fault (for example, the company goes bankrupt); or
• You drop your Medigap policy to join a Medicare Advantage plan, a Medicare cost plan, or buy a Medicare select policy for the first time, and then leave the plan or policy within one year after joining. However, you may only return the policy under which you were originally covered, if available; or
• You join a Medicare Advantage plan, or a Medicare cost plan and within one year of joining, you decide to leave the health plan.
• You have Medicare Parts A and B and are covered under Medical Assistance and lose eligibility in Medical Assistance.

When you meet the above conditions and you apply for your new Medigap policy no later than 63 calendar days after your health plan or policy coverage ends, the Medigap insurance company:

• Cannot deny you insurance coverage or place conditions on the policy (such as a waiting period),
• Must cover you for all preexisting conditions, and
• Cannot charge you more for a policy because of past or present health problems.

The insurance company terminating coverage must provide a notification that explains individual rights to guaranteed issue of Medigap plans. You must submit a copy of this notice or other evidence of termination with the application for the new policy.

Suspension of Medigap Policy

Medicare supplement and Medicare select policies must allow Medicare beneficiaries with coverage due to disability the right to suspend their Medigap coverage when they have employer group health plan coverage. This option was created by federal law and is referred to as a Ticket to Work provision. If you are an under age 65 Medicare beneficiary with Medigap coverage and you want to suspend your Medigap policy, you can do so by calling your Medigap insurance company. If you later lose your employer group health plan coverage, you can contact the Medigap insurance company within 90 days of losing your employer coverage and get your Medigap policy back.

30-day Free Look

All Medicare supplement and Medicare select insurance policies sold in Wisconsin have a 30-day free look period. If you are at all dissatisfied with a policy, you may return it to the company within 30 days and get a full refund if no claims have been made. You should use the time to make sure the policy offers the benefits you expected. Check your application for accuracy and check the policy for any limitations, exclusions, or waiting periods. Medicare Advantage contracts also permit disenrollment.

Renewability

All Medicare supplement and Medicare select policies sold today must be guaranteed renewable for life. This means that you can keep the policy as long as you pay the premium. It does not mean that the insurance company cannot raise the premium. Policies that are guaranteed renewable offer added protection. Be sure to ask the insurance agent or company about the renewability of the policy.

Medicare Advantage plans are not guaranteed renewable. Medicare Advantage plans are a special arrangement between federal Centers for Medicare & Medicaid Services (CMS) and certain health maintenance organizations (HMOs) or insurance companies. Either CMS, HMOs, or insurance companies may choose to terminate plans at the end of any calendar year.

Waiting Periods, Limitations, and Exclusions

Many Medicare supplement insurance policies have waiting periods before coverage begins. If your policy excludes coverage for preexisting conditions for a limited time, it must provide this information on the first page of the policy. The waiting period for preexisting conditions may not be longer than 6 months, and only conditions treated during the 6 months before the effective date of the policy may be excluded.

Insurance companies are required to waive any waiting periods for preexisting conditions if you buy a Medicare supplement policy during the open enrollment period and have been continuously covered with creditable coverage for at least 6 months prior to applying for the Medicare supplement policy. Insurance companies are also required to waive any waiting periods for preexisting conditions when one Medicare supplement policy is replaced with another.

Remember: For the first 6 months after you first enroll in Part B of Medicare, insurance companies offering Medigap policies must accept you regardless of your health. Some companies have continuous open enrollments. However, the policies may include waiting periods before coverage begins.

Common Exclusions

No insurance policy will cover everything that is not covered by Medicare. Medicare excludes certain types of medical expenses. So do many Medicare supplement, Medicare select, Medicare cost policies, and Medicare Advantage plans.

Important exclusions to understand

Some services that are frequently excluded under these policies are:

• custodial care in nursing homes,
• private duty nursing,
• routine check-ups,
• eye glasses,
• hearing aids,
• dental work,
• cosmetic surgery, and
• prescription drugs.

Midterm Cancellation

All Medicare supplement and Medicare select policies include the right to a pro rata refund of premium if you want to cancel a policy before the end of a term. All you need to do is to send your Medicare supplement or Medicare select policy to the insurance company with a letter requesting cancellation. The insurance company is required to send you a pro rata refund of premium. The right to midterm cancellation does not apply to Medicare cost or Medicare Advantage contracts.

Outline of Coverage

The Outline of Coverage contains a chart summarizing the benefits provided by Medicare Parts A and B and the benefits provided by the Medigap policy. The chart also shows the expenses that are not covered by either Medicare or the Medigap policy. An agent or insurance company must give you an Outline of Coverage when selling you a new policy or replacing one you already own.

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