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Medicare Consumer Protections

 

There are three types of consumer protections available to you;

Open Enrollment Period (When you first join Medicare Part B): This Period refers to a specific amount of time that you have to apply for a Medicare Supplement (Medigap) policy and not be denied coverage by the insurance company due to your health conditions or claims experience. You have an open enrollment period of 6 months beginning with the effective date of your Medicare Part B coverage (usually age 65). This applies to any Medicare beneficiary. The Medicare Part B effective date can be found on your Red, White and Blue Medicare card where it reads “Medical Insurance”. This means that for six months from the day your Part B coverage begins (usually the 1st of the month) you will be able to obtain an individual Medicare Supplement (Medigap) insurance policy regardless of your health. You cannot be denied coverage because of pre-existing health conditions.

Guarantee Issue: If you are losing your employer group health insurance coverage through no fault of your own, you have the right to purchase a Medigap policy without having to answer underwriting (health) questions. This is called a Guarantee Issue Right and continues for 63 days from the date your coverage ends or after you receive notice that your group policy is going to end, whichever is later.

Events that May Trigger a Guaranteed Issue Period:

  • Your Medicare Advantage or Medicare Cost plan stops participating in Medicare or providing care in your service area.
  • You move outside of your plan’s geographic service area.
  • You leave a health plan because it failed to meet its contract obligations to you.
  • Your employer group health plan ends a portion or all of your coverage.
  • The Medicare Supplement (Medigap) insurance company ends your Medigap or Medicare Select policy through no fault of your own.
  • You are within your 12 month “trial period” with a Medicare Advantage plan or a Medicare Cost Plan and want to purchase a Medigap policy or go back to the Medigap policy you had previously.
  • You are eligible for Medicare Parts A and B and covered under the Medical Assistance program and you lose your Medical Assistance eligibility.
  • Your Employer Group plan increases your cost from one 12 month period the next by more than 25% and the new payment for the coverage is greater than the premium charged under the Medigap plan you apply for.
  • Your Medicare Select plan notifies you that a hospital is leaving the plan network and there is no other participating hospital within a 30 minute or 30 mile radius of the policyholder.

Creditable Coverage / Waiting Periods for Pre-Existing Conditions: A pre-existing condition waiting period is the length of time you must be enrolled in a policy before that policy will begin paying claims for any health condition the insurer determines to be pre-existing (treatment for medical conditions within 6 months prior to the effective date of coverage).

Creditable Coverage is the term given to the time or “credit” you are granted for the amount of time you have been enrolled in and covered by qualified health insurance coverage. Having creditable coverage means you will not have to serve a pre-existing condition waiting period. Creditable coverage applies to situations where you are losing employer group health coverage (either voluntarily or involuntarily) and you want to go into another employer group plan or a Medicare supplement policy. There cannot be more than 63 days between the time your prior coverage ends and the day you apply for the new coverage.

Special Medicare Supplement / Medigap Policy Replacement Rule: If you are replacing one Medicare Supplement (Medigap) with another Medigap policy, a special rule about pre-existing condition waiting periods applies. In replacement situations, you will be given credit toward meeting the new policy’s waiting period based on the length of time you have been covered under a previous Medigap policy that was in force immediately before the effective date of the newer policy.

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