State-Specific Medicare Rules – How Does Living in My State Affect My Medicare?

State-Specific Medicare Rules – How Does Living in My State Affect My Medicare?

While Original Medicare, consisting of your hospital (Part A) and medical (Part B) coverage, is a standardized option provided by the government after meeting applicable requirements throughout your life, an alternative option like a Medigap plan, or supplement policy, tends to alter and reshape itself to fit the mold of the state where it will be providing its services. 

Even further, Medigap plans can take much more into account when ultimately choosing to accept you into its coverage – things like age, medical history, and some past events can give a supplement coverage some perspective on how best to provide their coverage to you, including at what cost, or if at all. Additionally, Medigap is also subject to certain rulesets that can define its ability to change on a state level – while you are still available to perfectly enroll or switch using the familiar, standardized methods, you may also have some special circumstances that you have been unaware of just because of the state you live in!

  1. The Birthday Rule – Using Your Birthday to Make a Medigap Supplement Plan Switch

Despite some of the considerations, both California and Oregon provide an additional unique period for selecting the most optimal supplement plan – titled the “Birthday Rule,” this legal addendum puts the respective state’s residents in a situation where they are given a special bridge for switching between Medigap plans in the days surrounding their birthday. 

Basically, by using the “Birthday Rule” law, you’re given a period of 30 days after your birthday – annually, of course – to switch from your Medigap plan to another of the same quality (or lower) with no necessary medical underwriting; this essentially makes you capable to approach alternative plans, occasionally through other healthcare providers, and present your application for their supplementary coverage with no scrutiny towards your age, medical history, or current health status whatsoever.

Now, while it’s exemplary to have another chance to switch between Medigap plans in general, there are certain further considerations that truly make this “Birthday Rule” an endeavor worth looking over. After all, the acceptance regarding use of the rule isn’t complicated, and only requires a few necessary requirements, such as:

  1. You must be a living resident of a “Birthday Rule” applicable state – this currently includes only California or Oregon.
  1. You must have a currently active supplement plan – while you may choose to enroll into a Medigap plan during your first eligibility to do so, or during an annual open enrollment, the “Birthday Rule” is available to those who are switching between plans only.
  1. If you do fully intend to switch, it must be to a plan of equal or lesser quality – when running the spectrum of Medigap plans, from A to F, you must take your current plan’s coverage and cost in account when making your choice viable using the Birthday Rule. Attempting to move into a plan with more available coverage will generally not be considered acceptable; however, always consult your healthcare provider, as they may operate with considerations in mind that may allow further flexibility.

Generally, when using Medigap, there may be an interest to switch from one supplement plan to another that better suits a premium you find affordable – however, to be fair, the entire idea can seem somewhat daunting. After all, when enrolling outside of an applicable enrollment period, your qualification and pricing for a new supplement plan will generally follow some medical underwriting, where your health status and medical information will be taken into consideration when putting forward your intention to switch – you may even find yourself in a position where you’re completely denied! 

By taking a strong advantage of applicable enrollment periods, as well as state-specific positives much like the “Birthday Rule,” you can more regularly revisit and reconsider your current coverage against other options, all while shedding the fear of outright refusal by a healthcare provider.

  1. Guaranteed Annual Issuing – A State-Level Opportunity to Avoid Medical Underwriting 

Despite being familiar with Medigap or not, there is something very important to be recognized about both the application and enrollment regarding its provided supplement plans – the ability to “purchase” a plan from a healthcare provider is always available to you, year-round, with enrollment periods primarily operating as windows of protection for those who may find themselves at a price or eligibility crossroads with their preferred healthcare provider. 

Applicable periods for enrolling into or changing a Medigap plan, where you will not be scrutinized with medical underwriting, are typically the same times for people across the United States –however, some states have taken a firm initiative to secure these “protections” for its residents all year round! 

Some states in question – like New York and Connecticut– offer forms of “guaranteed annual issue” that will provide a shield against medical underwriting, with their enrollment periods being considered either annual or continuous. New York and Connecticut are considered under a “continuous enrollment,” and as such, your choice to enroll or switch for a plan at any point during the year can not be declined, no matter your health status, including pre-existing conditions including:

  • Heart disease
  • Cancer
  • Serious asthma or raspatory issues
  • Diabetes
  • Immune Disorder
  • ESRD and much more.

Maine, however, provides to somewhat less extent – you are given a guaranteed window of a month per year to enroll into at least a Medigap Plan A. Additionally, Maine also grants you a guaranteed right to switch your plan to one of equal or lower benefits, so long as you have not had any gaps in coverage that went longer than 90 days since initially enrolling into a Medigap plan.

A state like Washington offers a similar indulgence, but at a slightly different level of requirement – while Washington will allow you the utmost freedom and protection to change between supplement plans at will, without underwriting, this benefit only comes to those who are already enrolled (and not to those who seek to enroll, who must go through the normal channels.)

Essentially, without even knowing, you may be receiving coverage you normally would have no possibility to do so because of your state – by being provided on-going guaranteed issue protections, things like your age and medical history will continue to not be a consideration when you’re surveying your options. As such, typically when comparing costs, and while living in the applicable guaranteed continuous (or annual) states, you’ll likely only see changes depending on the location you actually live in the state – by stripping away the scaling of plan pricings and eligibility on age and medical history, it can occasionally fall to community ratings to denote fair and proper costs associated with a plan being offered by a healthcare provider.

  1. The Anniversary Guaranteed Issue – How Does Missouri’s Unique Medigap Rule Work?

Unlike any other state in the United States, Missouri residents are under jurisdiction for a very special law called the “Anniversary Guaranteed Issue Rule,” which allows them a unique opportunity to make a supplement plan switch with, again, no medical underwriting whatsoever. However, you’re likely curious as to what, and when, you can take advantage of this “anniversary” period – unlike California and Oregon’s “Birthday Rule,” where the time surrounding your birthday is the window, this anniversary refers to the issue date of your current supplement policy. As such, this creates a continuous, on-going system where you’re provided a routine anniversary to compare, and consider, plans every year; additionally, with the anniversary always being tied to the issue date of your current policy, you can become very easily accustomed to scheduling your interest around the familiar date.

As with most tailored opportunities per state, outside of the standard chances to switch or enroll, you’re given a few notable considerations to approach as a Missouri resident before taking advantage, including:

  • Like some other states providing guaranteed issue protections and periods, you are still required to be initially enrolled into a Medigap plan at the time of trying to switch. There are no special considerations to new enrollees.
  • As you issue date is only a single day, you’re obviously given a very generous window of time to make your move – 30 days prior to the issue date anniversary, and the 30 days after; this date only changes if you happen to change plans and will affect the period the following year.
  • Most importantly, as Medigap plans can range from A to N with varying levels of involvement in your coverage provided, you can only move to the same plan type with another carrier. For example, if you are currently under a Medigap Plan G policy, you are only allowed to switch to another healthcare provider’s Plan G.

While somewhat limited by the ability to switch only to the same plan types, the business nature of healthcare providers can constantly output shifts in the values of plans, making the potential for your plan type’s pricing to always be offered at different, competitive rates; by making use of your anniversary rule, you can continue to keep to a plan type you may wholly prefer, while still attempting to 1) save costs annually and 2) avoid unnecessary and intrusive medical underwriting.

  1. The Standards of Medigap Plans – How and Why Do Medigap Plans Rate Themselves?

The pricing out for Medigap supplement plans can be a relatively complex process – after all, the costs of a policy is typically the sum of many elements built together from many parts associated with the plan, including bits and pieces of yourself, where you live, and your individual medical history. Fortunately, most of the work regarding this is done by the healthcare providers who seek to enroll you into their plans, always in attempts to compete enough to make the decision between another plan take more consideration; however, while it’s understandable that providers will obviously have plans with different prices, the method of how they approach those price selections actually differs between three separate methods – community-rated, issue-age-rated, and attained-aged-rated pricing.

  1. A community-rated policy requires your healthcare provider to charge the same premium to all enrollees, despite their age or quality of health; in this circumstance, a plan’s premium may change, but if it does, it will shift for all other policyholders as well, no matter the age. However, premiums may still be subject to change on factors that are removed from age or medical history, including a shift of cost based on policy’s location.
  1. An issue-age-rated policy is one that directly considers your age when you choose to enroll, allowing a healthcare provider substantial reason to alter your premium when enrolling based on their initial judgement surrounding this factor – additionally, in this circumstance, you’ll still also be weighed by things like your health or place of living. However, on a positive note, this age-considered rating is only used when you first enroll into a plan, and once the healthcare provider has selected a premium most fitting, your cost for that plan will never rise based on getting older.
  2. An attained-age-rated policy serves as likely both the least expensive option when initially enrolling and the plan least invested towards protecting against rising plan costs – these policies operate much like issue-age-rating, as they take into consideration many factors (including your age) during the initial enrollment, but that consideration does not end after enrollment. As such, an attained-age-rated plan’s premium will continue to increase as you age, with your healthcare provider still completely free to additionally raise costs based on other factors as well, such as your on-going health, place of residence or competition.

As there is no standard “method” of rating out a Medigap policy, providers will use whichever preferred method listed above to create timelines and entry-points of how they would prefer you to pay for their policy, and for what cost. As such, some states enact certain laws that enforce their preferred method amongst it’s available healthcare providers – states like Arkansas, Connecticut, Maine, Massachusetts, Minnesota, New York, Vermont, and Washington require, by law, for all offered Medigap plans to operate under the community-rated method, meaning that any and all plans that are sold in the listed states will never weigh a plan’s premium by your age or health quality; however, other states like Arizona, Florida, Georgia and Idaho, can only offer either issue-age-rated or community-rated plans, but never attained-age-rated. 

Remember, how a plan is rated denotes how the provider goes about deciding the factors necessary for crafting your plan’s premium – you can still be denied outright for a plan by a healthcare provider for several reasons and no rating will enforce a company to provide service to you.

  1. Enrolling While Under 65 – When Receiving Medigap Through Disability or Otherwise

When typically considering the interest into Medigap supplement insurance, healthcare providers will generally direct their efforts towards Medicare beneficiaries over the age of 65 – the pricing and standards set by how many of these plans operate work from the viewpoint that they would be servicing seniors primarily, with less complete understanding how to properly offer themselves to somebody who may be significant younger (but disabled or with a mountain of potential medical issues.) Additionally, there is generally no federal regulation towards insurers needing to provide their services to those below the age of 65, meaning any providers available to you may severely limit your options or quickly turn you away outright.

Fortunately, a plethora of states – including Colorado, Connecticut, Florida, Georgia, Hawaii, Illinois, Kansas, Louisiana, Maine, Maryland, Michigan, Minnesota, Mississippi, Missouri, Montana, New Hampshire, New Jersey, New York, North Carolina, Oklahoma, Oregon, Pennsylvania, South Dakota, Tennessee, Texas, and Wisconsin – have recognized the need, and produced, a slight opportunity to be made for those under 65 seeking Medigap coverage, introducing legislation to enforce healthcare providers to provide at least one kind of Medigap plan to anyone below the age of 65. However, a few states are a bit more particular – states like California and Vermont will exclude you from being provided a state-enforced Medigap option if you currently have ESRD, while other states, like Massachusetts and Delaware, will only provide plans to those under 65 if they have ESRD.

Now, a stern reality to face when approaching these offered plans is that their costs will likely be substantially higher than if you had enrolled into the plan over the age of 65. While healthcare providers may be regulated to allow at least one supplement plan option for Medicare beneficiaries under 65, they have the freedom to charge what they see fit to satisfy the costs they feel they may be sacrificing by being forced to offer the plan – typically, even the same plan with the same provider (take a supplement plan A, for example) will list two drastically different premiums between enrolling before and at, or after, turning 65. Additionally, the increases towards your supplement plan’s premium is likely to rise in very noticeable portions every year – be sure to greatly consider the cost-effectiveness of provided Medigap enrollment over the course of time when signing to an option.

References Used:

https://www.medicare.gov/supplements-other-insurance/when-can-i-buy-medigap
https://boomerbenefits.com/compare-medicare-plans-and-prices/states/washington-medicare-plans/
https://boomerbenefits.com/compare-medicare-plans-and-prices/states/missouri-medicare-plans/
https://boomerbenefits.com/medicare-supplement-guaranteed-issue/
https://boomerbenefits.com/medigap-under-age-65/