Medicare Supplement Plans – What Are Guaranteed Issue Periods and When Do They Occur?

Medicare Supplement plans have certain “Guaranteed Issue” periods that allow individuals to apply for a plan without denying you coverage, excluding your pre-existing conditions, or charging you more because of any health conditions. These guaranteed issue (GI) rights are Federally-mandated by the Centers for Medicare & Medicaid Services and apply to you all Medicare-enrollees who are in one of these specific situations.

The GI rights generally occur when your current health care coverage is changing in a certain way or you are involuntarily losing your coverage. Specific insurance companies may create their own GI situations, and they do; however, there are seven Federally-prescribed GI situations that all Medicare Supplement insurance companies must follow. If you fall into one of these periods, you should be able to sign up for a Medicare Supplement plan on a Guaranteed Issue basis. These seven situations are:

  1. You have employer or union coverage that pays AFTER Medicare, and that coverage is ending.
  2. You are enrolled in a Medicare Advantage plan, and this plan is leaving the Medicare program, stops servicing your area, OR you are moving out of the plan’s specific service area.
  3. You have a Medicare SELECT policy, and you are moving out of the plan’s service area. You can keep your current policy, but you do have the right, on a GI basis, to switch to a new policy.
  4. Your Medicare Supplement company goes bankrupt, which causes you to lose coverage. OR, you lose Medicare Supplement plan coverage through no fault of your own.
  5. You enrolled in a Medicare Advantage plan or PACE when you were first eligible to enroll, and within a year of joining, you wish to switch back to “original” Medicare (and a Medicare Supplement plan).
  6. You dropped a Medicare Supplement to switch to a Medicare Advantage or Medicare SELECT policy for the first time. You have been in that plan for less than a year and wish to switch back to Medigap.
  7. You decide to drop a Medigap policy or leave a Medicare Advantage plan because the company hasn’t followed the rules or misled you in some way.

Individual states also have the authority to create additional GI situations, and some have done so. Also, some of the specific GI situations have particular requirements for the plans that you can go into. For example, you may be eligible for a GI into a Medicare Supplement plan; however, it may have to be one of certain plans.

It is advantageous for you to be aware of these guaranteed issue situations if you are on Medicare. If you fall into one of them and elect not to sign up for a plan while that GI period is in effect, you will, most likely, have to qualify medically for a Medicare Supplement if you do decide to sign up at a later time.

Popular Medicare Supplement Plans J And F

Medicare supplement Plan F and Plan J are two of the most requested by seniors. The primary reason is these two plans fill in the most gaps that Medicare does not cover. Many supplemental insurance companies offer Plan F, but with the advent of Medicare Part D prescription drug coverage, Plan J can be harder to find. There are only a select few companies offering Plan J.

Medicare Supplement Plan J Coverage

Generally, Plan J is more expensive than the other available supplement plans. However, it offers the most comprehensive coverage available to seniors enrolled in Medicare. Consumers choose Plan J because it covers all eight gaps including:

Basic Benefits

Skilled Nursing Facility Coinsurance

Part A Deductible

Part B Deductible

Part B Excess (100%)

Foreign Travel Emergency

At-home Recovery

Preventive Care Not Covered by Medicare.

Medicare does not cover some yearly wellness checkups like an ordinary group or individual health insurance plan would. Medigap Plan J is the only plan designation that will pay benefits for preventive care visits. It differs from most other plans in that it also provides coverage for recovery time at home – such as a home visit from a physical therapist. Seniors who desire complete coverage usually select the J plan.

Medicare Supplement Plan F Coverage

Plan F is usually a little less expensive than Plan J. It provides coverage for only six of the eight gaps in Medicare. It does not pay benefits for “At Home Recovery” and “Preventive Care Not Covered by Medicare.” Seniors who are on a tighter budget, but who desire nearly complete coverage will select plan designation F.

Other Supplemental Plans

Of course, there are several other supplemental plans to choose from including Plans A, B, C, D, G, E, K, and L. These plans are less expensive than their more comprehensive counterparts, but will provide benefits for the most common claims. Additionally, several carriers offer high deductible Medigap plans. (Supplemental coverage with a high deductible won’t pay benefits until the consumer has reached his or her deductible.) However, the J and F plans remain most popular with seniors who wish to have thorough insurance coverage.

Changes to Medicare Advantage Plans

Last month I received a call from a woman concerned about her father’s UHC Medicare Advantage plan. A letter came in the mail informing her father of provider cuts, including his primary physician, which would be occurring shortly. UHC suggested her father find new providers, as most of his would be dropped. Upset and confused, this woman did not know what to do, and I suggested a Medicare Supplement versus finding another Medicare Advantage plan. Unfortunately, her father had only recently left the hospital, leaving him medically unqualified for the time being. Insurance carriers need only give 30 days notice to their beneficiaries, but for many this 30 day notice is not enough.

The father would be losing 8 of his doctors in the provider cut. By January 1st, he will not be able to afford any of his current providers.

After learning about this phenomenon, I began to research Medicare Advantage cuts for 2014, my thought being UHC had a reason for giving some doctors the boot.

I was right. Due to changes in government funding to Medicare Advantage plans, the company has taken measures to streamline their network of providers for solely MA plans. UHC Medicare Supplement policyholders will not be affected by these cuts.

The “Doctor Fix” is part of a ten-year plan to strip down the spending on Medicare Advantage plans by $156 billion. For those who have MA plans, you know that funding is already tight. While premiums will only increase slightly, there will be other cuts down the road for MA plans. These include new plans concerning provider payment. There is new legislation (well, new to me and you) that will stall doctor cuts for now, but will contain a new formula. This formula will be the method of which Medicare determines payment to individual providers. Doctor’s will be judged on multiple areas that are meant to assess provider quality. Currently, doctor’s make a flat rate on seeing patients and flat rates for different services they provide.

With less funding to their Medicare Advantage plans, UHC was “forced” to reorganize their provider network, which means the 14 million UHC Medicare Advantage beneficiaries might have to find new providers. In a news article from USA Today, Susan Jaffe of Kaiser Health News writes that Medicare officials are currently reviewing UHC provider networks, which might result in another reconfiguration, hopefully for the better. Jaffe also urges that “losing a doctor does not constitute an exception” to the special enrollment period. An enrollment period available for extraneous situations only. For example, moving from your network or the insurance carrier filing for bankruptcy are situations in which you would qualify for a special enrollment period outside of open enrollment.

Unfortunately, for many Americans, Part C is the only supplemental insurance they can afford. There are also many Medicare beneficiaries who are stuck with their Advantage plans due to health reasons. I wish I could say that I see these plans turning around in the future, but it doesn’t look promising. Hopefully things will change for the better.

As for those people who can afford to switch from your current Advantage plan, now might be a good time. Of course you will have to wait until the Annual Dis-enrollment Period (January 1st to February 14th for 2014).

Medicare Supplement plans are currently not going to be impacted by this legislation or the Affordable Healthcare Act– Medigap beneficiaries will be able to keep using current providers and their coverage will not change.