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Medigap (Medicare Supplemental) Policies and Rates in New York State - with 2013 Rate Tables

Views: 13832
Posted: 13 Apr, 2009
by Cathy Roberts (Empire Justice Center)
Updated: 30 Sep, 2013
by Valerie Bogart (New York Legal Assistance Group)

Medigap (aka Medicare supplemental insurance) policies are sold by private health insurance companies to cover some of the "gaps" in expenses not covered under original Medicare.   

There are different types and costs of Medigap policies in New York State.  

Rate tables for policies in the current year, and contact information for specific Medigap insurers are posted by the New York State Department of Financial Services (formerly Dept. of Insurance) which oversees and regulates Medigap plans.   

  • TYPES OF PLANS -- Medicare Rights Center publishes charts showing the benefits covered by each Plan type.  Also see see this info on the  Medicare Rights Center website (note that this information is national, but some rules vary by state -- NYS rules are explained further below). 

    • Chart for Medigap plan types sold after June 1, 2010 (PAGE 2 of link) (Beginning 6/1/2010, two new Medigap plans added (M and N), and four plans (E, H, I and J) will no longer be sold, but consumers could keep plans E, H, I, and J if they bought them before June 1, 2010.  They will want to compare benefits with the other plans to decide whether to change plans at renewal). 

      • Plan F is most comprehensive but all benefits may not be necessar

      • Plan N may be best value 

      • Note that cost of same Plan Type varies significantly between insurance companies.  Benefits are the same if plan has same Plan Type letter. 

    • Chart for Medigap plan types sold before June 1, 2010  -- Before June 1, 2010, the plans were labeled A - L.  Note that Plan types E, H, I and J) may  no longer be sold to new consumers after that date, but consumers could keep plans E, H, I, and J if they bought them before June 1, 2010. 

CONSUMER PROTECTIONS

Guaranteed Issue

Guaranteed issue means that an insurance company is required to sell a policy and may not force an individual to prove "insurability" by making the person pass an insurance physical examination to show they have no pre-existing conditions.   

All newly entitled Medicare beneficiaries have a right under federal law to guaranteed issue of any Medigap policy which is offered for sale for the first six months after their Medicare entitlement begins.  Federal law only gives this right to Medicare beneficiaries who are 65 years of age or older.   42 U.S.C. 1395ss (Balanced Budget Act of 1997).  After this 6-month period, federal law also guarantees people age 65+ the right to enroll in a Medigap policy within 63 days of:

  • disenrolling from a Medicare Advantage (MA) plan, if they enrolled in that MA plan when first becoming eligible for Medicare, and disenrolled from the MA plan within 12 months of joining it..   42 USC 1395ss(s). 

  • If the beneficiary dropped a Medigap policy to enroll in an MA plan, and then subsequently disenrolled from the MA plan within 12 months, she is entitled to re-enroll in the same Medigap policy, if it still is on the market,or a similar plan.   42 USC 1395ss(s).

  • moving out of the area covered by a Medigap policy, or after the insurer became bankrupt or misrepresented a provision of the plan, or after employer-sponsored  employee, retiree, or COBRA coverage ends. 

Open Enrollment

As stated on the State Dept. of Financial Services website, New York State law and regulation require that any insurer writing Medigap insurance must accept a Medicare enrollee’s application for coverage at any time throughout the year. Insurers may not deny the applicant a Medigap policy or make any premium rate distinctions because of health status, claims experience, medical condition or whether the applicant is receiving health care services. However, eligibility for policies offered on a group basis is limited to those individuals who are members of the group to which the policy is issued.  Moreover,  "All Medicare supplement insurance policies  . . . must be offered on an open enrollment basis to persons enrolled in Medicare whether enrolled by reason of age or by reason of disability."  11 NYCRR 360.4(h)

  • NOTE that the NYS rules described above are not nationwide.   Many states limit enrollment in Medigap plans to a limited window period each year, and may have different rules depending on whether one is over or under age 65.  

Rules on pre-existing condition -- also known as portability or "guaranteed issue"--

These are contained in 11 NYCRR 52.20 (click on Title 11, then Chapter III, then Subchapter A, then Part 52).  .  As explained on the NYS Dept. of Financial Services website -- 

Federal and state law allow Medigap policies  to  contain up to a six (6) month waiting period before pre-existing conditions are covered. (Federal HIPPA law at 42 USC 300gg).   A pre-existing condition is a condition for which medical advice was given or treatment was recommended or received from a physician within six months before the effective date of coverage. However, under New York State regulation (11 NYCRR 52.20), the waiting period may be either reduced or waived entirely, depending upon your individual circumstances. Medigap insurers are required to reduce the waiting period by the number of days that you were covered under some form of "creditable" coverage so long as there were no breaks in coverage of more than 63 calendar days. Coverage is considered "creditable" if it is one of the following types of coverage:

  1. A group health plan;

  2. Health insurance coverage;

  3. Medicare -- In New York, credit for Medicare coverage is only given if you apply for a Medigap policy before or during the first six months after you turn 65 and are enrolled in Medicare;

  4. Medicaid;

  5. CHAMPUS AND TRICARE health care programs for the uniformed military services;

  6. A medical care program of the Indian Health Service or of a tribal organization;

  7. A State health benefits risk pool;

  8. Federal Employees Health Benefits Program;

  9. A public health plan;

  10. A health benefit plan issued under the Peace Corps Act; and

  11. Medicare supplement insurance, Medicare select coverage or Medicare Advantage plan (Medicare HMO Plan).

NOTE: New York’s Open Enrollment and Portability provisions protect you whether you are Medicare eligible by reason of age or disability. 11 NYCRR 360.4(g).  The provisions also apply to Medicare beneficiaries with end stage renal disease.  Again, not all of these protections are nationwide.  New York's protections are more generous than those required by federal law, which only apply to those who applied for Medigap during their initial open enrollment period (within 6 months of turning age 65 and enrolling in Medicare Part B).  42 USC 1395ss(s)(2)(D).  

Prohibition against selling duplicate policies or selling Medigap to a Medicaid recipient

Insurers are prohibited from selling someone a second Medigap policy, or from selling a Medigap policy to a Medicaid or QMB recipient, since it essentially duplicates Medicaid coverage.   However,  if a Medicaid  or QMB recipient already has a Medigap policy, she may renew it or replace it with a different policy.   42 USC 1395ss(3)(3).   The insurer or agent must disclose the federal law prohibiting duplication, and must obtain a written acknowledgment that this information was given. 

For more information on national rules on Medigap policies:


This article was authored by the Empire Justice Center.

Empire Justice Center

External links
http://www.dfs.ny.gov/insurance/caremain.htm#sub_port
http://www.medicareinteractive.org/page2.php?topic=counselor&page=script&slide_id=1255
http://www.medicarerights.org/prejune2010medigaps.pdf
http://www.medicarerights.org/june2010medigaps.pdf

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