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