Birthdays Are Sweeter with Medicare’s Birthday Rule

If you’re enrolled in a Medicare supplement plan, live in Oregon or California, and will soon be blowing out a few birthday candles, Medicare has a special gift just for you.  Known as the “Birthday Rule,” this Medicare provision gives California, Oregon, Louisiana, Nevada, Idaho, and Illinois residents the option of changing their Medicare supplement plan with no medical underwriting.

How Does the Medigap Birthday Rule Work?

The Medigap Birthday Rule is a provision that allows individuals who already have a Medicare Supplement insurance plan (also known as Medigap) to switch to a different Medigap policy during a specific period around their birthday without being subject to medical underwriting.

Under this rule, Medicare beneficiaries have a one-time opportunity each year to switch to a Medigap policy that offers the same or fewer benefits as their current policy.

During this period, insurance companies that offer Medigap policies cannot deny coverage or charge higher premiums based on pre-existing health conditions. However, if you want to switch to a policy with more benefits, you may be subject to medical underwriting and could be denied coverage or charged higher premiums based on your health status.

It's important to note that the Medigap Birthday Rule applies only to individuals who already have a Medigap policy and want to switch to a different one. You may not be eligible for this rule if you don't currently have a Medigap policy.

In Which States Can I Use The Birthday Rule?

In certain states across the United States, a "birthday rule" exists that allows individuals to change their Medigap plans without undergoing medical underwriting. This rule was previously only applicable in California and Oregon but has since been adopted by four additional states, namely Idaho, Illinois, Nevada, Kentucky, and Louisiana, in 2024. It is important to note that each state has its own set of regulations regarding using the birthday rule.

To qualify for the birthday rule, you must be enrolled in a Medicare Supplement plan and reside in a state that offers this option. Using this rule, you can transfer to another Medigap plan that offers equal or fewer benefits and switch carriers without undergoing medical underwriting. The regulations for using the birthday rule vary across states; therefore, it is recommended that you check with your state to determine what your options can be.

How Birthday Rule Differs By States

Here are specific time frames for using Birthday Rule by State:

  • California: Individuals can use the birthday rule to switch to another Medigap plan with equal or fewer benefits starting 30 days before their birthday and continuing for 60 days after their birthday.

  • Oregon: The birthday rule in Oregon lasts for 31 days, starting on the individual's birthday and continuing for 30 days after.

  • Idaho: The birthday rule in Idaho allows individuals to switch to another Medigap plan with equal or fewer benefits within 63 days of their birthday.

  • Illinois: The birthday rule in Illinois provides a 45-day window, starting from the individual's birthday, to switch to another Medigap plan with their current provider with equal or fewer benefits.

  • Nevada: Nevada residents can use the birthday rule to switch to another Medigap plan with equal or fewer benefits within 60 days of the first day of their birth month.

  • Louisiana: Louisiana residents have 63 days from their birthday to choose a different Medigap plan with equal or fewer benefits offered by their current insurance carrier. It's important to note that the birthday rule in Louisiana only applies to plans the current insurance company offers.

  • Kentucky: Legislation enacted in 2023 allows a Medigap enrollee to switch to another insurer’s Medigap policy (same benefits as the plan they already have) within 60 days of their birthday.

Are the other times when can I switch my Medigap policy?

In addition to the Medigap Open Enrollment Period (OEP), which lasts for six months and begins on the first day of the month when you turn 65 and enroll in Medicare Part B, there are a few other times when you may be able to change your Medigap policy. These include

  • Guaranteed Issue Period (GIP): If you lose your existing coverage due to certain circumstances, such as losing employer-based health coverage, moving out of your Medicare Advantage plan's service area, or the insurance company selling the policy goes bankrupt, you may have a GIP to enroll in a new Medigap policy. During this period, you can enroll in any Medigap plan available in your state without being subject to medical underwriting.

  • Trial Right Period: If you enrolled in a Medicare Advantage plan when you turned 65 and enrolled in it for less than 12 months, you may be able to switch to a Medigap policy without medical underwriting during a Trial Right Period when you return to Original Medicare.

  • If you are still working at age 65: The initial enrollment period for Medigap is tied to the signup date for Medicare Part B. If you continue working at age 65 and have alternative coverage, you may delay Medicare Part B enrollment without penalty. This will also postpone the initial Medigap enrollment period, allowing you to receive guaranteed issue protections after you retire and require new coverage. However, delaying Part B enrollment necessitates qualifying for a Medicare special enrollment period due to having medical and prescription coverage from an employer or union that is at least equal to Medicare, with a minimum of 20 employees. You will not be eligible if you have a smaller group or an individual plan.

It's important to note that changing your Medigap policy outside of these periods may result in you being subject to medical underwriting. The insurance company can deny coverage or charge higher premiums based on your health status. In other words, you can switch carriers or enroll in Medigap policy anytime you want but it may be subject to medical underwriting, and you are at risk that your application will be denied. So, the best way, if you don’t live in a state with Birthday Rule, is to purchase a Medigap policy during your Initial Enrollment Period.

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