Medicare Supplement
Insurance Consumer Rights
Your Rights as a Medicare Supplement Consumer

Open Enrollment

Seniors: Medigap companies must sell you a policy - even if you have health problems - if you are at least 65 and apply within six months after enrolling in Medicare Part B. These six months are called your "open enrollment" period. During open enrollment, a company must allow you to buy any of the Medigap plans it offers. You can use your open enrollment rights more than once during this six-month period. For instance, you may change your mind about a policy you bought, cancel it, and still have the right to buy any other Medigap policy, so long as the sale takes place during the six months after you enroll in Medicare Part B.

Although a company must sell you a policy during your open enrollment period, it may require a waiting period of up to six months before covering your pre-existing conditions. Pre-existing conditions are conditions for which you received treatment or medical advice from a physician within the previous six months.

Your right to open enrollment is absolute, even if you wait for several years after you become 65 to enroll in Medicare Part B because of continued employment or other reasons.

Texans with disabilities: In Texas, people under age 65 who receive Medicare because of disabilities have a six-month open enrollment period beginning the day they enroll in Medicare Part B. This open enrollment right is only applicable to Medigap Plan A. Companies selling Medicare supplement insurance in Texas may not deny you a Plan A policy because you have pre-existing conditions. Companies are not required to offer the other plans to Texans with disabilities, but they may do so if they wish. During the first six months after you turn 65 and are enrolled in Medicare Part B, you will have a right to buy any of the 12 plans.

Guaranteed Issue

You may have the right to buy a Medigap policy outside of your open enrollment period if you lose certain types of health coverage. For people over age 65, the guaranteed issue right applies to Medigap plans A, B, C, F, K, and L. For people under age 65, this guaranteed issue right applies only to Medigap Plan A. In general, this right is for 63 days from the date coverage ends or from the date of notice that coverage will end. Companies may not place any restrictions, such as pre-existing condition waiting periods or exclusions, on these policies. This is called "guaranteed issue." You must provide proof of the loss of your health care coverage. Texans under age 65 with disabilities who enroll in Medicare Part B also have guaranteed issue rights, but they are only eligible for Medigap coverage under Plan A. This guaranteed issue right is also extended to people on Medicare who lose Medicaid because of a change in their financial situation. For more information, read the Guide to Health Insurance for People with Medicare.

30-Day "Free Look"

You can return your Medigap policy within 30 days after receiving it and get your money back-with no questions asked. Be sure to keep a record of the date you received the policy. Read the policy as soon as you get it. If you return the policy to the company, use certified mail with a return receipt as proof that it was returned within the 30-day time limit.

Renewability

All Medigap policies are guaranteed renewable. A company cannot cancel your policy or refuse to renew it unless you made intentional material false statements on your application or failed to pay your premium. However, the amount of the premium is not guaranteed. An insurance company may raise your premium as often as once a year on a class basis. In addition, if you have an "attained-age policy," a company may raise your premium on your birthday.

Medicare Supplement Claims

Your doctor and other health care providers must submit Medicare claims to the appropriate carrier or fiscal intermediary for you. In most cases, the carrier or intermediary will send your Medigap claim directly to your insurance company.

Medigap policies won´t pay for services that Medicare does not deem medically necessary.

Therefore, if the carrier or intermediary denies your claim as medically unnecessary, your Medigap company won´t pay it. You have the right to appeal the decision to deny a claim. The appeal process and timeframes to request an appeal are described in your Medicare Summary Notice.

Texas law requires insurance companies to pay claims promptly. If your Medigap company refuses to pay a claim for a Medicare-approved charge or delays payment of your claims, you may file a complaint with TDI.

Group Medicare Supplement Insurance

Your rights with a group Medigap policy are essentially the same as with an individual policy. Because the group might make decisions that are out of your control, you have the following additional protections:

• If the group changes insurance companies, the new company must offer coverage to everyone previously covered. The new Medigap policy must cover pre-existing conditions that were covered by the old policy.
• If you leave the group, the insurance company must offer to provide unbroken Medigap coverage with an individual policy or continuation of your group insurance.
• If the group cancels its coverage, the insurance company must offer you either an individual policy continuing the benefits you had before or a different policy meeting Texas requirements.