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Medicare

What is the Medigap Birthday Rule?

The Medicare birthday rule gives customers the ability to change their Medigap plan around their birthday. Discover how this enrollment window works in your state.

What is the Medigap Birthday Rule

Medigap, also called Medicare Supplement insurance, is supplemental coverage for some of the out-of-pocket costs you might pay with Medicare. For example, Medigap policies can cover expenses related to copayments, deductibles, and coinsurance

In most states, there’s only one open enrollment period for Medigap, which can make it hard to change plans or enroll in Medigap after your initial enrollment period. But in 6 states — California, Idaho, Illinois, Louisiana, Nevada, and Oregon — you can change your coverage within a certain number of days from your birthday every year. Learn more about how the birthday rule works, which states provide it, and the period it covers in each state.

What Is the Medicare Supplement Birthday Rule?

The “birthday rule” enables Medicare enrollees to change Medigap providers within a certain number of days of their birthday in a few guaranteed-issue states: California, Idaho, Illinois, Louisiana, Nevada, and Oregon. “Guaranteed issue” means the health plan provider has to allow you to enroll regardless of your age, health status, gender, or other factors. In other words, you are permitted to enroll during the enrollment period regardless of your situation. This is important because some insurers may otherwise deny them coverage or charge significantly higher premiums.

StateBirthday Rule Enrollment Period
California30 days from birthday to change to a different Medigap plan with similar or fewer coverage
Idaho63 days from birthday to change to a different Medigap plan with similar or fewer coverages
Illinois60 days from your birthday to change to a different Medigap plan with the same or fewer coverages
Louisiana45 days after your birthday to change to any plan offered in the state with the same or fewer coverages
Nevada61 days, starting from the first day of your birth month to change to a different Medigap plan with similar or fewer coverages
Oregon31 days, beginning on your date of birth to change to a different Medigap plan with similar or fewer coverages

What Can You Do During the Medigap Birthday Rule?

If you’re currently enrolled in a Medigap plan, you can change your plan to one with equal or lesser benefits without having to get a medical examination. This allows you to change to a different insurer, or elect for a less comprehensive plan that could help lower your monthly premiums if you find that you do not need as much coverage.

During this period, you also do not have to answer a number of questions regarding your health status, age, gender, or other factors that an insurance company could use to either boost your rates or disqualify you from getting coverage. You would receive the same premiums and options as someone who is healthy.

What Can You Not Do During the Medigap Birthday Rule?

The Medigap birthday rule does not apply to those who are applying for Medigap for the first time. Instead, it is geared to those who already have a Medigap policy. For those who are already enrolled in a Medicare Supplement plan, the Medicare birthday rule only applies to those switching to a plan of equal or lesser coverage. For example, if you are currently enrolled in a Medigap plan that provides 100% coverage for Part A deductibles, you can use the birthday rule provisions to change to another plan that offers 100% coverage for Part A deductibles or less.

Conversely, if your current plan does not provide coverage for Part B copays, you may not use the Medigap birthday rule provision to change to a plan that does provide coverage for Part B copays.

If you do not have a Medigap policy already, you would not be able to sign up for a new one without first submitting to the requirements of the insurance company’s underwriting department. For example, if you are signing up for the first time outside of your initial enrollment period, and your insurer wanted to charge you more because you had pre-existing conditions, you would not be able to avoid these extra fees under the Medigap birthday rule.

Other Medigap Enrollment Periods

Apart from the birthday rule, there are some other enrollment periods where you may change Medigap plans without medical underwriting. However, outside of these enrollment periods, you can enroll and change plans at any time throughout the year so long as you understand that your health status could impact your plan options, eligibility, and premiums.

Initial Enrollment Period

The initial enrollment period is when you can first purchase Medigap. It begins the month you’re 65 or older and enrolled in Medicare Part B or Medicare Advantage. During this 6-month period, Medigap companies must sell you a policy at the best rate available, no matter your health status.

For example, if you have heart disease that requires frequent, expensive trips to the doctor, you can still sign up for Medigap, and your insurance provider cannot use that pre-existing condition to charge you a higher rate or deny your application altogether. Even if you’re likely to require extra medical care, the insurer still has to give you a policy at the best rate possible.

Unlike the Medigap birthday rule, which only applies to residents in the 6 states where it is enacted, the initial enrollment period applies to residents of every state in the U.S.

Annual Open Enrollment Periods

In Connecticut, Massachusetts, Maine, and New York, instead of a birthday rule, there is an annual Open Enrollment Period for Medigap, which works the same way as the Medigap birthday rule. If you already have Medigap and live in a state that has an open enrollment period, insurance companies must provide you with coverage if you apply between October 15 and December 7. During this time, all available options must be offered to you and you cannot be charged more based on your health status.

Medigap Enrollment For States Without Birthday Rules or Annual Open Enrollment

If you live in a state that does not have either the birthday rule or an annual open enrollment period, there are still some situations where you might have an opportunity to change your Medigap enrollment without medical underwriting. 

  • You have a Medicare SELECT plan. You may change your plan without your health status being utilized if you have a Medicare SELECT policy. This gives you the right to make changes to your coverage within 12 months of signing up.
  • Your Medicare Advantage plan service area is changing. This may happen if you are enrolled in a Medicare Advantage plan that is leaving Medicare or will stop providing care in your local area, or if you have moved out of the service area the plan covers.
  • Your Medigap plan insurer has broken Medicare mandates or otherwise misled you. In the cases where your current Medigap plan has been found to be faulty, you may change plans without medical underwriting. This includes if the insurance company you use for Medigap goes bankrupt.

Medigap Open Enrollment vs. Medicare Annual Enrollment

Though they sound the same, the Medigap Open Enrollment Period and the Medicare Annual Enrollment Period (AEP) are completely different. For one, the Medigap Open Enrollment Period only applies to the specific states that offer it. The Medicare AEP, on the other hand, is nationwide. The Medicare AEP also has to do specifically with enrollment in Original Medicare, Medicare Advantage, and Medicare Part D (the Medicare drug plan). Medigap’s Open Enrollment Period only focuses on Medicare Supplement plans.

The Medicare AEP runs from October 15 to December 7 of every year in most states. Some states have slightly different AEP windows. During this time, you can make changes to your Medicare coverage if you wanted to do so, such as changing Medicare Advantage plans, dropping Medicare Advantage to go back to Original Medicare, or changing Part D plans.

The Medigap Open Enrollment Period only applies to people who want to sign up for or change their Medigap plan. It is only available for residents of Connecticut, Massachusetts, Maine, and New York.