Case Flash: Right To Purchase A Medigap When Retiree Coverage Ends

Mr. R had Original Medicare Parts A and B, as well as a stand-alone Medicare Part D prescription drug plan. He also had retiree health insurance that filled gaps in his Original Medicare coverage. Recently Mr. R moved to a new state to be closer to his children and grandchildren. Shortly after he moved, Mr. R developed an ear infection and went to see a nearby doctor. A few weeks later, Mr. R received a bill in the mail for a coinsurance for the appointment. Mr. R was confused because his retiree insurance had always paid his full Medicare coinsurances and deductibles as long as he went to doctors that took Medicare assignment (accepted Medicare’s approved amount for a service as payment in full). He called the doctor’s office and found out that the retiree plan had denied the claim.

Mr. R called the Medicare Rights Center and spoke to a hotline counselor, who explained to him that unlike Original Medicare, which allows you to receive medical care anywhere in the country, many private insurance plans, such as retiree plans (and Medicare private health plans and plans from current employers), cover you only when you are in their geographical service area. Together, the hotline counselor and Mr. R called the retiree plan and asked whether Mr. R could receive coverage from the plan in his new state. The retiree plan representative explained that Mr. R’s retiree plan was not a national plan and could only be used in the state where he used to live. Because of this, Mr. R’s retiree coverage had ended when he moved.

The hotline counselor explained to Mr. R that while he had lost his retiree plan coverage, it would still be possible for him to get supplemental coverage to Original Medicare through a “Medigap.” In many states, you can only buy a Medigap policy at certain times. If you miss your window of opportunity, you may not be able to buy one at all, or you may have to wait before a Medigap will cover pre-existing conditions. In all states, when you lose certain kinds of supplemental insurance through no fault of your own, you have a 63-day period during which you are entitled to purchase certain Medigaps; in the case of loss of retiree coverage, you can buy at least Medigap plans A, B, C or F (there are 12 types of Medigap plans, labeled A-L, each of which cover a different set of benefits).

The hotline counselor then helped Mr. R understand the different benefits offered by different types of Medigaps, and sent him a list of insurance companies in his new state that sell Medigap coverage. Mr. R reviewed the list and decided on a plan that would supplement the benefits he needed and that would be affordable for him. He then called the insurance company that offered the best price and enrolled in the Medigap.

-From: MEDICARE WATCH, a biweekly electronic newsletter of the Medicare Rights Center Vol. 11 , No. 18 : September 2, 2008.

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