Important Information
This is a reminder regarding California Insurance Code 10192.12, Section (D)(i), which defines guaranteed issue rights when a Medicare Advantage plan undergoes significant changes.
Summary
An individual becomes eligible for a Medicare Supplement (Medigap) policy if their Medicare Advantage plan:
- Increases premiums by 15% or more
- Increases physician, hospital, or drug copayments by 15% or more
- Reduces any benefits
- Terminates its contract with a provider currently furnishing services (except for good cause related to quality of care)
Eligibility Rules
- The individual may first apply for a Medigap policy from the same issuer they were enrolled with at the time of the Medicare Advantage change.
- Beginning January 1, 2007, eligibility also includes a subsidiary of the parent company or a network contracting with the parent company.
- If no Medigap policy is available from the same Medicare Advantage carrier or affiliates, the individual may apply for a policy from any carrier under subdivision (e).
Action Steps
- Confirm whether the triggering event meets the criteria above.
- Offer the individual a Medigap policy from the same Medicare Advantage carrier or its affiliates first.
- If unavailable, assist with applying for a policy from any issuer as permitted.
Thank you for your dedication to supporting clients and guiding them through these rules to ensure clarity and prevent confusion.
#GoldenCareAgent