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Pre-Existent Conditions and Special
Medigap Protection Mandated By Law
Under both Federal (CMS handbook "2008 Guide to
Health Insurance . . .") and New York State regulations, Medigap
policies purchased during your open enrollment period may contain up to
a six-month waiting period before pre-existing conditions are covered.
A pre-existing condition is a condition for which medical advice was
given or treatment was recommended or received from a physician within
six months before the effective date of the Medigap policy coverage. However, if the purchaser of the new
Medigap policy was covered by health insurance for six months or more,
without a break of 63 days or more, there will not be a waiting period
in the new Medigap policy for pre-existing conditions.
New York State, as a result of continuous open enrollment
"all year round", already provides more Medigap protection
than Federal law. In addition,
New York State’s special protection rules (which basically follow
Federal guidelines) state that if
you leave your managed care plan for any of the reasons described
below, you may return to Original Medicare, and obtain any Medigap policy (unlimited,
unlike Federal laws’ limited choices to Plans A, B, C, or F)
without a waiting period for preexisting conditions. But you must enroll in the Medigap
policy not later than 63 days after the date of termination of
enrollment in the HMO plan.
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1) The Medicare HMO ceases to provide services in the
area in which you reside. The
time period for "guaranteed issue" has been extended as follows:
the beneficiary may enroll in the Medigap policy any time between the
date he/she receives notice of the termination of the HMO, and ending
63 days after the date HMO coverage is terminated.
2) You were previously enrolled in a Medigap policy, subsequently
terminated the Medigap policy and enrolled in a Medicare HMO plan,
then terminated your enrollment within the first 12 months.
3) Upon first becoming eligible for Medicare benefits at age 65, you
enrolled in the Medicare HMO plan, and then leave the plan during the
first 12 months after the effective date of such enrollment.
4) You leave the HMO because you moved from the plan's service area
or the plan substantially violates a contract provision or
misrepresents the plan's provisions during marketing. The time period for
"guaranteed issue" has been extended in the above last two
cases, as follows: you may enroll in the Medigap policy beginning 60
days before the effective date of the disenrollment, and ending 63
days after the effective date of the disenrollment.
Updated: January 2, 2007
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