How It Works: Eligibility and Key Rules
Now that we know what Medigap is, let’s talk about how you can get a policy and the important rules you need to follow. This part is especially critical for getting the best price and ensuring you can’t be turned away.
Who is Eligible for Medigap?
The rules for eligibility are straightforward. To buy a Medigap policy, you must have Medicare Part A and Part B. That’s the main requirement. You pay a monthly premium to the private insurance company for your Medigap policy in addition to the monthly Part B premium you pay to the government.
The Most Important Enrollment Period of Your Life
This is a point we can’t stress enough. The absolute best time to buy a Medigap policy is during your Medigap Open Enrollment Period. This is a one-time, 6-month window that starts on the first day of the month in which you are both 65 or older and enrolled in Medicare Part B.
Why is this 6-month period so special? Because during this time, you have what are called “guaranteed issue rights.” This means that an insurance company:
Cannot deny you a Medigap policy for any reason.
Cannot charge you a higher premium because of pre-existing health conditions, like diabetes or heart disease.
This is your golden ticket. Once this 6-month period is over, you may lose these protections forever. If you apply for a policy later, insurance companies can require you to answer health questions (a process called medical underwriting). They could charge you much more or even refuse to sell you a policy at all if you have health problems.
How Do Medigap Policies Work at the Doctor’s Office?
Using a Medigap policy is typically very simple. When you visit a doctor or hospital, you will show them both your red, white, and blue Medicare card and your Medigap policy card.
The provider’s office will bill Medicare first. After Medicare pays its approved share of the bill, it automatically sends the remaining balance to your Medigap insurance company. Your Medigap plan then pays its share, which is usually all or most of what’s left, depending on which plan you have. In most cases, you will see very little paperwork and receive few, if any, bills.
This seamless process is one of the biggest benefits of having a Medigap policy. It takes the guesswork and worry out of paying for your care, allowing you to focus on your health. Resources for older adults on managing healthcare are often provided by the National Council on Aging (NCOA).
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