3.2 Pennsylvania Medicare Supplement (Medigap) Regulations
Key Takeaways
- Pennsylvania requires a 30-day free look on every Medicare Supplement policy delivered, with a full premium refund if returned.
- The federal Medigap Open Enrollment Period is 6 months, beginning the first month a person is BOTH age 65+ AND enrolled in Medicare Part B.
- During OEP and qualifying guaranteed-issue events, carriers cannot deny coverage, charge more, or impose new pre-existing waiting periods based on health.
- Medigap plans are federally standardized A through N; Plans C and F are closed to those first eligible for Medicare on or after January 1, 2020.
- Guaranteed-issue trigger events generally give a 63-day window to buy a Medigap policy without underwriting.
The 30-Day Free Look
Every Medicare Supplement (Medigap) policy delivered in Pennsylvania must give the buyer 30 days to examine it and return it for a full premium refund. This is triple the 10-day free look on ordinary health policies (3.1) because Medigap buyers are typically seniors who deserve extra review time. The 30 days run from policy delivery.
Exam anchor: Health = 10-day free look; Medigap and LTC = 30-day free look. Expect a question that lists all three side-by-side to test whether you mix them up.
The 6-Month Medigap Open Enrollment Period
The Medigap Open Enrollment Period (OEP) is a one-time, 6-month window that begins on the first day of the month in which a person is BOTH:
- Age 65 or older, AND
- Enrolled in Medicare Part B.
Both conditions must be satisfied; the period does not repeat annually. During OEP the beneficiary has full guaranteed issue and community-rated underwriting protection:
- The insurer must accept the applicant regardless of health.
- The insurer cannot charge more because of medical history.
- The applicant may buy any standardized plan the carrier offers (subject to the C/F eligibility cutoff).
- A pre-existing condition waiting period of up to 6 months may apply, but it is reduced day-for-day by prior creditable coverage held within the preceding 63 days.
Worked Scenario
Robert turns 65 on April 18 and his Part B coverage starts April 1. His Medigap OEP runs April 1 through September 30 (six months from the first of the month he is both 65 and on Part B). If a stroke history would normally make him uninsurable, the carrier must still issue and may not surcharge him during this window. Apply on October 2 and he could face medical underwriting and rate-ups.
Guaranteed-Issue Trigger Events
Outside OEP, federal and Pennsylvania rules grant guaranteed-issue rights — no health underwriting — when certain coverage is lost, generally within 63 days of the loss:
| Trigger event | Guaranteed-issue right |
|---|---|
| Loss of employer/retiree group health coverage | Buy Medigap within 63 days |
| Disenroll from Medicare Advantage in trial right (first 12 months) | Return to Medigap within 63 days |
| Medicare Advantage or SELECT plan leaves the service area | Buy a standardized Medigap plan |
| Medigap insurer becomes insolvent or is misrepresented | Switch to a comparable plan |
During a guaranteed-issue event, the insurer may not impose a new pre-existing condition waiting period.
A further protection is the Medicare Advantage trial right: a beneficiary who joins a Medicare Advantage plan at first eligibility for Medicare, then drops it within the first 12 months, may return to any Medigap plan with guaranteed issue. Distinguish this from the annual Medicare Open Enrollment (Oct 15–Dec 7) for Part C/Part D, which is unrelated to Medigap underwriting — a frequent exam decoy.
Standardized Medigap Plans A–N
Medigap is federally standardized: a Plan G from any carrier covers the identical benefits as a Plan G from another — only price and service differ. Pennsylvania adopts these standards.
| Plan | Distinguishing feature |
|---|---|
| A | Core/basic benefits only (the minimum every carrier must offer) |
| B | Core + Part A deductible |
| C | Comprehensive incl. Part B deductible — closed to those newly eligible on/after 1/1/2020 |
| D | Like C without Part B deductible coverage |
| F | Most comprehensive incl. Part B deductible & excess charges — closed on/after 1/1/2020 |
| G | Like F but does NOT cover the Part B deductible |
| K | 50% cost-sharing with annual out-of-pocket maximum |
| L | 75% cost-sharing with annual out-of-pocket maximum |
| M | Covers 50% of the Part A deductible |
| N | Lower premium; copays for some office and ER visits |
Critical 2020 rule: Plans C and F (the two that pay the Part B deductible) are closed to anyone first eligible for Medicare on or after January 1, 2020. Those eligible before that date may still buy or keep C/F. Plan G has become the popular comprehensive choice for new beneficiaries because it covers everything F does except the Part B deductible.
Required Offerings in Pennsylvania
A carrier selling Medigap in Pennsylvania must make Plan A (core benefits) available, and if it sells any other plan it must also offer either Plan C or Plan G (with F still permitted for pre-2020 eligibles). This guarantees consumers a basic option and a comprehensive option.
Pre-Existing Conditions and Rate Structures
| Situation | Pre-existing waiting period |
|---|---|
| During OEP, no prior coverage | Up to 6 months |
| During OEP with creditable coverage (within 63 days) | Reduced day-for-day, often eliminated |
| Guaranteed-issue event | Not permitted |
Pennsylvania permits three rating methods, and the exam tests the difference:
- Issue-age rating: premium based on age at purchase; does not rise simply because you grow older.
- Attained-age rating: premium rises each year as you age (cheapest early, costliest late).
- Community rating / no-age rating: everyone pays the same regardless of age.
All Medigap rate increases must be filed with the PID. Selling Medigap without delivering the CMS "Guide to Health Insurance for People with Medicare" and an outline of coverage is a market-conduct violation.
Robert is 66 and enrolls in Medicare Part B on June 1. When does his one-time 6-month Medigap Open Enrollment Period end, and what protection does it give him?
A client first becomes eligible for Medicare in 2026 and wants the plan that pays the Medicare Part B deductible. What must you tell her?