3.2 West Virginia Medicare Supplement Regulations
Key Takeaways
- The Medicare Supplement (Medigap) open enrollment period lasts 6 months and starts the first day of the month the applicant is both age 65 or older AND enrolled in Medicare Part B.
- During open enrollment, Medigap is guaranteed issue with no medical underwriting and no pre-existing waiting period (a prior-coverage credit shortens any look-back).
- Plans are standardized A, B, D, G, K, L, M, and N for new enrollees; Plans C and F (which cover the Part B deductible) are closed to anyone first Medicare-eligible on or after January 1, 2020.
- West Virginia requires a 30-day free look on replacement and a 6-month maximum pre-existing condition look-back; insurers must deliver an Outline of Coverage and the Medicare 'Choosing a Medigap Policy' guide.
- Guaranteed-issue rights also arise from loss of employer or Medicare Advantage coverage, the MA trial-right period, and insurer insolvency.
The 6-Month Open Enrollment Window
The single most-tested Medicare Supplement (Medigap) fact is the open enrollment period. It lasts 6 months and begins on the first day of the month in which the applicant is BOTH:
- age 65 or older, AND
- enrolled in Medicare Part B.
During this one-time, 6-month window the policy is guaranteed issue:
- The insurer cannot decline the applicant for health reasons.
- The insurer cannot charge a higher premium based on health status.
- The applicant may buy any Medigap plan the insurer sells in West Virginia.
- A pre-existing condition exclusion of up to 6 months is permitted, but prior creditable coverage reduces or eliminates it day-for-day.
Worked timing example: Maria turns 65 on April 18 and is already enrolled in Part B. Her open enrollment period runs from April 1 through September 30 (the first of her birth month plus six months). If she delays Part B until July, the 6-month clock instead starts July 1. Test items love to push the start date to the birthday itself — it is the first of the month, not the birthday.
Guaranteed-Issue Rights Outside Open Enrollment
After open enrollment closes, insurers may medically underwrite — EXCEPT in specific guaranteed-issue situations protected under federal and West Virginia law:
| Trigger | Guaranteed-issue right |
|---|---|
| Employer/retiree group coverage ends | Buy Medigap within 63 days of losing coverage |
| Medicare Advantage (MA) plan leaves the service area or terminates | Return to Original Medicare + Medigap |
| MA trial right — enrolled in MA at first eligibility and disenroll within 12 months | Buy any Medigap |
| Medigap insurer becomes insolvent or commits misrepresentation | Buy a replacement Medigap |
In each case the applicant generally has a 63-day window measured from the loss of coverage. A common distractor stretches this to 90 days — it is 63 days.
Standardized Medigap Plans
Medigap benefits are standardized by the federal government: a Plan G sold by any insurer in West Virginia provides identical core benefits, so consumers compare on price and service, not benefit design. The currently offered letters and what they emphasize:
| Plan | Key feature |
|---|---|
| A | Core/basic benefits only |
| B | Core + Part A deductible |
| D | Comprehensive, no Part B excess charges |
| G | Most comprehensive available to new enrollees; covers Part B excess charges (only the Part B deductible is not paid) — the most popular plan |
| K | 50% cost-sharing with an annual out-of-pocket limit |
| L | 75% cost-sharing with an annual out-of-pocket limit |
| M | Covers 50% of the Part A deductible |
| N | Lower premium with copays (up to $20 office, $50 ER that is not an admission) |
The Plan C / Plan F rule (heavily tested): Plans C and F pay the Part B deductible. Because of the federal MACRA change, they are closed to anyone who first became eligible for Medicare on or after January 1, 2020. Someone eligible before that date may still buy or keep C or F. So Plan G is the most comprehensive choice for new enrollees, which is why it overtook F in popularity.
Trap: an answer claiming Plan F is "unavailable to everyone" is wrong — it remains available to those Medicare-eligible before 1/1/2020.
West Virginia Disclosure and Replacement Rules
West Virginia adds consumer protections on top of standardization:
- Outline of Coverage must be delivered at or before application (or with the policy if not earlier).
- The official Medicare guide "Choosing a Medigap Policy" must be provided.
- Pre-existing condition look-back is capped at 6 months.
- On a replacement, the producer must furnish a Notice to Applicant Regarding Replacement and the policy carries a 30-day free look.
- Suitability / no excessive sales: producers may not knowingly sell a duplicate Medigap policy to someone who already has one or who has Medicaid — doing so is a prohibited practice.
Scenario: A producer replaces a client's Plan N with a Plan G. He must deliver the replacement notice, ensure the old policy is not cancelled until the new one is in force, and inform the client of the 30-day right to return the new policy for a full refund. Selling the Plan G in addition to an active duplicate Medigap would be an unfair trade practice.
Medigap vs. Medicare Advantage and Coordination
The exam tests the line between Medigap and Medicare Advantage (MA, Part C) — they are mutually exclusive products:
| Feature | Medigap (Supplement) | Medicare Advantage (Part C) |
|---|---|---|
| Works with | Original Medicare (Parts A and B) | Replaces Original Medicare |
| Networks | Any provider that accepts Medicare | Usually HMO/PPO networks |
| Standardization | Lettered Plans A–N | Not standardized |
| Can you have both? | No — illegal to sell Medigap to an active MA enrollee unless disenrolling | — |
Trap: it is a prohibited practice to sell a Medigap policy to someone enrolled in MA unless they are leaving MA and returning to Original Medicare. Likewise, Medigap does not cover Part D prescription drugs — those require a separate Part D plan.
Premium Rating Methods
West Virginia insurers may price Medigap using one of three rating methods, and producers must disclose which is used:
- Issue-age rated: premium based on age when purchased; does not rise with age.
- Attained-age rated: premium based on current age; rises as the insured grows older — cheapest early, most expensive later.
- Community rated (no-age): everyone pays the same regardless of age.
Common trap: attained-age policies look cheapest at issue but climb steeply over time; the exam expects you to flag attained-age as the method whose premium increases purely because of aging.
A man enrolls in Medicare Part B effective the month he turns 66. When does his Medigap open enrollment period begin?
Which statement about Medigap Plans C and F is correct in West Virginia?
What is the maximum pre-existing condition look-back West Virginia allows on a Medicare Supplement policy?