Medigap Guaranteed Issue Requirements: An Overview of Federal and State Rules
Medicare supplement insurance, known as Medigap, helps cover Medicare Part A and Part B cost-sharing requirements, including deductibles, copayments, and coinsurance. Medigap policies, which are sold by private insurance companies, are a key source of supplemental coverage for people in traditional Medicare without employer-sponsored retiree benefits or Medicaid. In 2024, 12.9 million Medicare beneficiaries, or 46% of all traditional Medicare beneficiaries, had a Medigap policy. While there are federal and state rules that govern the issuance of Medigap policies, including around the use of medical underwriting by insurers when issuing Medigap policies, guaranteed issue protections are generally time-limited and do not extend to beneficiaries in all age cohorts equally.
Key Takeaways
Federal law provides some guaranteed issue protections for Medicare beneficiaries who seek to purchase a Medigap policy, such as during the first six months when first enrolling in Medicare Part B, and for certain qualifying events, such as during the Medicare Advantage trial period or if a Medicare Advantage plan terminates coverage in their area.
Federal law allows Medigap insurers to use medical underwriting to either deny Medicare beneficiaries a policy or charge higher premiums outside of guaranteed issue periods. For example, beneficiaries may be denied a Medigap policy if they have a pre-existing condition and choose to switch from Medicare Advantage to traditional Medicare outside the initial 12-month trial period or seek to purchase a Medigap policy beyond the six-month window after enrolling in Medicare.
States can go beyond minimum federal requirements to establish broader guaranteed issue protections, including continuous or annual guaranteed issue requirements, establishing guaranteed issue periods for certain qualifying events, or providing guaranteed issue protections to people under age 65.
Eight states have relatively generous continuous or annual guaranteed issue protections.
Four states (CT, MA, ME, NY) require either continuous or annual guaranteed issue protections for Medigap for all beneficiaries ages 65 and older, regardless of medical history.
Four other states (DE, IL, MN, and RI) have expanded guaranteed issue protections, though they are not as comprehensive as in CT, MA, ME, and NY. For example, Rhode Island enacted legislation in 2025 to institute annual guaranteed issue protections for people 65 and older with Medicare Advantage to purchase a Medigap policy (though they do not apply to people with traditional Medicare who do not have a Medigap policy). And in Minnesota, there are annual guaranteed issue protections for individuals ages 65 to 70, which went into effect August 1, 2026.
Thirty-seven states require Medigap insurers to issue policies to Medicare beneficiaries ages 65 and older due to certain qualifying events, such as when an applicant has a change in their employer retiree coverage (29 states) or when beneficiaries lose their Medicaid eligibility (13 states).
Thirty-eight states require insurance companies to offer at least one kind of Medigap policy to Medicare beneficiaries under age 65 with disabilities during an initial open enrollment period, regardless of medical conditions. When these beneficiaries turn age 65, federal law entitles them to the same six-month open enrollment period for Medigap that is available to new beneficiaries ages 65 and older.
Federal Regulations Related to Medigap
Medigap insurance is subject to certain federal minimum requirements:
A six-month open enrollment period beginning the first month a beneficiary is enrolled in Medicare Part B, for beneficiaries ages 65 and older
A standardized set of benefits across Medigap policies, with 10 standard Medigap policies available to newly eligible beneficiaries. (Three states – Massachusetts, Minnesota, and Wisconsin – have a different set of standardized policies.)
Guaranteed plan renewability
Minimum medical loss ratio requirements
Limiting the waiting period for coverage for pre-existing medical conditions to six months for applicants that do not have at least six months of prior continuous creditable coverage
Prohibiting insurers from issuing new policies that cover the full Part B deductible, making Plans C and F no longer available to beneficiaries who turned age 65 on or after January 1, 2020.
During the one-time, six-month Medigap open enrollment period for beneficiaries ages 65 and older and certain other qualifying events, Medigap insurers cannot deny a Medigap policy to any qualifying applicant based on factors such as age, gender, or health status, nor can they vary premiums based on an applicant’s pre-existing medical conditions or exclude coverage for a pre-existing medical condition (i.e., medical underwriting).
The one-time, six-month guaranteed issue period is intended to mitigate potential selection issues in the Medigap market. Rather than waiting to incur high health care costs before purchasing a Medigap policy, beneficiaries must generally purchase a policy during the initial open enrollment period, or they risk not being able to purchase a Medigap policy later. This also has the effect of ensuring that the risk pool includes a mix of both healthier and sicker enrollees, which could keep premiums lower, on average.
However, as discussed in more detail below, the one-time open enrollment period also has the effect of locking people out of the Medigap market who might not be at higher risk of incurring high medical expenses in the short term. This could include, for example, a beneficiary who has been enrolled in a Medicare Advantage plan for a few years and wants to switch to traditional Medicare, but faces medical underwriting based on having pre-existing medical conditions.