Guaranteed Acceptance Guide
Rev 9.2019
Blue Shield CALIFORNIA 

This is just a summary of the major reasons.  Check this entire page and website for all situations and Insurance Carriers.

Enrolled in Medicare and are age 65 or older; or  New to Medicare, are age 64 or younger, and do not have end-stage renal disease

You enrolled with  A Medicare Advantage Plan and the plan is being terminated;

terminated from any employer-sponsored health plan,

moved outside the plan’s service area.

disenrolled from the plan or program within twelve (12) months of the effective date of that enrollment.

You terminated enrollment in a Medicare Supplement plan and subsequently enrolled, for the first time, in any of the following:
• A Medicare Advantage Plan;

MAPD Trial Privileges #02110 Medi-Gap Guide

The company substantially violated a material provision of the contract; or

The company or its agent materially misrepresented a provision of the plan in marketing the contract to you.

You enrolled in a Blue Shield Medicare Advantage Plan, and Blue Shield either:
Reduced any of its benefits;
Increased the amount of cost-sharing or premium; 

You are no longer eligible for Medi-Cal benefits.

References:

CA Health Care Advocates
Federal Choosing a Medi Gap Policy  #02110
Guaranteed Acceptance Guide Blue Shield

Blue Shield Authorized Agent
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Paper Application  * Short Form - Transfers  65 Insipre, Plus, Choice & Trio
Medi Gap 

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Get Plan Documents 
Be sure though to use THIS link to enroll, so we get paid for helping you!

Special enrollment  on your birthday 
 On your birthday, you can change Medi Gap plans, guaranteed issue!

An individual shall be entitled to an annual open enrollment period lasting 30 days or more, commencing with the individual’s birthday, during which time that person may purchase any Medicare supplement policy that offers benefits equal to or lesser than those provided by the previous coverage.

Thus, if your looking to go from F to Blue Cross Innovative F or Blue Shield Plan F Extra, those are BETTER – more than equal plans and it’s not guaranteed issue.  You would have to pass underwriting.  If you can’t pass underwriting one would still be able to use the Birthday Rule GI right for plan A, F, G or N.  

During this open enrollment period, no issuer that falls under this provision shall deny or condition the issuance or effectiveness of Medicare supplement coverage, nor discriminate in the pricing of coverage, because of health status, claims experience, receipt of health care, or medical condition of the individual if, at the time of the open enrollment period, the individual is covered under another Medicare supplement policy or contract.

An issuer shall notify a policyholder of his or her rights under this subdivision at least 30 and no more than 60 days before the beginning of the open enrollment period.,  CA Insurance Code  §10192.11 (h(1)

Blue Shield - Birthday Rule
Blue Shield – Birthday Rule – Guaranteed Issue Guide

MediGap Plans from Anthem Blue Cross –
Click for Information and ONLINE enrollment

blue cross medi gap

4 comments on “Birthday Rule

  1. I’m transferring from Plan F to Plan G under the birthday rule to save premium. How come the Insurance Company called and asked about tobacco usage? It’s guaranteed issue isn’t it?

    • My initial thought is that if you are currently on a Medi Gap plan and paying the Tobacco Rate, that the new plan would have the tobacco rate too. Just because you change would not eliminate that surcharge. Let me see if I can find a citation. That’s one reason I prefer email for complex questions. So I can get the CORRECT answer and not some off the cuff answer. Even “Quick Questions” generally don’t have simple or quick answers.

      CA Insurance Code 10192.11. (h) (1) … annual open enrollment period … During this open enrollment period, no issuer that falls under this provision shall deny or condition the issuance or effectiveness of Medicare supplement coverage, nor discriminate in the pricing of coverage, because of health status, claims experience, receipt of health care, or medical condition of the individual if, at the time of the open enrollment period, the individual is covered under another Medicare supplement policy or contract.

      So, is tobacco usage protected under health status?

      Resource Brokerage.com Central States Indemnity agent underwriting guide – CA requires Tobacco usage question even in Open Enrollment or Guaranteed Issue

      Alisprotect.com says tobacco rates don’t apply

      (24)(36) “Health status” means the determination bya carrier ofthe past, present, or expected risk of an individual or the employer due to the health conditions of THE INDIVIDUAL OR the employees of the employer.
      (24.5) (37) “Health-status-related factor” means any of the following factors:
      (a) Health status;
      (b) Medical condition, including both physical and mental illnesses;
      (c) Claims experience;
      (d) Receipt of health care; Ch. 217 Insurance 913
      (e) Medical history;
      (f) Genetic information;
      (g) Evidence of insurability, including conditions arising out of acts of domestic
      violence; and
      (h) Disability. Colorado.Gov

      One might also check with https://cahealthadvocates.org/ for their research, which isn’t answered on their website

      d. Tobacco Use – If a carrier reflects tobacco usage in the calculation of rates, then it shall do so according to the following requirements:

      (3) Any rate adjustment attributable to an individual (and all similarly situated individuals) based upon tobacco usage shall be applied to that individual (and all similarly situated individuals), and shall not be distributed to the entire group; and,

      h. Health status and claims experience may not be used as case characteristics. A health questionnaire, requesting reasonable information, may be used to obtain information about the health status of group enrollees. However, the health questionnaire may not be used in any way to determine the premium rate or any rating factor that is used in the determination of the premium rate that is charged to the group, except as provided in Subparagraph (d) of this paragraph. Colorado Secretary of State

      UHC Confidential Agent Manual 2017

      Members who have smoked tobacco cigarettes or used any tobacco product at any time within the past 12 months will pay the tobacco rate. Non-tobacco rates apply to all applicants who meet open enrollment or guaranteed issue requirements.

      Obamacare/ACA doesn’t allow health questions, but it does allow tobacco usage to be surcharged 50%. CA though doesn’t allow the surcharge. Our Website

  2. If I sign up for a Hi-F Medicare Supplement plan now, can I easily switch to a regular Plan F later?

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