Medicare by State

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Medicare by State

Original Medicare is a federal healthcare program that provides the same benefits nationwide, regardless of state. Thus, Original Medicare benefits do not differ by state.

However, each individual state can implement rules around enrollment, guaranteed issue rights, and more if the rules meet federal Medicare regulations.

Below, we review different Medicare rules you should know, and to which states they apply.

How is Medicare Different in Each State

Original Medicare is made up of Medicare Part A and Medicare Part B. These parts of Medicare cover your inpatient services, outpatient services, durable medical equipment, and more. No matter where you live in the U.S. Original Medicare coverage will be the exact same. This is because Original Medicare is regulated by the federal government.

Once you have enrolled in Original Medicare, you can enroll in Medicare Part D plans which cover the cost of prescription drugs.

To supplement your Original Medicare benefits, you can enroll in a Medicare Supplement plan or a Medicare Advantage plan. These two plan types provide benefits to enrollees that Original Medicare does not cover. Medicare Supplement plans cover the out-of-pocket costs left over by Original Medicare and some plans provide international emergency coverage. Medicare Advantage plans can cover additional benefits like dental, vision, transportation, or hearing.

Is Medicare Part D Different in Each State?

Medicare Part D plans do vary based on where you live. Your location can affect the plans available to you as well as the monthly premium you pay.

Most carriers offer plans throughout the U.S. However, those plans may have a different monthly premium. Keep in mind, plans of the same name will have the same preferred pharmacies, out-of-pocket costs, and formulary.

Is Medicare Advantage Different in Each State?

Medicare Advantage plans are sold by private insurance companies. Thus, they differ by location. While the same carriers may offer plans by the same name, it is important to understand your plans benefits as they may change by ZIP Code.

Are Medicare Supplement Plans Different in Each State?

Medicare Supplement plans are the same regardless of the state where you enroll. There are 10 lettered plans (A-N) and 2 high deductible Medicare Supplement plans that are standardized throughout the U.S. However, many states have state-specific rules in place to help the enrollment process for residents of the state who have Medicare.

Not every state offers state-specific perks and states that do each have their own rules how the rules can be used.

State-specific rules for Medicare Supplement plans include:

State-Specific Medicare Supplement Plans
Costs by state
Excess Charges
Available plans for those under 65
Employer coverage termination

State-Specific Medicare Supplement Plans

Medicare Supplement plans are standardized nationwide. However, there are three states that have unique Medicare Supplement plans for its residents.

These states are:

Massachusetts
Minnesota
Wisconsin

Massachusetts has three Medicare Supplement plans available to beneficiaries. These include:

Core Plan
Supplement 1
Supplement 1A

These Medicare Supplement plans offer basic Medicare benefits with additional coverage options. Supplement 1A is the most comprehensive, and the Core Plan is the most basic.

Minnesota offers two Medicare Supplement plans for Original Medicare enrollees. These plans are:

Basic Plan
Extended Basic Plan

These plans provide basic Medicare benefits, foreign travel coverage, and more. While the options work very similarly, the Extended Plan has more benefits.

Wisconsin offers three Medicare Supplement plans that are fully customizable to include the benefits you need. These Medicare Supplement plans are:

Basic Plan
25% Cost-Sharing Plan
50% Cost-Sharing Plan

Each plan above offers a list of add-ons that provide extra benefits. In addition to the three plans listed above, Wisconsin also offers the standardized Medicare Supplement High Deductible Plan F. This is the exact same Medicare Supplement High Deductible Plan F that is available nationwide.

Additionally, like the traditional lettered plans in the other 47 states and Washington, D.C., plans do not vary between carriers. This means regardless of the carrier you choose, the benefits of each plan are the exact same.

Medicare Supplement Difference by State: Birthday Rules

Medicare Supplement Open Enrollment allows you to enroll in a Medicare Supplement plan without answering medical underwriting health questions. This means that your policy cannot be denied due to pre-existing health conditions. Typically, this is a one-time enrollment period. However, certain states open this enrollment period annually for enrollees.

Birthday rules are a unique opportunity for Medicare Supplement Open Enrollment in some states. If your state includes a provision for a birthday rule, each year around your birthday, you can enroll in a Medicare Supplement plan with no underwriting health questions and no risk of denial.

You can still enroll in a Medicare Supplement plan outside of this enrollment period. However, you may be required to answer underwriting health questions. So, your policy could be denied due to your health. Having a birthday rule in place allows you to have the freedom to change plans if your health changes and you would otherwise not be eligible to change plans.

Not every state allows a birthday rule. Further, states offering this perk have their own regulations regarding enrollment. Below is a list of the states providing birthday rules for their Medicare Supplement enrollees and how to utilize each state’s rule.

Remember, all birthday rules only apply to those with a Medigap plan already.

California – The California birthday rule begins 30 days before your birthday and ends 60 days after your birthday. During this window, you can enroll in any plan of equal or lesser benefits to your current plan with the carrier of your choice.
Idaho – The Idaho birthday rule begins on your birthday each year and lasts 63 days. You can enroll in any plan of equal or lesser benefit with any carrier during this time.
Oregon –Each year, the Oregon birthday rule begins on your birthday and ends 30 days later. This period allows you to enroll in any Medicare Supplement plan with equal or lesser benefits, through the carrier of your choice.
Illinois – The Illinois birthday rule offers a 45-day window to enroll in any plan beginning on your birthday each year. The policy in which you enroll must have equal or lesser benefits and be through your current carrier.
Louisiana – The Louisiana birthday rule is a 93 day open enrollment period that begins 30 days before your birthday. During this time you may change your Medicare Supplement plan to a Medicare Supplement plan of equal or lesser benefit with your current carrier.
Nevada – The Nevada birthday rule lasts 61 days, beginning on the first day of your birth month. During this time, you can change to any plan of lesser or equal benefit with any carrier.

Medicare Supplement Difference by State: Annual Guaranteed Issue Rights

Guaranteed issue rights allow you to enroll in a Medicare Supplement plan without underwriting health questions and this typically happens once in your lifetime during your Medicare Supplement Open Enrollment Period.

However, if you live in a state that allows an annual guaranteed issue period, you will be able to enroll in a Medicare Supplement plan and be accepted to the plan with no underwriting health questions once a year. This annual guaranteed issue period happens one time each year at an allotted time. This means that during this time, your pre-existing health conditions do not affect enrollment.

Unlike a birthday rule, every beneficiary in the state is given the exact same time period to enroll in a plan without health questions. This is not individualized.

Missouri – Each year, you can make a change to your Medicare Supplement plan up to 30 days before your policy anniversary and up to 30 days after your policy aniversery. During this time, you can enroll in a Medicare Supplement plan of equal or lesser benefits through the carrier of your choice.
Maine – All Medicare Supplement carriers must designate one month each year to guarantee acceptance to applicants for at least Medicare Supplement Plan A. The designated month in Maine is June, however, carriers may choose to extend this period.

Is Medicare Different in Each State: No Health Questions Year-Round

Four states allow you to enroll in a Medicare Supplement plan at any time throughout the year without answering underwriting health questions. There are no limits to how many times you can change your plan.

Unlike a birthday rule or annual guaranteed-issue rights, these states allow you to enroll in a plan with no health questions at any time as many times as you wish during the year.

By allowing you to enroll in a plan without health questions, this means you can change plans at any time for any reason, regardless of your health. These states are:

Connecticut
New York
Vermont (UnitedHealthcare and Mutual of Omaha only)
Washington

If you live in any of the above states, you do not need to be concerned about pre-existing health conditions when enrolling in a Medicare Supplement plan.

Medicare Supplement Plans for Those Under 65

Often, Medicare Supplement carriers will charge higher premiums to those under 65 on Medicare due to their high-risk disability status. Not every state requires companies to provide Medicare Supplement coverage to disabled individuals under 65, but those that do often have low enrollment for those under 65 due to the high premium costs.

States that require Medicare Supplement plan carriers to provide at least one plan to those under 65 include:

Alabama
Arkansas
Arizona
Idaho
Indiana
Iowa
Nebraska
Nevada
New Mexico
North Dakota
Ohio
Rhode Island
South Carolina
Utah
Virginia
Washington
West Virginia
Wyoming

Is Medicare Different in Each State: Employer Coverage Termination

You may be receiving healthcare coverage through your employer after turning 65. In this case, states have different rules regarding when you can apply for Medicare Supplement coverage once voluntarily terminating group coverage.

Generally, leaving employer coverage voluntarily before retirement will not allow you to enroll in any Medicare Supplement plan with guaranteed issue rights. This means when you choose to drop your employer plan and pick up a Medicare Supplement plan before retiring, while you are still eligible for employer coverage and after your Initial Enrollment Period ends, you may need to answer underwriting health questions.

For example, if you become eligible for Medicare at 65 and do not retire until 75 but decide to drop your employer coverage at age 70, you may not be eligible for guaranteed issue rights until you retire at 75.

However, not all states share this same rule. There are some states that will allow you to receive guaranteed issue rights when you leave group insurance voluntarily.

The states that do allow guaranteed issue rights are:

Alaska
Arkansas
California
Colorado
Florida
Idaho
Illinois
Indiana
Iowa
Kansas
Louisiana
Maine
Mississippi
Montana
Nevada
New Jersey
New Mexico
Ohio
Oklahoma
Pennsylvania
South Dakota
Texas
Virginia
West Virginia
Wisconsin

Does Medicare Cost Different in Each State?

Original Medicare costs are the same across the country. As a federal program, Original Medicare benefits, price, and availability do not differ across state lines.

However, Medicare Advantage, Medicare Supplement, and Medicare Part D plan costs vary by state. Additionally, Medicare costs may not differ across state lines, but they can vary based on your income due to IRMAA. This requires higher earners to pay more monthly for Medicare Part B and Part D.

Wisconsin offers three Medicare Supplement plans that are fully customizable to include the benefits you need. These Medicare Supplement plans are:

Basic Plan
25% Cost-Sharing Plan
50% Cost-Sharing Plan

Is Medicare Different in Each State: Medicare Excess Charges

Medicare excess charges are an additional charge of up to 15% above the Medicare-approved cost for a service, otherwise known as Medicare assignment.

A doctor can accept Medicare without accepting Medicare assignment. If this is the case, they can bill the excess charge of up to 15%.

Excess charges are rare, and not every state allows them. The states that do not allow excess charges are:

Connecticut
Massachusetts
Minnesota
Ohio
New York
Pennsylvania
Rhode Island
Vermont

However, even if you live in a state that allows these charges, it is unlikely you will run into them—only a small percentage of Medicare-accepting doctors nationwide bill for excess charges.

Understanding How Medicare is Different in Each State

It is no secret that Medicare can be confusing. State-specific rules can add even more twists and turns to the Medicare maze. That is where your licensed Medicare agent comes in.

Before making any decisions about coverage, it is important to sync up with a licensed Medicare professional to help you through these crucial choices to ensure you do not miss out on any of the great Medicare-related perks your state offers.