🎂 Medicare’s Birthday Rule – What You Need to Know (Agent & Client Guide)

For Agents:

Unlike Medicare Advantage and Part D, Medicare Supplements (Medigap) can be changed any time of year—as long as the client qualifies for underwriting. (i.e. There is no open enrollment period for Medigap plans).

However, in a handful of states, there’s a unique provision called the Birthday Rule that allows certain clients to switch without medical underwriting. Here’s how it works:

• During the client’s birthday month (exact timing can vary by state and carrier),

• They can switch to a different carrier offering the same Medigap plan,

• No medical questions asked—a guaranteed issue switch.

• The 9 states are: California, Idaho, Illinois, Kentucky, Louisiana, Maryland, Nevada, Oklahoma, Oregon, Utah, and now Virginia.

❗ Important Limitations:

• They must stay on the same plan type.
  Example: Plan G ➝ Plan G is allowed.
  Plan N ➝ Plan G is not allowed.

• This is not an upgrade or downgrade opportunity, just a rate shopping tool.

Why This Matters:

• Clients can potentially lower their premium without risking coverage loss.

• Good option for clients with health issues who wouldn’t pass underwriting.

However, agents should be aware:

• In Birthday Rule states, Medigap premiums are often higher overall, because insurers must accept sicker individuals during the birthday window.

• Agent compensation for Birthday Rule changes is often very low (typically 0.7%–3%)—carriers intentionally discourage these switches.

• Doing too many Birthday Rule apps can damage your relationship with carriers. Carriers track this activity and may label agents as “high churn.”

Explaining It to the Client:

“Some states have what’s called a Birthday Rule, which gives you a once-a-year chance, around your birthday, to change your Medicare Supplement to another company—without answering any health questions. You have to stay on the same type of plan, but if you find a lower premium, this could help you save money each month.”

When to Consider Medicare Advantage Instead

If the cost of a Medigap plan is rising, it may be time to re-evaluate your overall Medicare strategy.

Let’s break it down:

Compare this with a Medicare Advantage (MA) plan:

• Lower (or $0) premium

• Includes drug, dental, and vision

• Out-of-pocket costs only apply if you use services

• Annual MOOP (Maximum Out-of-Pocket) in many counties: $3,500–$4,000

So with Medigap, you’ll pay $3,720 no matter what.
With an MA plan, you only pay up to $3,500 if you use enough care to hit the cap.

For some clients, that switch makes financial sense.

⚖️ Final Thoughts: Know the Whole Picture

• The Birthday Rule can be a great tool, but it comes with limitations.

• It’s not always the best solution—especially in high-premium states.

• Take a holistic view: premium, coverage, network, and out-of-pocket risk.

• And always ask: Does this serve the client’s long-term health and financial needs?