Medicare's parts, Medicaid and long-term care basics are covered in the national Senior and Special Needs guide. This guide covers Virginia's Medicare supplement rules (38.2-3600 series; 14VAC5-170) and long-term care rules (38.2-5200 series; 14VAC5-200).

Medicare supplement

Open enrollment and access

• Open enrollment: the 6 months beginning with the first month a person is 65 or older and enrolled in Part B. Issuers can't deny, condition or price coverage on health (14VAC5-170-100).
  • With at least 6 months of creditable coverage, no preexisting exclusion applies.
• Disabled beneficiaries under 65 (38.2-3610):
  • Issuers must offer at least one plan if they apply within 6 months of first eligibility, or within 63 days of losing group coverage.
  • Since January 1, 2024, their premium can't exceed the rate for a 65-year-old on the same plan.

Policy terms

• Preexisting conditions: no denial for losses more than 6 months after the effective date (38.2-3605).
• Free look: 30 days (38.2-3604).
• The first page must say "Notice to buyer: This policy may not cover all of your medical expenses" (14VAC5-170-180).
• Medicaid: benefits and premiums may be suspended for up to 24 months, if requested within 90 days of Medicaid eligibility (14VAC5-170-160).

Selling rules

• The outline of coverage is given when the application is presented, with a signed acknowledgment (14VAC5-170-150).
• The Guide to Health Insurance for People with Medicare is also given.
• Replacement: agents list the health policies they've sold the applicant that are still in force, and those sold in the past 5 years (14VAC5-170-160).
• Appropriateness and duplication (14VAC5-170-190):
  • Agents make reasonable efforts to decide whether a purchase or replacement is appropriate.
  • Selling someone a second Medigap policy is prohibited.
  • A Medicare Advantage enrollee may buy only a policy that starts after Part C ends.
• Commissions: first-year pay is capped at 200% of second-year pay. Renewal pay equals the second year's for at least 5 years (14VAC5-170-140).
• Prohibited marketing (14VAC5-170-180):
  • high-pressure tactics
  • cold lead advertising
• Medigap ads are filed with the Commission (38.2-3609).
• Self-conferred senior designations are prohibited (14VAC5-43-20).

Long-term care

Policy protections

• Guaranteed renewable or noncancellable only (14VAC5-200-60).
• Free look: 30 days from delivery (38.2-5208).
• Preexisting conditions: a 6-month look-back, and no exclusion beyond 6 months after coverage starts (38.2-5204).
• Rescission (38.2-5209):
  • From 6 months to 2 years, a misrepresentation must be material and related to the condition claimed.
  • After 2 years, only knowing and intentional health misrepresentations count.
• Replacement: the new insurer waives preexisting and probationary periods already satisfied (14VAC5-200-190).
• Rate increases: notice within 60 days of filing, and at least 90 days before an approved increase takes effect (38.2-5206.1).

Benefit triggers (14VAC5-200-187)

• A policy can require no more than a deficiency in 3 ADLs, or a cognitive impairment.
• The ADLs include bathing, continence, dressing, eating, toileting and transferring.

Inflation and nonforfeiture

• Insurers offer inflation protection at least as good as 5% compound (14VAC5-200-100).
• They offer nonforfeiture. If it's declined, the contingent benefit upon lapse applies after a substantial rate increase (38.2-5210).

Lapse protection (14VAC5-200-65)

• The applicant names a third-party designee or signs a waiver.
• The lapse notice goes out 30 days ahead.
• Reinstatement within 5 months is available for cognitive or functional impairment.

Selling rules

• The outline of coverage is delivered before an application is presented (38.2-5207).
• The Long-Term Care Insurance Consumer Guide is delivered with the policy.
• The Personal Worksheet is used at or before application (14VAC5-200-175).

Partnership policies (14VAC5-200-205)

• Agents need 8 hours of training, then 4 hours every 24 months.
• Inflation protection by age:

Common exam traps

• Medigap and LTC free looks are both 30 days. Individual A&H is 10 days.
• Disabled people under 65 must be offered a Medigap plan, at no more than the age-65 rate.
• LTC outline of coverage comes before the application. The Consumer Guide comes at delivery.
• LTC rate increases need 90 days' notice.