Medicare Birthday Rule Explained: What Agents Need to Know About Medigap Switching

What is the Medicare Birthday Rule?

The Medicare birthday rule gives people with a Medicare Supplement (also known as Medigap) plan the chance to switch plans each year around their birthday — without going through medical underwriting.

That said, it’s not a one-size-fits-all rule. The details — like timing, what plans clients can choose, and whether they can switch companies — depend heavily on the state you live in.

In simple terms, once someone is past their initial Medicare enrollment period, the birthday rule can act as a yearly opportunity to revisit and adjust their coverage.

Why the Birthday Rule Matters for Agents

If you’re working with Medicare clients, the birthday rule creates a built-in reason to reconnect every year. It’s a natural touchpoint to review coverage, check for savings, and make sure clients still have the right plan for their needs.

Which States Have a Birthday Rule?

The number of states offering some version of the birthday rule has grown, and it’s still evolving.

The most established states include:

• California
• Oregon
• Idaho
• Illinois
• Nevada

Other states — like Louisiana, Maryland, Oklahoma, Kentucky, Indiana, Virginia, Utah and Wyoming — have introduced similar rules or are in the process of doing so, though they may work a bit differently.

The big takeaway: fewer than half of all states offer a true birthday rule or something equivalent. Because of that, understanding the specifics in each state you work in is essential.

How the Birthday Rule Works (And How It Varies)

While the general idea is the same, states differ in three main ways:

• When the window happens
• What plans the client can switch to
• Whether clients can change insurance carriers

For example:

• Some states give you 30 days, others closer to 60
• Most require you to move to a plan with equal or lesser benefits
• Some allow switching carriers freely, while others limit you to the same company

A few states are even stricter, requiring you to keep the same plan letter (like Plan G to Plan G).

These differences can have a big impact on how you quote and position options for clients.

Birthday Rule Versus Medigap Open Enrollment

It’s easy to confuse the birthday rule with Medigap’s open enrollment, but they’re not the same.

• Open enrollment is a one-time window when someone first enrolls in Part B. During that time, they can choose any plan with no restrictions.
• The birthday rule happens annually but comes with limitations — usually requiring equal or lesser coverage.

Think of the birthday rule as a second chance to make changes — but not with the same level of flexibility as that initial window.

Is It the Same as Guaranteed Issue?

Not exactly.

The birthday rule shares some similarities with guaranteed issue — mainly that underwriting is typically waived — but it’s more limited.

Guaranteed issue rights are triggered by specific life events and usually offer broader plan access. The birthday rule, on the other hand, is tied to a yearly window and comes with stricter plan rules.

Does It Waive Underwriting?

In most states, yes.

That means:

• No health questions
• No denials based on conditions
• No rate changes due to health

This is a big deal, especially for clients whose health has changed over time.

Can Clients Switch Carriers?

Sometimes.

States like California, Oregon, Idaho and Nevada generally allow carrier switching. Others — like Illinois — often limit changes to the same carrier or an affiliate.

This matters when you’re comparing options, since it can affect how competitive your recommendations can be.

What About Plan Types?

There are rules here. Most states require equal or lesser benefits. For example, moving from Plan G to Plan N might be allowed, but upgrading to richer benefits usually isn’t.

These restrictions are meant to prevent people from increasing coverage without underwriting, while still allowing them to lower costs.

Common Requirements To Keep in Mind

Even though underwriting is waived, there are still rules to follow:

• The client must already have an active Medicare Supplement policy
• The application has to fall within the birthday window
• The new plan must meet state guidelines
• Proper replacement documentation is required

Missing any of these can still lead to a declined application.

Commission Considerations

As more states adopt the birthday rule, carriers are getting more structured in how they handle compensation.

In general:

• Switching to a new carrier often pays full commission
• Internal replacements may pay less

Carriers also tend to track birthday rule business separately, which can affect reporting and long-term compensation. There are many birthday rule states that have reduced commissions or will pay at the guarantee commission rate. Some states require the carrier to pay full commissions so this can also vary by state and carrier.^*

Need assistance using the birthday rule to gain additional sales and commission? Senior Market Sales^® (SMS) is here to help. With more than 40 years of Medicare market success, no field marketing organization (FMO) is more equipped to help agents save time, make more money and differentiate their practice, than SMS. Contact an SMS marketing consultant at 1.877.888.9996 to discuss this Medicare Supplement sales opportunity. Alternatively, complete this form.

For additional birthday rule information, read The Birthday Rule: Is It in Your State and What It Means for Agents and Med Supp Clients.