Suspend Medigap Policy After QMB Approval in Texas

Your parent just got approved for QMB in Texas. QMB covers all Medicare cost sharing — the Part B premium, Part A and Part B deductibles, and coinsurance. That makes the Medigap plan they've been paying for largely redundant. But dropping it outright is risky, because getting it back later means going through medical underwriting. There's a middle path.

The 24-Month Suspension Right

For Medigap policies sold on or after November 5, 1990, federal law lets Medicare beneficiaries request suspension — not cancellation — when they become eligible for Medicaid, including QMB. Under CMS guidance, request suspension within 90 days of the eligibility determination. The suspension can last up to 24 months.

During the suspension period:

• Your parent pays no premiums on the Medigap policy
• The insurance company holds the policy in force but inactive
• If your parent loses Medicaid eligibility during the 24-month suspension, the insurer must reinstate the policy (or substantially equivalent coverage) when your parent gives notice within 90 days and resumes premiums from the eligibility-loss date

This is critical because Medigap policies sold to people over 65 in most states, including Texas, are medically underwritten after the initial open enrollment window. If your parent cancels the policy and later loses QMB — say, because income rises at renewal — buying a new Medigap plan could mean higher premiums or outright denial based on health conditions.

How to Request the Suspension

Contact the Medigap insurer in writing. Include:

• Your parent's name and policy number
• A copy of the HHSC Form H1009 (Notice of Eligibility) showing the QMB approval and effective date
• A written request to suspend (not cancel) the policy under the federal Medigap suspension right
• A request for written confirmation that the policy is suspended and the terms under which it can be reactivated

Keep copies of everything. If the insurer's customer service representative isn't familiar with the suspension rule, cite Section 1882(q)(5)(A) of the Social Security Act (42 U.S.C. § 1395ss(q)(5)(A)), which requires reinstatement when Medicaid eligibility ends during the 24-month suspension and notice is given within 90 days.

What Happens After 24 Months

The federal suspension period cannot exceed 24 months. If QMB continues beyond that point, contact the insurer before the window ends to ask how the policy will continue. If more than 24 months have passed when Medicaid eligibility later ends, the insurer may treat the policy as lapsed.

If your parent loses Medicaid eligibility during the suspension — for example, after an income change or a move without continued Medicaid eligibility — they can:

• Within 24 months of suspension start: if Medicaid eligibility ends, request reinstatement within 90 days and resume premiums from the eligibility-loss date; new pre-existing-condition waiting periods are not allowed
• After 24 months: the insurer may treat the policyholder as a new applicant or as having a lapsed policy, so medical underwriting could apply

When Suspension Doesn't Make Sense

If your parent has a Medicare Advantage plan instead of Original Medicare plus Medigap, QMB still covers Medicare Part A and Part B premiums and Medicare cost sharing. The Medigap suspension rule doesn't apply to Medicare Advantage plans.

If the Medigap premium is very low and your parent's income is close to the QMB limit, keeping the policy active (paying premiums) might be worth the insurance against losing QMB at the next renewal. That's a judgment call based on your parent's specific financial situation.

The Texas Medicare Savings Programs & Extra Help Guide covers this decision in detail, including how to time the suspension request around the QMB effective date and what to do if QMB is denied at renewal.

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