Can I Change From Medicare Advantage to Medigap?

Medicare offers various options for health coverage. Medicare Advantage (MA) plans and Medigap (Medicare Supplement Insurance) plans are two distinct ways to supplement Original Medicare. Original Medicare includes Part A (hospital insurance) and Part B (medical insurance). Medicare Advantage plans, offered by private companies, combine Part A and Part B, often including Part D (prescription drug coverage) and other benefits. Medigap policies are sold by private companies to help cover out-of-pocket costs that Original Medicare does not, such as deductibles, copayments, and coinsurance.

Eligibility and Timing for Switching

Switching from a Medicare Advantage plan to Original Medicare and then enrolling in a Medigap policy involves specific enrollment periods. The Annual Enrollment Period (AEP), from October 15 to December 7, allows individuals to switch from a Medicare Advantage plan back to Original Medicare. Changes made during this period become effective on January 1 of the following year.

Certain life events may trigger a Special Enrollment Period (SEP), allowing a switch outside the standard timeframe. For instance, moving out of a plan’s service area, a Medicare Advantage plan leaving Medicare, or losing other creditable coverage can qualify an individual for an SEP. These periods offer a limited window, often 2 to 3 months, to make changes.

A “trial right” allows individuals to try out a Medicare Advantage plan when first eligible for Medicare Part A at age 65. They have up to 12 months to switch back to Original Medicare and purchase a Medigap policy without medical underwriting. Similarly, if an individual drops a Medigap policy to join a Medicare Advantage plan for the first time, they have a 12-month trial right to return to Original Medicare and potentially get their Medigap policy back.

Navigating Medigap Enrollment

Securing a Medigap policy after being on a Medicare Advantage plan can present challenges due to medical underwriting. Medical underwriting is a process where insurance companies evaluate an applicant’s health history to determine eligibility and premium. An insurer can deny coverage or charge a higher premium based on health status if medical underwriting applies.

However, individuals have “guaranteed issue rights” to a Medigap policy in specific situations. These rights mean an insurer cannot deny coverage or charge more due to health conditions. Common scenarios triggering guaranteed issue rights include losing employer-sponsored group health coverage that supplemented Medicare, a Medicare Advantage plan terminating its contract, or moving out of a Medicare Advantage plan’s service area. The “trial rights” also fall under guaranteed issue rights, allowing a return to Medigap without underwriting.

Individuals typically have a limited timeframe, often 60 to 63 days, to exercise these guaranteed issue rights after a qualifying event. While federal law establishes certain guaranteed issue rights, some states may offer additional protections or different rules regarding Medigap enrollment.

Steps for Making the Switch

Transitioning from a Medicare Advantage plan to Original Medicare with a Medigap policy involves several steps. The initial action is to disenroll from the existing Medicare Advantage plan. This can be done by contacting the plan provider, calling Medicare at 1-800-MEDICARE, or using the Medicare.gov website.

Concurrently, or immediately after disenrollment, confirm active enrollment in Medicare Part A and Part B, as Medigap policies only supplement Original Medicare. Once confirmed, apply for a Medigap policy from a private insurance company. Compare standardized Medigap plans, such as Plan G or Plan N, and obtain quotes from various insurers. Applications can be submitted online, by phone, or through an insurance agent.

Because Medigap policies do not include prescription drug coverage, a standalone Medicare Part D prescription drug plan must also be selected and enrolled in. Individuals can compare Part D plans using Medicare’s online plan finder tool or by contacting Medicare directly. Enrollment in a Part D plan can occur during specific enrollment periods, such as the Annual Enrollment Period, or through a Special Enrollment Period if returning from a Medicare Advantage plan that included drug coverage.

Comparing Coverage and Costs

After switching from a Medicare Advantage plan to Original Medicare supplemented by Medigap, the structure of healthcare coverage and associated costs changes. With Original Medicare and a Medigap policy, individuals can see any doctor or visit any hospital nationwide that accepts Medicare, without network restrictions. This combination also eliminates the need for referrals to specialists.

Medigap policies help cover the deductibles, copayments, and coinsurance that Original Medicare does not pay. This leads to more predictable out-of-pocket expenses for medical services, as Medigap plans significantly reduce or eliminate these costs. Medicare Advantage plans often have lower monthly premiums but typically involve copayments and coinsurance for services, along with an annual out-of-pocket maximum.

A notable difference lies in prescription drug coverage. Medicare Advantage plans frequently bundle prescription drug coverage (Part D) directly into their plan. When switching to Original Medicare and Medigap, individuals must enroll in a separate Part D plan and pay a distinct premium. Additionally, Medicare Advantage plans often provide extra benefits not covered by Original Medicare or Medigap, such as routine dental, vision, hearing care, and fitness programs. These supplementary benefits would no longer be available after the switch unless purchased separately.