Can I Switch From Medicare Advantage to Medigap?

Navigating Medicare coverage options can present complexities, particularly when considering changes between different plan types. Individuals enrolled in a Medicare Advantage plan may consider switching to a Medigap policy to meet evolving healthcare needs. This transition is possible, but it depends on specific circumstances and adherence to established rules. Understanding the structure of these plans and the conditions under which a change can occur is important for making informed healthcare decisions.

Medicare Advantage and Medigap Basics

Medicare Advantage plans, also known as Medicare Part C, are offered by private companies approved by Medicare and serve as an alternative to Original Medicare. These plans bundle Medicare Part A (hospital insurance) and Part B (medical insurance), often incorporating Part D (prescription drug coverage) and additional benefits. Medicare Advantage plans typically have their own provider networks, meaning care is often received from doctors and hospitals within the plan’s network.

Medigap, or Medicare Supplement Insurance, is also provided by private companies. Medigap policies are designed to help cover some of the out-of-pocket costs that Original Medicare (Parts A and B) does not, such as deductibles, copayments, and coinsurance. Medigap plans supplement Original Medicare, rather than replacing it, and they do not include prescription drug coverage.

When You Can Switch Without Medical Underwriting

Certain situations allow individuals to switch from a Medicare Advantage plan to a Medigap plan without medical underwriting, meaning an insurer cannot deny coverage or charge higher premiums due to health status. One such period is the Medigap Open Enrollment Period, a one-time, six-month window that begins the first month an individual is 65 or older and enrolled in Medicare Part B. During this period, any Medigap policy sold in their state can be purchased regardless of health conditions.

Guaranteed issue rights also allow for a switch without medical underwriting under specific scenarios. A guaranteed issue right applies if an individual joined a Medicare Advantage plan when first eligible for Medicare Part A at age 65 and decides to switch back to Original Medicare within the first 12 months. This is a trial right, providing a period to test the Medicare Advantage plan and return to Original Medicare with the ability to buy a Medigap policy. Similarly, if an individual dropped a Medigap policy to join a Medicare Advantage plan for the first time, they may have a 12-month trial right to switch back to Original Medicare and reacquire a Medigap policy.

Additional guaranteed issue rights apply if an individual loses Medicare Advantage coverage through no fault of their own. This includes situations where a Medicare Advantage plan leaves Medicare or stops serving the individual’s area, or if the individual moves out of the plan’s service area. In these cases, a specific timeframe, 63 days from the loss of coverage, is provided to apply for a Medigap policy without medical underwriting. Documentation of the triggering event, such as a termination notice, is required to exercise these rights.

Switching When Medical Underwriting Applies

When an individual wishes to transition from a Medicare Advantage plan to Medigap outside of their Medigap Open Enrollment Period or without qualifying for guaranteed issue rights, medical underwriting generally applies. Medical underwriting is a process where private insurance companies evaluate an applicant’s health status to determine eligibility for coverage and to set premiums. This assessment typically involves answering detailed health questions on the application, and the insurer may request access to medical records.

An insurance company can deny coverage based on pre-existing health conditions, or it may offer a policy but at a higher premium to account for perceived increased risk. A waiting period might be imposed before coverage for certain pre-existing conditions begins. This process can make switching to Medigap challenging for those with health issues.

While federal law outlines the primary Medigap Open Enrollment Period and guaranteed issue rights, some states have their own regulations that may offer additional consumer protections. These state-specific rules could include broader guaranteed issue periods or limitations on medical underwriting, providing more flexibility for residents in those areas. Individuals should investigate specific state provisions to understand all potential avenues for acquiring a Medigap policy.

How to Make the Switch

Making a switch from a Medicare Advantage plan to a Medigap policy requires deliberate actions. The first step involves researching and selecting a suitable Medigap plan from the standardized options (Plans A-N) available in one’s area. It is important to confirm that healthcare providers one wishes to continue seeing accept Original Medicare, as Medigap plans work with Original Medicare.

Once a Medigap plan is chosen, the application process begins. If guaranteed issue rights apply, the application will not involve health questions; otherwise, medical underwriting will be part of the review. Avoid disenrolling from the current Medicare Advantage plan until the Medigap application is approved and the effective date of the new policy is confirmed. This prevents a gap in health coverage.

Upon Medigap plan approval and activation, the next step is to disenroll from the Medicare Advantage plan. This can be done by contacting the Medicare Advantage plan directly, calling Medicare, or by enrolling in a stand-alone Medicare Part D prescription drug plan, which automatically disenrolls one from Medicare Advantage and returns them to Original Medicare. Since Medigap policies do not include prescription drug coverage, enrolling in a separate Medicare Part D plan is necessary to avoid late enrollment penalties and ensure continuous drug coverage.

Key Considerations Before Switching

Before switching from a Medicare Advantage plan to Medigap, several factors warrant consideration. Cost differences are a significant aspect; Medigap policies generally involve higher monthly premiums compared to many Medicare Advantage plans, which often have low or even zero monthly premiums. However, Medigap plans typically result in lower out-of-pocket costs for services once activated, as they cover most deductibles, copayments, and coinsurance associated with Original Medicare.

Prescription drug coverage is another distinction. Medicare Advantage plans frequently include Part D drug coverage as part of their bundled benefits. In contrast, Medigap policies do not cover prescription drugs, necessitating enrollment in a separate stand-alone Medicare Part D plan to maintain drug coverage and avoid late enrollment penalties. This means managing an additional premium and potentially a separate deductible for prescription medications.

Provider networks also differ between the two plan types. Medigap, by supplementing Original Medicare, allows access to any doctor, specialist, or hospital nationwide that accepts Medicare. Medicare Advantage plans, however, typically operate within specific networks, such as Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs), which may require referrals or limit choices for in-network care. Individuals who value flexibility in choosing healthcare providers may find Medigap more appealing.

Medicare Advantage plans frequently offer extra benefits not covered by Original Medicare or Medigap, such as routine dental, vision, and hearing care, as well as fitness programs. Travel coverage also varies, with some Medicare Advantage plans offering limited international emergency coverage, while many Medigap plans include a foreign travel emergency benefit.