Can I Switch From Medicare Advantage to Medigap Without Underwriting?

Many individuals enrolled in Medicare Advantage plans consider transitioning to Medigap coverage. A primary concern during such a switch involves medical underwriting. This article clarifies specific situations where individuals can change from a Medicare Advantage plan to a Medigap policy without undergoing medical underwriting.

Understanding Medicare Coverage and Underwriting

Medicare offers various ways to receive health benefits, with Medicare Advantage and Medigap representing distinct approaches. Medicare Advantage plans (Part C) are offered by private insurance companies approved by Medicare. These plans combine Medicare Part A (hospital insurance) and Part B (medical insurance) benefits, often including Part D (prescription drug coverage) and additional benefits like vision or dental care. Medicare Advantage plans serve as an alternative to Original Medicare.

Medigap, or Medicare Supplement Insurance, is also provided by private companies. Unlike Medicare Advantage, Medigap policies work alongside Original Medicare to help cover out-of-pocket costs such as deductibles, copayments, and coinsurance that Original Medicare does not fully cover. A Medigap policy cannot be used if you are enrolled in a Medicare Advantage plan; it is designed to supplement Original Medicare.

Medical underwriting is a process insurance companies use to assess an applicant’s health status, medical history, and pre-existing conditions. This evaluation helps insurers determine eligibility and premium rates. Typically, if you apply for a Medigap policy outside of specific enrollment periods or guaranteed issue rights, insurers can deny coverage or charge higher premiums based on your health.

Guaranteed Issue Rights for Medigap

Guaranteed Issue (GI) Rights are federal protections that allow individuals to purchase certain Medigap policies without medical underwriting. These rights ensure an insurance company cannot deny coverage, impose a waiting period for pre-existing conditions, or charge higher premiums based on your health status.

When a GI Right applies, insurers must sell you any Medigap Plan A, B, D, G, K, or L that they offer in your state. For individuals eligible for Medicare before January 1, 2020, Plans C and F may also be available. These rights are time-limited and typically apply only for a specific period after a qualifying event. This protected period is distinct from the Medigap Open Enrollment Period, a one-time, six-month window when you first enroll in Medicare Part B at age 65 or older.

Qualifying Situations for Guaranteed Issue Rights

Several scenarios trigger Guaranteed Issue Rights, allowing a switch to Medigap without underwriting.

If your Medicare Advantage plan leaves your service area or stops offering coverage, you typically have 63 days after coverage ends to apply for a Medigap policy.
A guaranteed issue right also applies if your Medicare Advantage plan violates its contract, misrepresents information, or fails to meet its contractual obligations. In such cases, you have a 63-day window after coverage ends to return to Original Medicare and use your GI rights for a Medigap policy.
Two “trial periods” also grant guaranteed issue rights. The first applies if you joined a Medicare Advantage plan when you first became eligible for Medicare (typically at age 65) and wish to switch back to Original Medicare and Medigap within the first 12 months. This allows you to try a Medicare Advantage plan and return to Original Medicare with Medigap if it isn’t a suitable fit.
The second trial period occurs if you dropped a Medigap policy to join a Medicare Advantage plan for the first time. If you decide to switch back to Original Medicare and Medigap within the first 12 months of your Medicare Advantage plan enrollment, you generally have the right to purchase your old Medigap policy or an equivalent.
If your employer group health plan, including retiree or COBRA coverage, that supplemented Medicare ends, you typically have guaranteed issue rights. This applies if the plan paid secondary to Medicare and its termination was not your fault.
If you leave a Program of All-Inclusive Care for the Elderly (PACE), you may also qualify for a guaranteed issue right to enroll in Medigap.

How to Switch to Medigap

Once you qualify for Guaranteed Issue Rights, switching to a Medigap policy involves several steps.

First, gather documentation proving your qualifying event. This might include a termination letter from your Medicare Advantage plan, proof of moving out of the service area, or other official notices confirming your eligibility for a GI right. Insurers will require this evidence to process your application.
Next, choose a Medigap plan. While GI rights exempt you from medical underwriting, you still select from the standardized Medigap plans available in your state, such as Plan G or Plan N. These plans are standardized with letter designations (A through N), meaning benefits for a Plan G are the same regardless of the insurance company.
After selecting a plan, contact Medigap insurance companies that sell policies in your state. When applying, clearly state you are applying under Guaranteed Issue Rights and provide all necessary documentation. Insurance companies are required to accept your application during this period.
The effective date of your new Medigap policy typically aligns with the termination of your previous coverage or the end of the guaranteed issue period, ensuring a smooth transition.
Before canceling your Medicare Advantage plan, ensure your Medigap policy is approved and effective to prevent gaps in coverage. You will need to disenroll from your Medicare Advantage plan and return to Original Medicare to utilize your Medigap policy. You can initiate this disenrollment by contacting your Medicare Advantage plan directly or by enrolling in a standalone Medicare Part D prescription drug plan, which automatically disenrolls you from your Medicare Advantage plan.