Can You Switch From Medigap to Medicare Advantage?

Understanding Medicare coverage options is important for managing healthcare costs. As needs change, beneficiaries may consider switching their supplementary insurance. Navigating Medicare plans requires understanding how each option functions and integrates with Original Medicare. Knowing the pathways for making such changes is a practical step for many beneficiaries.

Eligibility for Switching

Transitioning from a Medigap policy to a Medicare Advantage plan is generally possible for Medicare beneficiaries, often during specific enrollment periods. “Trial rights” offer protections for individuals who initially enrolled in a Medicare Advantage plan or who switched from Medigap to Medicare Advantage for the first time. These rights typically provide a limited period, often 12 months, during which a beneficiary can return to Original Medicare and purchase certain Medigap policies without medical underwriting.

Medical underwriting involves health questions and can result in denial or higher premiums for Medigap policies if applying outside specific guaranteed issue periods. However, trial rights exist: if a person joined a Medicare Advantage plan at age 65, they may switch to Original Medicare and purchase any Medigap policy in their state within 12 months. Similarly, if someone leaves a Medigap policy for a Medicare Advantage plan for the first time, they have a 12-month trial period to return to their previous Medigap policy or purchase certain others if they disenroll from the Medicare Advantage plan.

Distinctions Between Medigap and Medicare Advantage

Medicare beneficiaries typically choose between Original Medicare supplemented by a Medigap policy, or a Medicare Advantage plan. These two approaches differ significantly in structure, coverage, and costs. Understanding these differences is important for informed decisions about healthcare coverage.

Medigap, or Medicare Supplement Insurance, works alongside Original Medicare (Parts A and B) to help cover out-of-pocket expenses like deductibles, copayments, and coinsurance. Medigap plans can cover the Part A hospital deductible, Part B coinsurance, and sometimes emergency care when traveling outside the United States. Medigap policies are standardized across most of the United States; plans of the same letter (e.g., Plan G) offer the same basic benefits regardless of the insurance company selling them. This simplifies comparison, as the primary difference between identical letter plans from different insurers is often the premium cost.

Medigap policies allow beneficiaries to see any doctor or hospital nationwide that accepts Medicare. Since Medigap supplements Original Medicare, it does not include prescription drug coverage (Part D), which must be purchased separately. Medigap plans are guaranteed renewable, meaning the insurer cannot cancel the policy as long as premiums are paid. While Medigap helps manage out-of-pocket costs, it does not have an annual out-of-pocket maximum, though some plans like K and L have specific limits.

In contrast, Medicare Advantage (Medicare Part C) is an alternative way to receive Medicare benefits through private insurance companies. These plans bundle Original Medicare Parts A and B, and most include prescription drug coverage (Part D), often referred to as MAPD plans. Medicare Advantage plans often offer additional benefits not covered by Original Medicare, such as routine vision, dental, hearing care, and wellness programs. These extra benefits can be a draw for many beneficiaries.

Medicare Advantage plans typically operate with network restrictions, such as Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs), requiring beneficiaries to use in-network providers for non-emergency care. Going outside the network may result in higher costs or no coverage. Unlike Medigap, Medicare Advantage plans have an annual out-of-pocket maximum, limiting how much a beneficiary will pay for covered services in a year. Once this maximum is reached, the plan pays 100% of covered healthcare costs.

While some plans may have low or $0 monthly premiums (in addition to the Part B premium), beneficiaries will still have copayments, coinsurance, and deductibles. Costs and benefits vary significantly between plans and insurers.

Enrollment Periods for Making a Change

Changing Medicare coverage, including switching from a Medigap policy to a Medicare Advantage plan, is generally restricted to specific enrollment periods. Understanding these periods is important for planning coverage adjustments, as changes outside these windows are typically not possible unless qualifying events apply.

The Annual Enrollment Period (AEP) is a primary time for Medicare beneficiaries to make coverage changes. This period occurs annually from October 15 to December 7. During AEP, individuals can switch from Original Medicare and a Medigap plan to a Medicare Advantage plan. Any changes made during this period become effective on January 1 of the following year. This window is for evaluating current coverage and selecting a plan for the upcoming year.

The Medicare Advantage Open Enrollment Period (MA OEP) runs from January 1 to March 31 each year. This period is for individuals already enrolled in a Medicare Advantage plan. During the MA OEP, a beneficiary can make a one-time change, such as switching to a different Medicare Advantage plan or disenrolling to return to Original Medicare. If returning to Original Medicare, a person can also join a Medicare Part D prescription drug plan. The MA OEP cannot be used to switch from Original Medicare (with or without Medigap) to a Medicare Advantage plan.

Outside regular enrollment periods, certain life events may trigger a Special Enrollment Period (SEP). SEPs allow beneficiaries to change Medicare coverage due to circumstances like moving to a new service area, losing other creditable health coverage, or qualifying for Extra Help. The duration and types of changes allowed during an SEP depend on the specific qualifying event. For instance, moving out of your plan’s service area may qualify you for an SEP to choose a new plan. These periods provide flexibility for unexpected changes.

Steps to Switch Your Coverage

Once a beneficiary determines that switching from a Medigap policy to a Medicare Advantage plan is appropriate and they qualify for an enrollment period, the process involves several steps. Following these steps helps ensure a smooth transition of healthcare coverage.

The initial step involves researching and selecting a new Medicare Advantage plan that meets healthcare and financial needs. This requires comparing available plans in your service area, considering network providers, covered benefits, out-of-pocket costs (copayments and deductibles), and whether the plan includes prescription drug coverage. Medicare tools can assist in this comparison.

After choosing a suitable Medicare Advantage plan, apply for enrollment directly with the private insurance company, often online, by phone, or through a licensed insurance agent. The new Medicare Advantage plan’s effective date will depend on the enrollment period used for the switch, commonly January 1 if the Annual Enrollment Period is utilized.

Upon successful enrollment in a Medicare Advantage plan, the Medigap policy generally becomes redundant. Medigap policies cannot be used to pay for Medicare Advantage plan costs, such as copayments or deductibles, and having both types of coverage simultaneously is typically not permissible. Therefore, contact the Medigap insurance company directly to cancel the existing policy. While Medicare Advantage enrollment may automatically disenroll an individual from a standalone Medicare Part D prescription drug plan, it does not automatically cancel a Medigap policy. Confirming the cancellation date with the Medigap insurer avoids unintended premium payments or coverage overlaps.

The final step involves confirming enrollment in the new Medicare Advantage plan. This includes receiving a new plan identification card and a welcome packet from the insurance company. Reviewing these materials ensures all details are correct and provides information about the plan’s benefits, network, and how to access care. This confirmation helps verify that the switch has been successfully completed and new coverage is active.