When Can I Switch From Medicare Advantage to Medigap?

Switching health coverage within Medicare, particularly between Medicare Advantage and Medigap policies, is a significant decision. Medicare Advantage plans (Medicare Part C) are offered by private companies approved by Medicare, providing an alternative way to receive Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) benefits. These plans often include prescription drug coverage and additional benefits. Medigap policies, or Medicare Supplement Insurance, are sold by private companies to help pay some healthcare costs Original Medicare does not cover, such as copayments, coinsurance, and deductibles.

Understanding Key Differences for Switching

The fundamental difference between Medicare Advantage plans and Medigap policies lies in their structure. Medicare Advantage plans essentially replace Original Medicare benefits; the private insurance company administers all Medicare Part A and Part B benefits. Many plans also offer extra benefits like dental, vision, or hearing coverage, and prescription drug coverage.

In contrast, Medigap policies work alongside Original Medicare, supplementing its coverage rather than replacing it. A Medigap policy helps cover out-of-pocket costs Original Medicare does not pay. A person with a Medigap policy must also be enrolled in Original Medicare Part A and Part B. You cannot have both a Medicare Advantage plan and a Medigap policy simultaneously.

Medicare Enrollment Periods and Medigap Guaranteed Issue Rights

Navigating the various Medicare enrollment periods is a key aspect of making changes to coverage. The Annual Enrollment Period (AEP), running from October 15 to December 7 each year, allows individuals to switch from Original Medicare to a Medicare Advantage plan, change Medicare Advantage plans, or drop a Medicare Advantage plan to return to Original Medicare. Any changes made during AEP become effective on January 1 of the following year.

The Medicare Advantage Open Enrollment Period (MA OEP), from January 1 to March 31 annually, allows a one-time change for those already enrolled in a Medicare Advantage plan to switch to a different Medicare Advantage plan or disenroll to return to Original Medicare. Returning to Original Medicare during this period also allows for joining a stand-alone Medicare Part D prescription drug plan. Special Enrollment Periods (SEPs) may also allow changes outside of these standard windows due to specific life events. While these periods facilitate Medicare Advantage changes, they do not automatically grant the right to purchase a Medigap policy without medical underwriting.

Medical underwriting is a process where insurance companies evaluate an applicant’s health status, including medical history and current conditions, to determine eligibility for coverage and set premiums. Outside of specific protected periods, a Medigap insurer can deny coverage or charge higher premiums based on health. However, specific situations trigger “guaranteed issue rights,” allowing individuals to buy a Medigap policy without medical underwriting. During these periods, insurers cannot deny coverage or charge more due to past or present health conditions.

Trial Right 1

This right applies if you joined a Medicare Advantage plan when first becoming eligible for Medicare at age 65 and then decide to switch back to Original Medicare within the first 12 months. In this scenario, the individual has the right to purchase any Medigap policy sold in their state by any insurance company. The application for the Medigap policy must typically be made as early as 60 days before the Medicare Advantage coverage ends, but no later than 63 days after it terminates.

Trial Right 2

This applies if a beneficiary had a Medigap policy, then switched to a Medicare Advantage plan for the first time, and decides to disenroll from the Medicare Advantage plan within 12 months. This right generally allows the individual to return to their previous Medigap policy if it is still available. If the original policy is not available, specific Medigap plans (Plans A, B, D, G, K, or L, with some variations based on when Medicare eligibility began) can be purchased from any company. The application window for this right also typically falls within a period starting 60 days before and ending 63 days after the Medicare Advantage coverage ceases.

Other Guaranteed Issue Events

Certain other events also trigger guaranteed issue rights, providing a 63-day window to apply for a Medigap policy without underwriting. This window usually begins when the qualifying event occurs or when existing coverage ends. These include:
Your Medicare Advantage plan leaves Medicare or stops serving your area.
You move out of your Medicare Advantage plan’s service area.
You lose employer-sponsored group health plan coverage that supplemented Medicare, such as due to retirement or loss of COBRA benefits.

Missing these specific windows can result in being subject to medical underwriting, where health conditions could lead to higher premiums or denial of a Medigap policy.

The Medigap Application and Medicare Advantage Disenrollment Process

Before applying for a Medigap policy, it is essential to ensure enrollment in Original Medicare Part A and Part B, as Medigap policies only work in conjunction with Original Medicare. Beneficiaries should also research the available Medigap plans in their state and understand that while plan benefits are standardized by letter (e.g., Plan G), premiums can vary significantly between insurance companies for the same plan.

Applying for a Medigap policy typically involves contacting insurance companies directly, utilizing resources from the State Health Insurance Assistance Program (SHIP), or working with a licensed insurance agent. These resources can provide information on available plans and pricing in a specific area. When applying, especially if relying on a guaranteed issue right, it is important to provide any necessary documentation, such as notices of coverage termination, to prove eligibility for the special enrollment conditions.

Disenrolling from a Medicare Advantage plan can be done through a few methods. One common way is to call 1-800-MEDICARE, the official Medicare helpline, and request disenrollment. Another option is to contact the Medicare Advantage plan directly to initiate the disenrollment process. Some plans may also offer online disenrollment options.

Careful timing of the disenrollment from the Medicare Advantage plan and the effective date of the new Medigap policy is important to avoid gaps in coverage. If a guaranteed issue right is being utilized, it is often advisable to apply for the Medigap policy before the Medicare Advantage plan coverage ends. This coordinated approach helps ensure continuous coverage and a smooth transition, preventing any period where the beneficiary might be responsible for the full cost of medical services.