Kate Ashford, NerdWallet
About half of Medicare Advantage members left their plans by the end of five years, according to a 2023 study from Brown University School of Public Health. Most switched to another Medicare Advantage plan, but not necessarily because they liked Medicare Advantage. Returning to Original Medicare can be tricky after you first sign up, because you may not be able to get a Medicare Supplement Insurance plan, known as Medigap.
But for people with serious or chronic health conditions who have Medicare Advantage, limited provider networks and prior authorization requirements may make it difficult or expensive for them to get the care they need. It’s helpful to understand your options.
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When Medicare Advantage isn’t the right plan
Medicare Advantage plans typically require members to get health care from doctors and hospitals within a network. Members might have trouble if their doctor falls out of network or they want to see a specialist who doesn’t take their plan. Medicare Advantage plans also may require you to get approval before they cover some services or medications.
While most Medicare Advantage enrollees are in plans with a $0 premium, getting medical care costs money, and Medicare Advantage plans can have an annual out-of-pocket maximum as high as $8,850 in 2024.
Joanne Giardini-Russell, owner of the insurance agency Giardini Medicare in Michigan, recalls a client who had a Medicare Advantage plan and got cancer. “He was hitting his max out-of-pocket year after year,” she says. “And then throw in prior authorizations, which he wasn’t a fan of.”
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When you can change plans
If you have Medicare Advantage and you want to switch plans or go back to Original Medicare, there are two annual opportunities: Medicare’s fall open enrollment from Oct. 15 to Dec. 7 and Medicare Advantage open enrollment from Jan. 1 to March 31.
However, if you want to return to Original Medicare and you have health issues, you may not qualify for Medigap, which helps keep Original Medicare affordable. In most states, after Medigap’s initial enrollment period — in which you can buy any plan from any insurer, regardless of health status — companies can decline to cover you.
“Everybody thinks the open enrollment in the fall is going to save them,” Giardini-Russell says, remembering a client with a Medicare Advantage plan who couldn’t qualify for Medigap due to a heart condition.
“She said, ‘I thought in November, you could just change during open enrollment,’” Giardini-Russell says. “She didn’t have any way to get out.”
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What are the exceptions?
There are two “trial rights” scenarios in which someone with Medicare Advantage can switch back to a Medigap plan without a medical exam:
— If you start with a Medicare Advantage plan when you first qualify for Medicare, you have 12 months to go back to Original Medicare with any Medigap plan.
— If you have a Medigap plan and drop it to try a Medicare Advantage plan for the first time, you have 12 months to return to Original Medicare and the Medigap plan you dropped, as long as the company still sells it.
If you work with an insurance agent, they might also know which Medigap company would approve you based on your health. “There are some that will treat certain conditions differently than others,” says Adam Hyers, an insurance broker and founder of the insurance agency Hyers and Associates in Columbus, Ohio. “We keep a list of who might be more likely to accept a client who is in a gray area.”
In four states, residents have a chance at least once a year to buy a guaranteed-issue Medigap plan: Connecticut, Maine, Massachusetts and New York. There are also quirky exceptions: In 2022 and 2023, Blue Shield of California offered an “underwriting holiday” during which California residents could join Medigap Plan G without medical underwriting.
Blue Cross Blue Shield of Illinois offers guaranteed-issue Medigap plans to Illinois residents. “Obviously, the premiums are going to be higher, because they’re going to have higher claims,” says Cynthia Pruemm, founder and CEO of SIS Financial Group in Hoffman Estates, Illinois.
In the worst-case scenario, moving out of your plan’s service area grants you another chance at guaranteed-issue Medigap.
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What if you can’t get Medigap?
If it’s not possible to get Medigap, you may have to find the best Medicare Advantage plan for your needs. Don’t get sidetracked by perks; pay attention to doctors and drug coverage.
For guidance, call a broker rather than the providers directly. “You want to talk to somebody who’s independent, that represents all of the companies,” Pruemm says.
But for people with serious or chronic health conditions who have Medicare Advantage, limited provider networks and prior authorization requirements may make it difficult or expensive for them to get the care they need. It’s helpful to understand your options.
—————
When Medicare Advantage isn’t the right plan
Medicare Advantage plans typically require members to get health care from doctors and hospitals within a network. Members might have trouble if their doctor falls out of network or they want to see a specialist who doesn’t take their plan. Medicare Advantage plans also may require you to get approval before they cover some services or medications.
While most Medicare Advantage enrollees are in plans with a $0 premium, getting medical care costs money, and Medicare Advantage plans can have an annual out-of-pocket maximum as high as $8,850 in 2024.
Joanne Giardini-Russell, owner of the insurance agency Giardini Medicare in Michigan, recalls a client who had a Medicare Advantage plan and got cancer. “He was hitting his max out-of-pocket year after year,” she says. “And then throw in prior authorizations, which he wasn’t a fan of.”
—————
When you can change plans
If you have Medicare Advantage and you want to switch plans or go back to Original Medicare, there are two annual opportunities: Medicare’s fall open enrollment from Oct. 15 to Dec. 7 and Medicare Advantage open enrollment from Jan. 1 to March 31.
However, if you want to return to Original Medicare and you have health issues, you may not qualify for Medigap, which helps keep Original Medicare affordable. In most states, after Medigap’s initial enrollment period — in which you can buy any plan from any insurer, regardless of health status — companies can decline to cover you.
“Everybody thinks the open enrollment in the fall is going to save them,” Giardini-Russell says, remembering a client with a Medicare Advantage plan who couldn’t qualify for Medigap due to a heart condition.
“She said, ‘I thought in November, you could just change during open enrollment,’” Giardini-Russell says. “She didn’t have any way to get out.”
—————
What are the exceptions?
There are two “trial rights” scenarios in which someone with Medicare Advantage can switch back to a Medigap plan without a medical exam:
— If you start with a Medicare Advantage plan when you first qualify for Medicare, you have 12 months to go back to Original Medicare with any Medigap plan.
— If you have a Medigap plan and drop it to try a Medicare Advantage plan for the first time, you have 12 months to return to Original Medicare and the Medigap plan you dropped, as long as the company still sells it.
If you work with an insurance agent, they might also know which Medigap company would approve you based on your health. “There are some that will treat certain conditions differently than others,” says Adam Hyers, an insurance broker and founder of the insurance agency Hyers and Associates in Columbus, Ohio. “We keep a list of who might be more likely to accept a client who is in a gray area.”
In four states, residents have a chance at least once a year to buy a guaranteed-issue Medigap plan: Connecticut, Maine, Massachusetts and New York. There are also quirky exceptions: In 2022 and 2023, Blue Shield of California offered an “underwriting holiday” during which California residents could join Medigap Plan G without medical underwriting.
Blue Cross Blue Shield of Illinois offers guaranteed-issue Medigap plans to Illinois residents. “Obviously, the premiums are going to be higher, because they’re going to have higher claims,” says Cynthia Pruemm, founder and CEO of SIS Financial Group in Hoffman Estates, Illinois.
In the worst-case scenario, moving out of your plan’s service area grants you another chance at guaranteed-issue Medigap.
—————
What if you can’t get Medigap?
If it’s not possible to get Medigap, you may have to find the best Medicare Advantage plan for your needs. Don’t get sidetracked by perks; pay attention to doctors and drug coverage.
For guidance, call a broker rather than the providers directly. “You want to talk to somebody who’s independent, that represents all of the companies,” Pruemm says.
