Switching From Medicare Advantage Back to Medigap

What This Means

Original Medicare pays most of a medical bill, but not all of it. A Medigap policy is private insurance you buy separately to cover the part Medicare leaves you — most importantly the 20% of every doctor’s bill that Original Medicare never pays, which has no yearly limit on it.

Here is the part that matters to you right now. Most of the time, a company selling Medigap is allowed to ask about your health first and then decide. If you have had a heart attack, a cancer diagnosis, diabetes that needed treatment — whatever is on their list — they can charge you more, make you wait before they will cover that condition, or simply refuse to sell you a policy at all. There is no appeal, and it is perfectly legal. The industry word for that check is medical underwriting, and you will see it on application forms. It is the reason people who leave Medigap often cannot get back in.

A guaranteed issue right is the exception to that. While you have one, a company selling that policy in your state has to sell it to you. It cannot ask about your health, cannot charge you more because of it, and cannot refuse to cover something you are already being treated for.

If your Medicare Advantage plan is leaving Medicare or pulling out of your area, you have one — but only if you go back to Original Medicare, which is the government’s own coverage. Joining a different Medicare Advantage plan instead gives the right up.

The rest of this page is mostly about dates, because almost everything written about them gives only half the rule — and it is the half that makes people give up while they still have time.

Why This Happens

Medicare Advantage plans are contracts between an insurance company and Medicare, renewed each year. Companies withdraw from counties and sometimes from the programme altogether, usually because the arithmetic stopped working for them in that market. It has nothing to do with you, and it is not something you can appeal.

What you get instead is the guaranteed issue right, and a letter. Keep the letter.

The Deadline Is Later Than Almost Everyone Thinks

Nearly everything written about this says 63 days, and leaves it there. Sixty-three days from what is the part that matters.

The 63 days run from the day your coverage ENDS, not from the day the letter arrives. If the non-renewal notice lands in early October and the plan runs to December 31, your last day to apply is around the start of March — not some date in December. People who count 63 days from the letter believe they are out of time in the new year and give up a right they still hold.

The other end of the window is where the law and the market disagree, so plan around the market. The statute opens the period on the day you receive the notice of termination. Medicare’s own instruction to consumers is narrower: apply no earlier than 60 days before your coverage ends, and no later than 63 days after. Insurers administer it that way, so an application filed in October for a plan ending December 31 is likely to come back as premature. Treat the letter as the cue to get ready and file from the 60-day mark — about November 1 for a December 31 end date. If an insurer does refuse an earlier application, that is why, and it does not mean you have lost the right.

Do not drift to the end of the window either. Aim for the new policy to start the day the old one stops — a Medigap policy cannot begin before your Medicare Advantage coverage ends anyway. Otherwise you are on Original Medicare with no supplement, personally liable for 20% of every doctor’s bill with no annual cap on it.

If you MOVED out of the service area, none of the above timing applies. There is no letter telling you the plan is ending, because you are the one ending it. Leaving by choice runs on its own clock: from 60 days before the day your plan coverage stops to 63 days after it. Work from the date your coverage ends and ignore the talk of letters.

Which Policies the Right Actually Covers

A guaranteed issue right is not a right to buy any Medigap plan. For a plan that is leaving or withdrawing from your area it covers Plans A, B, C, D, F, G, K and L.

Plans M and N are not on that list. Plan N in particular is one of the most commonly recommended lower-premium policies on the market, and a company may still ask about your health and turn you down for it, exactly as it would for any ordinary applicant. Applying for the wrong plan under a right that does not cover it is a real way to lose the window.

Narrowing it further: Plans C and F cover the Part B deductible, and a 2015 law closed both to anyone who first became eligible for Medicare on or after January 1, 2020. If you were eligible before then and simply never bought one, you may still be able to. Everyone else is choosing among A, B, D, G, K and L.

Leaving By Choice Is a Different Rule

If your plan is not ending and you simply want out — during Open Enrollment, say — you usually have no guaranteed issue right at all, which means a Medigap company can ask about your health and turn you down.

The exceptions are the two “trial rights”, and both are narrower than the name suggests:

• You joined Medicare Advantage at the moment you first became eligible for Medicare at 65, and you leave within 12 months. This one lets you buy any of the policies listed above.
• You already had a Medigap policy and gave it up to try Medicare Advantage for the first time, and you leave within 12 months. This one gets you your old policy back from your old insurer — or, if it is no longer sold, one from that same restricted list.

If you were on Original Medicare with no Medigap for some years and then joined your first Medicare Advantage plan at, say, 70, you have neither. That reader looks like they qualify and does not. Leaving on that assumption can mean being declined for Medigap on health grounds and stuck with unlimited exposure until the next election period. Check before you leave the plan, not after.

Your State May Give You More

These are the federal rules, and they are a floor, not a ceiling. Several states require insurers to sell Medigap policies in circumstances where federal law does not — some annually, some year-round. That is decided state by state and it changes, so do not take a national article’s word for your own state. Two places will tell you for certain, both free: your state’s insurance department, and your SHIP.

What To Do Next

1. Keep the letter. Whatever the plan sent telling you it is ending, leaving your area or non-renewing — keep it, with the envelope if it is dated. Insurers ask for proof of the guaranteed issue right and this is it. Keep any claim denials that came with it.

2. Write down two dates. The day your Medicare Advantage coverage ends, and that date plus 63 days. The first is when you can realistically file from 60 days before; the second is your true deadline.

3. Decide about drug coverage in the same breath. Medigap never covers prescriptions. If you have no other drug coverage, buy a standalone Part D plan for the same start date. A gap under 63 days costs nothing, and VA, TRICARE or retiree drug coverage often counts, but do not leave it to chance.

4. Choose the plan letter first, then shop it. Every insurer selling Plan G sells the identical Plan G — the benefits are set by law. Price is then the main difference, with three caveats worth a conversation: premiums are rated three different ways, so the cheapest policy at 65 is routinely the dearest at 80; a Medicare SELECT policy restricts you to a network and is not the same product; and “high-deductible Plan G” is also sold as Plan G. Medicare’s plan finder at medicare.gov lists what is sold in your area.

5. Say “guaranteed issue right” when you apply. Applications default to the underwritten path. Say at the outset that you are applying under a guaranteed issue right, say why, and send the proof with the application.

6. Get free, unconflicted help. Most of what you will find online about switching is written by people who are paid when you buy. Your SHIP is not — free state counselling, no commission. Find yours at shiphelp.org.

Sources

• 42 U.S.C. 1395ss(s)(3) — the guaranteed issue rights and their timing. Subparagraph (E)(ii) sets the period for an involuntary termination as “beginning on the date that the individual receives a notice of termination and ending on the date that is 63 days after the date the applicable coverage is terminated.” Subparagraph (E)(iv) sets the voluntary-disenrolment period as beginning 60 days before the effective date and ending 63 days after it. Subparagraph (A) is the bar on refusing issuance, pricing for health status, or excluding a pre-existing condition.
• Medicare.gov: When can I buy a Medigap policy? — the guaranteed issue situations in plain language, and the instruction that you must apply “60 days before the date your coverage ends” and “no more than 63 days after your coverage ends.” This is the operative rule in practice, and it is narrower at the front end than the statute: the statute opens the window at the notice, insurers work to the 60-day mark. It also states the plan list (A, B, C, D, F, G, K or L), that the right applies only if you switch to Original Medicare, and that Medigap coverage cannot start before your Medicare Advantage coverage ends.
• Medicare.gov: Can I switch or drop my Medigap policy? — “Make sure you keep any letters, notices, or emails … You may need to include copies of these documents with your new Medigap application to prove you have the right to buy a new policy.”
• Medicare.gov: Choosing a Medigap Policy (CMS Product 02110) — the standardised benefit packages, and that Plans C and F are unavailable to people who first became eligible for Medicare on or after January 1, 2020.
• Medicare.gov: Part D late enrollment penalty — how the penalty accrues for months without drug coverage. 42 CFR 423.46(a) is the rule that it applies only after “a continuous period of 63 days or longer” without drug coverage that is creditable for Part D.
• Subparagraph (B)(vi) of 42 U.S.C. 1395ss(s)(3) is the trial right for someone who joined Medicare Advantage “upon first becoming eligible for benefits under part A at age 65”; (B)(v) is the separate right for someone who “was enrolled under a medicare supplemental policy”, gave it up to try Medicare Advantage “for the first time”, and left within 12 months. Subparagraph (C) sets which policies each right reaches — (C)(i) the statutory package, (C)(ii) the same-policy-back rule for (B)(v).

Frequently Asked Questions