California Medicare Options - Can I go back to medigap after dropping Advantage plans?
Can I go back to Medigap from the Advantage plan? A Practical Guide
We help people with this all the time.
They tried an Advantage plan, usually with the push from a carrier or agent, and found that it didn't work for them.
Usually, the issue revolves around one of the 3:
- Can't see my doctors on the Advantage plan
- Can't get my meds on the Advantage plan
- There's too much hassle in getting the care I need
This is part of having an HMO generally and Advantage plans are definitely HMOs!
We have big reviews on the Trade-off between Advantage plans and Medigap or how to Compare Medigap and Advantage plans.
So...the PPO side of things or Medigap may be the better fit.
When and how can we switch back though?
Let's walk through the big questions here:
- A quick intro for
- dropping Advantage plans and going back to Medigap
- The initial enrollment period
- The annual Open Enrollment period
- The first 3-month window
- Losing Advantage plans involuntarily
- Special rules for dropping Advantage
- The Medigap rules for enrollment
- Don't forget Part D
- The Advantage plan to Medigap switch strategy
Of course, reach out to us with any questions! There's zero cost for our assistance.
Look...the rules around this are one of the most complicated parts of Advantage plans so definitely get some help for your situation.
A quick intro for dropping Advantage plans and going back to Medigap
Most of the rules are around when you drop Advantage. It's just more regulated than the Medigap world.
Outside of some situations that occur early in your Medicare career, you can think of this as a two parter:
- Dropping Advantage
- Being able to enroll in Medigap
We'll go through each trigger but there are situations when you first start Medicare or around annual periods that we can take advantage of.
Two important notes...
You cannot have an Advantage plan AND a supplement at the same time. Technically, they will not work together. It's double coverage.
Don't forget Part D for medication!
Most Advantage plans (all that we recommend) have a built-in Part D benefit for medications.
Medigap plans do not cover medications so you need to add a Part D and they have rules very similar to Advantage plans in terms of adding.
There may be situations where you can drop the Advantage plan but you have to wait till your birthday (in California) to add a Medigap plan.
This is if you're in very serious health and can't qualify based on health.
Otherwise, we can enroll in a Medigap plan any time of the year! We'll go through the special circumstances coming off of an Advantage plan where we can get a supplement regardless of health.
So it's more a question of when we can drop an Advantage plan!
Let's start to work through the common triggers.
The initial enrollment period
When you first sign up for Medicare (Part A and B), you have much more flexibility than at any time.
Let's say you sign up for an Advantage plan right away after getting a new Part B.
Although dropping an Advantage plan usually removes your guaranteed issue rights for Medigap (no health underwriting), you have a 12 month window to go back to traditional Medicare and get a Medigap plan with no underwriting.
This is great news but many people are already past this initial window.
The annual Open Enrollment period
Every year, we have open enrollment from Oct 15-Dec 7th which allows you to switch, enroll, or drop from an Advantage plan.
We can then enroll in a Medigap plan but may be subject to health underwriting.
You would also want to get a Part D plan during this time since it also has the same open enrollment.
What if we're past our initial 12 months and we can't qualify for Medigap based on health?
Worst case, we would have to wait for the Birthday rule to kick in which allows us to enroll in Medigap without medical underwriting.
Make a note next to that since we'll keep coming back to it if we can't qualify based on health.
There may be a gap though between when we drop the Advantage plan and when we get the Medigap coverage during which, we'll just have Traditional Medicare.
We'll address this gap below and strategize how to address it.
For now, just know we can definitely drop Advantage plans end of the year for a Jan 1st eff date.
Adding the Medigap plan can also be done then but may be subject to health underwriting. Part D can be enrolled during this same window regardless of health.
Oct 15 - Dec 7th. Mark your calendar!
Let's look at another special window.
The first 3 month window - the Open Enrollment period
This window generally runs from Jan 1st - March 31st since most people are adding/switching during Open Enrollment above for a Jan 1st eff date.
It can also apply if you enroll mid year (say from a move or special enrollment trigger).
During this window, you are allowed to drop your Advantage plan and go back to traditional Medicare.
This then allows you to apply for a Medigap plan although it may be subject to health underwriting if we're outside other open or special enrollment periods.
One note...enrolling in Part D during OEP may also be available.
The effective date is generally the 1st of the month following enrollment.
The OEP is essentially a do-over period for people who don't like their new Advantage plan or find it wasn't what they thought it was (see how to avoid bad Advantage plans).
What if we lose our Advantage plan at no fault of our own?
Losing Advantage plans involuntarily
This can happen due to a move outside of the Advantage plan area (most common) and may even include moving to California from another State.
Advantage plans are HMOs so they have defined areas and a significant enough move can cause you to no longer be eligible for that plan.
The plan will drop your coverage, generally on the 1st of the month following the address change.
This sets you up for a guaranteed issue situation for Medigap and even Part D.
Make sure to enroll as soon as possible as their time constraints on all these rules.
What else do we have up our sleeve?
Special rules for dropping Advantage
We're linking to Blue Shield of California's Guaranteed Issue Guide since it's pretty fabulous.
Keep in mind that the rules may be Federal but there can be slight differences (above and beyond) by carrier but at least we have Shield's guide as a benchmark.
A few items stand out!
- Originally enrolling in a supplement for the first time and then switching to
an Advantage plan; canceling the Advantage plan within that 12 month window
- An existing Advantage plan reduces benefits or networks and they don't offer a
supplement
- Involuntarily lose PACE, Military, or Group Coverage
You'll notice that most of these revolve around involuntarily losing Advantage
coverage or using the various enrollment periods to 'change your mind". Once!
We love helping people use that guide to figure out their situation (since it's not easy to read). Reach out to us at help@calhealth.net with your situation.
This is for guaranteed issue coverage with Medigap. Let's touch base on this second part (after the Advantage plan is dropped).
The Medigap rules for enrollment
We looked at Shield's Guaranteed issue guide. These rules are Federal in nature (which is why they're so fun to read:) so they should apply across the carriers.
Generally, Medigap enrollment is of two forms which can be done anytime during the year:
- Guaranteed issue (list above)
- Medically underwritten
For the first batch, if we're on an Advantage plan, the most common are:
- Just signed up for Medicare Part A and B; enrolled in the Advantage plan and
want to switch within the first 12 months
- Enrolled in a supplement and then first time enrolled in Advantage plan and want
to switch within first 12 months
- Enrolled in a supplement, then switch to an Advantage plan which you lose within
24 months from the original supplement enrollment
- Involuntarily lost coverage
- Advantage plan downgrades benefits or network options
Again, reach out to us.
Otherwise, we can submit an application at any time and see if we qualify.
Worst case, we wait till your Birthday (60 days prior and after the 1st of the month your birthday is in) to enroll for Medigap guaranteed issue.
Again, this is the 2nd part of the equation (with dropping the Advantage plan being the 1st part).
Okay...what about Part D?
Don't forget Part D
Part D for medications has similar rules to Advantage so we can refer to those above.
Generally, if we're able to drop Advantage coverage, we may be able to enroll in a new Part D.
It's best to check with us for your situation and we'll verify with the carrier of choice of your ability to enroll alongside a Medigap plan.
Keep in mind that Part D can (generally is) from a different carrier than the Medigap plans.
Certain carriers are just stronger with Part D than with Medigap.
You can run quotes for Part D here:
Now...let's talk strategy!
The Advantage plan to Medigap switch strategy
First, reach out to us with your situation at help@calhealth.net We can jump on a call and quickly size up your situation.
If it's particularly complicated, we'll get it verified first! No cost for our assistance.
If you're in one of the "special" periods (new to Medicare, involuntarily losing coverage, etc.) that gives you "Guaranteed issue" Medigap enrollment, that makes it much easier.
We'll guide you through the process.
What if we can drop the Advantage plan but we're not guaranteed the issue AND we're outside our birthday (60 days before and after the 1st of the month)?
We can submit a Medigap application with the health underwriting section completed up to 60 days prior to the 1st of the month we want it enrolled.
So...we don't need to cancel the Advantage plan till we hear back from the Medigap carrier about whether we've been approved or not.
On the app, there's a question to the effect "Will you cancel your existing plan if this is approved" to which, we'll answer yes.
You can't have both an Advantage plan and a Medigap plan (nor would you want to). This just allows us to "test the underwriting water" first without committing to canceling our Advantage plan.
Once approved, we should notify the Advantage carrier within any special window but make sure they know the effective date so it coincides with when the Medigap plan starts.
And of course, don't forget Part D! Loss of the Advantage plan may trigger enrollment windows for part D as well.
Does all this sound ridiculously complicated just to see Dr. Howard? Sure but it's not that bad when you help.
25+ years and we'll guide you through it. No cost for our assistance and you run your Medigap and Part D quotes across the major carriers here:
Learn about how to pick the best Medigap plan or check out What do the Medigap plans cover.
You can quote and even enroll online here:
