Navigating Medicare Advantage to Medigap Transition
As the Medicare Advantage open enrollment period continues, individuals enrolled in private managed-care plans can switch to original Medicare until March 31. However, transitioning from Medicare Advantage to original Medicare can be complex, especially when purchasing a Medigap policy to cover additional healthcare expenses.
Medigap insurers have the right to deny coverage based on medical underwriting, which evaluates applicants' medical history or existing health conditions. This process can hinder individuals from obtaining essential Medigap policies to cover gaps in traditional Medicare.
Kata Kertesz, managing policy attorney at the Center for Medicare Advocacy, advises factoring in these challenges. She notes that individuals who've been with a Medicare Advantage plan for years may find difficulty securing a Medigap plan.
While Medicare Advantage plans are often affordable and include extra benefits like vision and hearing, they typically have limited provider networks and require extensive prior authorizations. Additionally, a study in JAMA indicates changes in the market may affect approximately 10% of MA plan members this year as plans exit certain markets, impacting coverage options.
Despite these hurdles, federal regulations allow obtaining a Medigap policy without underwriting during a specific initial enrollment period when individuals first become eligible for Medicare Part B. After this period, obtaining a Medigap policy without underwriting is less certain, yet some guaranteed opportunities exist.
Working with the State Health Insurance Assistance Program (SHIP) counselors can be advantageous in navigating Medigap options. These counselors provide unbiased support and can identify plans waiving underwriting for certain conditions.
Applicants not exempt from underwriting may still secure coverage, potentially at higher premiums, and might encounter a waiting period for preexisting conditions. The necessity for medical claims has squeezed Medigap insurers' profits, resulting in more stringent underwriting criteria.
Nick Ortner, a consulting actuary at Milliman, highlights that applicants for Medigap plans requiring medical underwriting often complete health questionnaires and undergo prescription drug history checks, which influence underwriting decisions significantly.
Underwriting practices differ among insurers, so consulting SHIP counselors may guide applicants to carriers accommodating various diagnoses or offering favorable terms on waiting periods and exclusions. Ryan Ramsey of the National Council on Aging suggests using resources like the Medigap comparison tool to estimate potential costs associated with different plans.