Navigating Medicare: Key Insights on Medigap and Enrollment Periods

The Medicare General Enrollment Period is currently underway, running from January 1 through March 31. For retirees contemplating a transition from Medicare Advantage to original Medicare, securing a Medigap policy in 2026 could pose challenges due to potential medical underwriting barriers.

Medigap plans are designed to cover costs not included in Medicare, such as coinsurance and deductibles. However, the approval process often involves medical underwriting, which can hinder coverage for retirees with preexisting conditions. Kata Kertesz, managing policy attorney at the Center for Medicare Advocacy, emphasizes the need for beneficiaries to consider this when planning a switch from Medicare Advantage to original Medicare.

Retirees frequently opt for original Medicare to gain access to a broader network of providers and reduce prior authorization hurdles. While Medicare Advantage might offer additional benefits like dental or vision care, these are absent in original Medicare plans. The evolving market dynamics, including the decreasing availability of Medicare Advantage plans, add further complexity. According to a JAMA study, approximately 10% of Medicare Advantage members could lose their plans this year due to provider market exits.

Federal regulations provide a one-time, six-month opportunity for new Medicare Part B enrollees to purchase any Medigap plan without medical underwriting. Missing this window might result in restricted access based on health status. Nonetheless, exceptions exist in states like Connecticut, Massachusetts, and New York, where residents can enroll without underwriting throughout the year. Exceptions also apply to retirees using trial rights after their first year in Medicare Advantage or when their plan exits the market.

During specific special enrollment periods, such as relocation or plan termination, enrollees are protected from underwriting denials. Those outside these parameters may apply but face uncertain acceptance, as insurers are increasingly scrutinizing medical histories. Bonnie Burns from California Health Advocates notes that conditions like Alzheimer's and diabetes complications are common reasons for coverage denial or premium hikes.

To assist retirees navigating these complexities, SHIP counselors offer free, impartial advice on Medigap options that could be more accommodating to their health history, providing advantageous waiting periods and reducing the risk of coverage gaps.