“Can I Be Refused Medigap After 5 Years With Medicare Advantage?”


Question Yesterday I was asked, “Can I be refused Medigap insurance after 5 years with Medicare Advantage?”

I found this question consistent with what I have been reading about the changes to the Advantage program in the Affordable Care Act.  Under Obamacare, the way private insurance companies are paid by the government to administer Medicare benefits has changed.  Only the strongest of companies will survive.

Already several insurance companies have stopped offering Medicare Advantage or have been bought by the giant insurance companies as we head to a market place where there are only a few major players.

Ironically, the law that was supposed to have promoted competition by health insurance companies has had the opposite effect.  Several private insurance companies have disappeared and given the government a bigger monopoly of health insurance for people over 65 than they had.

When the PPACA was first passed, I read that over the next 5-7 years there would be a migration of people from Medicare Advantage to Medigap.  I read one prediction that said that as high as 60% of people with Medicare Advantage plans in 2010 would switch to Original Medigap with Medicare D within 5-7 years.

So much for competition!

But I digress…

In this post I will try to answer, “Can I be refused Medigap insurance after 5 years with Medicare Advantage?”  The answer is both, “yes” and “no.”

SPECIAL ENROLLMENT

When you first enrolled in both Medicare A & B you had the right to a “Guaranteed Issue” Medigap and Medicare D plan for several months.

If you elected to use private Medicare Advantage plans to cover your medical needs instead, your options for Medigap in the future is limited.  You are only eligible for “Guaranteed Issue” if you qualify for one of the Special Enrollment Periods (SEP)  if you wish to change from Medicare Advantage to Original Medicare with Medigap.

In order to claim your Special Election Period’s “Guaranteed Issue” rights you must apply for Medigap within a small period of time after you cancel your Medicare Advantage.

The Special Election Periods for “Guaranteed Issue” Medigap are…

  1. Trial right (Original Election) –  This allows you to experiment with Medicare Advantage for no more than 12 months.  If you elect a Medicare Advantage plan when you were first eligible for Medicare and change your mind and wish to Original Medicare with a Medigap during your first year, you may do so with a “Guaranteed Issue” right if you apply for the Medigap within 63 days of cancelling the Medicare Advantage.
  2. Trial Right (Return) –  Some people are persuaded to change from Medigap to Medicare Advantage.  If you are persuaded to cancel an existing Medigap plan to try Medicare Advantage, you have some protection if you find that the Advantage plan is not what you anticipated and wish to return to Original Medicare with Medigap.  As long as the insurance company that administered your Medigap prior to you switching still offers Medigap, you may return, with a “Guaranteed Issue” right so long as you apply for the Medigap within 63 days of cancelling your Medicare Advantage.Trial Right
  3. Involuntary Cancellation (Medicare Advantage) –  If for some reason, that you do not control, your Medicare Advantage provider stops offering coverage (e.g. they do not renew their contract with CMS, they go bankrupt, etc.) or you move out of the Advantage plan’s service area, you have a right for “Guaranteed Issue” Medigap if you apply within 63 days of the qualifying event.
  4. Fraudulent Selling Information – If you are able to prove that you were tricked into buying a Medicare Advantage plan with misleading information, you have the right to return to Original Medicare and get a “Guaranteed Issue” Medigap.  Just remember the 63 day rule.  In order to qualify for “Guaranteed Issue” you must be able to prove that you were misled and submit your Medigap application with 63 days of cancelling your Medicare Advantage.

NON-GUARANTEED ISSUE

In the above paragraphs I discussed the “Guaranteed Issue” rights for Medigap.  Those rights are specifically to protect those with pre-existing medical conditions (i.e. diabetes, heart disease, cancer, etc.)  They guarantee that people have a fair chance to get, and keep, Medigap to help pay for medical bills that Medicare does not.

Some people elect not to buy Medigap when they are first eligible.  When they first enroll in Medicare, they are often still healthy and see no reason to pay for additional health insurance at that time.

If you do not purchase Medigap during a “Guaranteed Issue” election period, although you can still buy it, you must be healthy enough to pass medical underwriting.

In many cases, medical underwriting for Medigap is not as restrictive as medical underwriting for traditional Major Medical insurance.  However, there are still some conditions that insurance companies will use to deny your application.

In the specific case of, “Can I be refused Medigap insurance after 5 years with Medicare Advantage plan?” my answer would have to be, “Yes, you can be refused Medigap.”

Since this person has had Advantage for longer than 5 years, unless he qualifies for a Special Election Period, he must be healthy enough to pass the insurance companies medical underwriting review.

If his health is good enough, he can still get Medigap.  However, if he has a pre-existing condition for which he is still being treated, the insurance company that he applies to has the right to deny coverage to him.

If you have participated in Medicare Advantage for over 2 years and wish to return to Original Medicare with Medigap, my advice is to secure your Medigap policy before you make the switch.  You are not guaranteed to be approved for Medigap.  You could end up with only Original Medicare without any “Maximum Out-of-Pocket” limit on your personal liability for medical bills.

To learn more about Medigap, click the banner below.

Medigap

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