Recovering From a Medicare “Wrong Turn”

By Marc Manor

Much of what I do is problem solving.  Frequently, the problems relate to “wrong turns” through the streets of the Medicare “Metropolis”.  By wrong turns, I mean when someone that has been enrolled in Medicare Part A and Part B beyond their initial enrollment period finds themselves outside the traditional open or annual enrollment periods and wants to transition to or from Original Medicare.  Sometimes the constraints of the Medicare “system” prevent immediate relief. However, there are solutions in many cases depending on when and how the “wrong turns” occurred.

Courtesy of pexels.com

Under the Medicare system, there are two basic paths: 1) Original Medicare and 2) Medicare Advantage (or Medicare Part C).  You can only be on one path or the other.  Typically, the path you choose occurs at the time you initially enroll fully into Medicare Parts A and B.  The choice initially of which path you take is very important so is necessary to give some basic information about these choices:



Original Medicare (Path 1): 

- Medicare (the government agency) is pays your claims.
- Covers Part A (Hospitals and other facilities), and Part B (Doctors/providers and other services)
- Part A has no cost (for most people) and Part B has a monthly Premium.  The Part B premium is $135.50 in 2019 for most people and more for others depending on their income.  A breakdown of deductibles and other costs associated with Medicare can be found: https://www.medicare.gov/your-medicare-costs/medicare-costs-at-a-glance#collapse-4809
- Most services are covered at 80%.  For those services covered at 80%, you will have to pay the remaining 20%.  There is NO maximum for what you could pay out of pocket.
- Medicare Supplement or “Medigap” insurance covers some or most of the 20% Medicare does not pay.  These plans have an additional premium or monthly payment that must be made to an insurer.
- Part D is NOT included.  A separate Prescription Drug Plan (PDP) will be required if you want coverage for prescription drugs.  These plans are provided by private insurance companies and also have a monthly premium.
- No networks can use Original Medicare with any provider or facility that accepts Medicare payment.

Medicare Advantage or Part C (Path 2):

- Private insurance company pays your claims.
- Covers Part A, B, and in many cases D in the same plan.
- Can include other services that Medicare does not cover.
- You must continue to pay your Part B premium; but, depending on where you reside, many people - pay no additional premium for Medicare Advantage Plans.
- Out of pocket costs are in accordance with specific benefit schedules for each plan.
- Have annual out-of-pocket limits.

Original Medicare to Medicare Advantage (Part C)

If you have been enrolled in Part A and B and you are under Original Medicare, you can enroll in a Medicare Advantage Plan during the Annual Enrollment Period each year from October 15th to December 7th.  This is an easy process, just be sure you understand how your Medicare Advantage Plan will affect your current network of providers.  For some people this is not an issue but people with multiple specialists and other services they’re used to may or may not be available under some Medicare Advantage Plans.

Medicare Advantage (Part C) to Original Medicare

This can be done during the Open Enrollment Period that occurs between January 1 and March 31.  You can also enroll in a Prescription Drug Plan during this time as well if you are dropping your Medicare Advantage Plan.   You will likely want to enroll into a Medicare Supplement or Medigap plan during this time as well to cover that 20% out of pocket cost that Original Medicare exposes.

Medicare Supplement/Medigap Guaranteed Issue Rights

Courtesy of pexels.com

This is the upmost importance if you want to go back to Original Medicare and you want the protection from those out of pocket costs associated with obtaining a Medicare Supplement/Medigap plan to cover the 20% coinsurance that Original Medicare does not cover.  Guaranteed Issue Rights really mean you will be accepted without regard to any pre-existing conditions.  This is because under normal circumstances if you try to enroll in a Medicare Supplement plan you may have to answer medical underwriting questions.  You may be denied or charged a higher monthly rate depending on your medical history.

There are situations where you may be able to obtain a Medicare Supplement plan using Guaranteed Issue Rights and avoid being scrutinized about your medical history:

- You’re in a Medicare Advantage Plan, and your plan is leaving Medicare or stops giving care in your area, or you move out of the plan's service area.

- You have Original Medicare and an employer group health plan (including retiree or COBRA coverage) or union coverage that pays after Medicare pays and that plan is ending.

- You have Original Medicare and a Medicare SELECT policy. You move out of the Medicare SELECT policy's service area.

- You joined a Medicare Advantage Plan or Programs of All-inclusive Care for the Elderly (PACE) when you were first eligible for Medicare Part A at 65, and within the first year of joining, you decide you want to switch to Original Medicare. (Trial Right)

-You dropped a Medigap policy to join a Medicare Advantage Plan (or to switch to a Medicare SELECT policy) for the first time, you’ve been in the plan less than a year, and you want to switch back. (Trial Right)

- Your Medigap insurance company goes bankrupt and you lose your coverage, or your Medigap policy coverage otherwise ends through no fault of your own.

- You leave a Medicare Advantage Plan or drop a Medigap policy because the company hasn't followed the rules, or it misled you.

Source: https://www.medicare.gov/supplements-other-insurance/when-can-i-buy-medigap/guaranteed-issue-rights

Courtesy of pexels.com

There could be other solutions, depending on your State, that allow you to obtain Medicare Supplement Plans using your Guaranteed Issue Rights.  If you think this is something you would like to do, I recommend contacting a licensed Independent Agent and/or Medicare to get your questions answered.  Every Medicare Beneficiary should have the confidence that their insurance is appropriate for their needs and budget.  This is one area where a little help can go a long way.











Marc Manor is a 30-year military veteran who is now dedicated to teaching his 
fellow Americans how to make the most of their Medicare and Supplemental Insurance 
benefits. As an independent agent, Marc has access to a wide variety of carriers with 
an abundance of resources to find tailored solutions. There is no charge for a 
consultation so call 904-222-0698 or email: marc@marcmanor.com.