How to Get Out of a Medicare Advantage Plan
Originally published December 12, 2017
Revised February 13, 2019
Medicare Advantage isn’t for everyone, but sometimes you don’t realize that until you’ve already enrolled in a plan! There are ways to get out of a Medicare Advantage plan, but it’s limited to certain times of the year and special situations.
We’ll help you learn how to get out of your Medicare Advantage plan, but first, let’s go over some of the reasons our clients have opted out of their Medicare Advantage plans.
Disclaimer: We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.
My Favorite Doctors Aren’t In My Network
Medicare Advantage plans do have their benefits, and for individuals in larger cities and more densely populated areas, networks are less of an issue.
However, in smaller cities and rural areas, it’s very common to learn that your favorite doctor is not in your network. The same goes for hospitals and pharmacies.
Medicare Advantage plans are network-based, so in order to actually use the plan, you have to see their approved doctors and go to their approved hospitals and pharmacies.
It’s actually somewhat difficult to find out the in-network doctors, hospitals, and pharmacies if you’re searching for your plan on Medicare’s website.
Once you make your way through the Plan Finder tool, you can select the plan you want to look at.
In this example, we’ll look at a Humana HMO plan. You can’t actually see the in-network options in the results. Medicare prompts you to “View provider and physician network website.”
This link takes you the general Humana website. Now, you have to navigate through the Humana site to find your specific network.
Once you enter your zip code, you see 10 or more plan options, and you have to match up the plan you were viewing on Medicare.gov with one of the options on Humana’s site.
And in this case, there are several Humana HMOs, so you actually have to match up the numbers to view the network for the plan you were searching on Medicare’s site.
Now that we’ve located the plan, we have to figure out how to actually see the network – and of course, there’s no button for that.
After clicking “View details” and scrolling all the way to the bottom, you see a little link for “List of providers.”
But wait – there’s more. You choose your state from a dropdown menu and are served with a massive list of PDFs. You have to figure out which one matches your specific needs.
At this point, you can see why so many individuals don’t actually know who is in their network until they’ve already signed up for the plan.
This is a major reason why individuals want to get out of their Medicare Advantage plan.
→ We recommend working with one of our licensed agents if you are interested in a Medicare Advantage plan. We can confirm if your preferred doctors, hospitals, and pharmacies are in your network before you make your decision. No hassles, everything simplified.
I Pay More Out of Pocket Than I Thought I Would
Sometimes, insurance presentations can be confusing. Before we know it, we’re nodding our heads and signing up for a plan that we don’t actually understand.
It has happened to most of us at one time or another. Unfortunately, we have clients tell us the same thing about Medicare Advantage plans.
While these plans are $0 premium, and you don’t have to pay a monthly fee to carry the plan, there are out of pocket costs.
For example, that Humana HMO we were talking about earlier has a $25 specialist copay, an $80 emergency room copay, $15 copays for urgent care centers, copays for diagnostic services and labs, $250 charge for ambulance rides, and so on.
Additionally, some plans make it seem like they have full vision coverage, but in reality, this Humana plan only offers a $50 maximum benefit for contacts or glasses. If you don’t have 20/20 vision, you know $50 is a drop in the bucket when it comes to a year’s worth of disposable contact lenses.
This doesn’t mean that Medicare Advantage plans don’t offer really great coverage – this Humana plan also boasts excellent benefits, such as no medical deductible and no prescription drug deductible. Plus, when you visit your primary care provider, there’s no copay.
For individuals who rarely go to the doctor and are otherwise healthy, this plan is a dream!
However, we understand that there are times when you realize that the plan isn’t what you thought it was. This plan has a $6,700 in-network out-of-pocket responsibility, and that can be a big number if you’re constantly shelling out money for copays and coinsurance costs.
In those cases, a Medicare Supplement can be a better fit, and you might want to consider getting out of your Medicare Advantage plan.
How to Get Out of Your Medicare Advantage Plan
It happens – you realize you’re in a Medicare Advantage plan that doesn’t fit your needs and budget. There is hope!
You have a few opportunities to get out of your Medicare Advantage plan, which include:
- During the Annual Enrollment Period (AEP)
- During the Open Enrollment Period (OEP)
- During your “Trial Right”
- During a Special Enrollment Period (SEP)
Let’s go over what these mean and when you’d be eligible for each.
Get Out of Medicare Advantage During AEP
The Annual Enrollment Period occurs every single year from October 15-December 7. During this window of time, you can sign up for or get out of your Medicare Advantage plan. You can also make changes to your Part D drug plan if needed.
Cancel Your Medicare Advantage Plan During OEP
The second option is called the Open Enrollment Period (OEP). This happens every year from January 1-March 31. This is when you can drop your Medicare Advantage Plan and switch to Medicare with a Medigap Plan.
Note: CMS has done away with the “Disenrollment Period.” This used to be from January 1-February 14, and you could leave your MA plan during this time. The Disenrollment Period is gone and has been replaced by the OEP.
Use Your Trial Right
Using your Medicare Advantage trial right is another way to get out of your Medicare Advantage Plan.
Basically, if you choose Medicare Advantage during your open enrollment period, you have up to 1 year to “try it out.”
This only applies if you chose Medicare Advantage when you were first eligible for Medicare Part A at 65.
If during that “trial” year, you decide you don’t like Medicare Advantage, you can drop it and go back to open enrollment.
In this scenario, you can choose any Medigap policy that is sold in your state.
As with anything Medicare-related, some states are different when it comes to their rules. To make sure you’re prepared, contact us so we can review your plan and your state regulations.
Switch Back to Your Medigap Plan
Many seniors will enroll in a Medigap plan when they first join Medicare. After a few years, they might decide they want to try Medicare Advantage. But once they use it for a while, they realize it’s just not what they expected.
In this situation, you can go back to your Medigap plan. It’s considered a Special Enrollment Period, but we also call it a trial right.
So, if you dropped a Medigap policy the first time you joined a Medicare Advantage plan, you have 12 months to change your mind and go back to Medigap.
You have to go back to the plan you had, but if that plan is no longer available, your situation is considered Guaranteed Issue (GI). That means you will be accepted into certain Medigap plans, and you don’t have to pass medical underwriting.
Get Out of Medicare Advantage During a Special Enrollment Period
Special enrollment periods are tricky and often more confusing than we’d like.
There are currently 25 special enrollment situations, and rules about when you can make changes and the type of changes you can make are different for each one.
There are 5 main categories, which include:
- You change where you live
- You lose your current coverage
- You have a chance to get other coverage
- Your plan changes its contract with Medicare
- Other special situations
If you change where you live, you must match one of these special circumstances:
- Moved to a new address that isn’t in your plan’s service area
- Moved to a new address that’s still in your plan’s service area, but you have new plan options in your new location
- Moved back to the U.S. after living outside the country
- Just moved into, currently live in, or just moved out of an institution (such as skilled nursing or long-term care)
- You’ve been released from jail
If you’ve lost your current coverage, it must meet one of these criterias:
- You’re no longer eligible for Medicaid
- You left coverage from your employer or union (including COBRA coverage)
- You involuntarily lose other drug coverage that's as good as Medicare drug coverage (creditable coverage), or your other coverage changes and is no longer creditable
- You had drug coverage through a Medicare Cost Plan and you left the plan
- You dropped your coverage in a Program of All-inclusive Care for the Elderly (PACE) plan
If you have a chance to get other coverage, it must match these situations:
- You have a chance to enroll in other coverage offered by your employer or union
- You have or are enrolling in other drug coverage as good as Medicare prescription drug coverage (like TRICARE or VA coverage).
- You enrolled in a Program of All-inclusive Care for the Elderly (PACE) plan.
If your plan changes its contract with Medicare, it must meet this criteria:
- Medicare takes an official action (called a "sanction") because of a problem with the plan that affects you.
- Medicare ends (terminates) your plan's contract.
- Your Medicare Advantage Plan, Medicare Prescription Drug Plan, or Medicare Cost Plan's contract with Medicare isn't renewed.
These are the rest of the situations that qualify for a Special Enrollment Period:
- You’re eligible for both Medicare and Medicaid.
- You qualify for Extra Help paying for Medicare prescription drug coverage.
- You’re enrolled in a State Pharmaceutical Assistance Program (SPAP) or lose SPAP eligibility.
- You dropped a Medigap policy the first time you joined a Medicare Advantage Plan.
- You have a severe or disabling condition, and there’s a Medicare Chronic Care Special Needs Plan (SNP) available that serves people with my condition.
- You’re enrolled in a Special Needs Plan (SNP) and no longer have a condition that qualifies as a special need that the plan serves.
- You joined a plan, or chose not to join a plan, due to an error by a federal employee.
- You weren’t properly told that your other private drug coverage wasn't as good as Medicare drug coverage (creditable coverage).
- You weren’t properly told that you were losing private drug coverage that was as good as Medicare drug coverage (creditable coverage).
Medicare Advantage can be tricky, and while it can work for some people, it won’t work for others. It’s important that you talk to an agent to weigh your options.
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