(The following is for general information and should not be relied upon without reviewing your circumstances with a Medicare expert.))

   I have been a volunteer trying to help people with Medicare for over 7 years, but it is only within the last year that I have dealt first hand with one of the least understood complications in the Medicare program.

       There are limited situations when a Medicare Supplemental Insurance (also called Medigap) Company must permit a Medicare beneficiary to subscribe regardless of any pre-existing conditions:

  • During the initial enrollment period – when the individual first turns 65 (even if they have been a Medicare beneficiary following 24 months of receiving Social Security Disability payments).
  • During a delayed initial enrollment period – when the individual or the individual’s spouse was actively working so that the individual was covered by an employee group health plan (EGHP) when the individual turned 65. (The initial enrollment period is delayed until the individual or his spouse loses the EGHP or stops working whichever first occurs.)
  • During a special enrollment period – which can happen when someone moves to another state or loses employer retiree health coverage (which must have included prescription drug coverage creditable to Medicare prescription drug coverage) through no fault of their own or when an individual disenrolls from a Medicare Advantage Plan (also called a Medicare Health Plan) during the trial period (the first 12 months of membership in the Plan).

         The so-called “open enrollment period” between 10/15 and 12/7 each year is not an opportunity to enroll in a new Medicare Supplemental Insurance Plan.  During that time of the year every beneficiary can review their options for prescription drug coverage for the following year and enrollees in a Medicare Advantage Plan can change their choice of Advantage Plan.

A Medicare Supplement Insurance provider will be happy to have the business of a healthy Medicare beneficiary and will accept an application at any time. But anyone who has been ill or had a hospital stay will either not be accepted or only accepted at a higher premium.

         Where this gets even more confusing is when a participant in a Medicare Advantage Plan is beyond the 12 month trial period and wishes to disenroll. The Medicare process allows them to return to original Medicare and obtain Part B coverage of doctor visits, test, durable medical equipment, etc. without any penalty. But there is no guaranteed right to a Medicare Supplemental Insurance Plan without consideration of pre-existing conditions.

One couple, who came to the Delaware Medicare Assistance Bureau for help, wanted to disenroll from their Advantage Plan and the Medicare supplement was willing to take the husband but, because the wife was in the hospital overnight in December, the supplement would not accept her until July. If she disenrolled, she would be without coverage for 3 months. The disenrollment periods for Medicare Advantage plans are only once a year, so her choice was to take a chance for couple of months this year or wait until the next disenrollment period and hope she did not have occasion to visit the hospital in the six months before the next disenrollment period.

           Another couple were disenrolling during the twelve month trial period but the enrolling agents did not know about the special enrollment period. Not only did they seek to impose a higher premium on the wife reflecting underwriting but they initially denied acceptance in the prescription drug plan because it was not the open enrollment period. After several hours on the phone, we were able to correct the mistakes and get them properly enrolled in both the Medicare Supplemental Insurance and prescription drug plan.

            This is why I cringe when I see the TV ads for the Medicare Advantage Plans. I feel as if the ad should end with a warning similar to the drug-side-effect warning in drug ads. A quiet voice speaking very fast would say something like: “Beneficiaries enrolling in a Medicare Advantage Plan should be aware that if they disenroll after the 12 month trial period, a Medicare Supplemental Insurance Plan may subject them to underwriting, use of providers outside the plan network may increase copays and total copays may exceed the Medicare copays and deductibles in some instances.”