Thinking of Dropping Medicare Advantage This Fall? Medigap May Refuse You

Medicare says you can exit Medicare Advantage by Dec. 7, but it leaves out a key question: who decides whether you can get covered after that?

On Medicare’s open enrollment page, the process sounds straightforward. It says that between Oct. 15 and Dec. 7, you can leave a Medicare Advantage plan and return to Original Medicare, with the switch taking effect Jan. 1.

What the page does not explain is the catch. Leaving Medicare Advantage is simple. Getting a Medigap policy to pair with Original Medicare is often the hard part.

As the name suggests, Medigap is designed to cover the “gap” in Medicare expenses. It is a separate policy that can help pay copayments and deductibles and reduce out-of-pocket costs.

In most states, except in a few protected cases, Medigap insurers can ask about your health, charge more, or decline to sell you a policy.

If you discover that only after dropping Medicare Advantage, you may be left with Original Medicare and nothing to fill those gaps.

This is not a minor issue. KFF, the health policy research organization, estimated that 74% of Medicare Advantage enrollees — about 20.9 million people based on recent data — have a medical condition that could lead to denial.

After writing about money for more than 35 years, I can say few rules punish ignorance as harshly as this one. Here are five things to know before making the change.

1. Original Medicare by itself can be risky

One detail many people overlook is that Medicare Advantage plans cap annual out-of-pocket spending on covered care. Original Medicare does not. According to Medicare.gov, there is no yearly limit on what you pay unless you have supplemental coverage or other insurance.

That can add up quickly. In 2026, the Part A hospital deductible is $1,736 for each benefit period, not each year. Two separate hospital stays could mean $3,472 in deductibles before anything else.

Part B, which covers doctor visits and outpatient care, has its own costs. After a $283 deductible, you usually pay 20% of the cost of each covered service, and that share does not stop.

If you were to face $60,000 in outpatient treatment over a year, the 20% share would come to about $12,000. The next year, the same thing could happen again.

That is why many people who leave Medicare Advantage want Medigap. Without it, you are effectively self-insuring against the worst year of your life.

What to do: Do not think of Medigap as a luxury add-on. If you cannot get one, staying in Medicare Advantage may be the safer choice.

2. Medigap insurers can underwrite you

Outside protected situations, buying Medigap works more like buying life insurance than buying Medicare. Insurers use a process called medical underwriting.

Medicare.gov says an insurer can deny you if you fail its underwriting review, and a higher premium may also be possible. The government’s Medigap guide adds that no company is required to sell you a policy.

In practice, that often means a health questionnaire. More insurers are also asking applicants to allow a review of prescription drug history, and one actuary told KFF Health News that medication records may carry more weight than anything else.

And the process may be getting tougher. “Medigap insurers’ underwriting has tightened up considerably recently,” Bonnie Burns, a consultant with California Health Advocates, told KFF Health News.

Even if you are approved, there can be conditions. The government guide says an insurer may delay paying for preexisting-condition costs for up to six months.

What to do: Assume you will face underwriting unless you have written proof of a guaranteed right to buy. That leads to the next point.

3. Know your guaranteed rights and the deadlines

In certain situations, federal law gives you what Medicare calls guaranteed issue rights. When one of those applies, the insurer must sell you a policy, cover preexisting conditions and avoid charging you more because of your health.

For people leaving Medicare Advantage, two situations matter most.

The trial right: If you joined Medicare Advantage when you were first eligible at 65 and decide within your first year to return to Original Medicare, you can buy any Medigap policy sold in your state.

A second trial right applies if you left Medigap to try Medicare Advantage for the first time and have been in the plan for less than a year. In that case, you may buy back the Medigap policy you had before, or, if it is no longer sold, one of several standard plans.

Your plan is leaving: You also have a guaranteed right if your Medicare Advantage plan exits Medicare, stops serving your area, or if you move out of its service area.

This happens more often than many people realize. A JAMA study published in February estimated that about 1 in 10 people in individual Medicare Advantage plans would be forced out because their plan left their county.

This right comes with a shorter list of options. Medicare lists Plans A, B, C, D, F, G, K and L, although C and F are not available if you became newly eligible for Medicare in 2020 or later. And this only applies if you move to Original Medicare, not to another Medicare Advantage plan.

The deadlines are tight. According to the government guide, you can apply as early as 60 days before your Medicare Advantage coverage ends and no later than 63 days after it ends.

If you received a non-renewal notice, see the detailed guidance in “Your Medicare Advantage Plan Won’t Be Back in 2027? A CPA on the Medigap Window That Protects You.”

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4. Some states offer year-round protection, but birthday rules do not

Where you live can make a major difference.

A May 2026 chart from the National Association of Insurance Commissioners says New York and Massachusetts have continuous Medigap open enrollment. KFF says Connecticut also offers continuous open enrollment and guaranteed issue all year. In those states, much of the situation described here does not apply.

Maine provides a narrower exception. According to KFF, insurers there must sell at least Plan A during one month each year, with each insurer choosing its own month. Plan A is basic, but it is still coverage. KFF also says Maine extends the federal one-year trial right to three years.

Now for the confusing part. You may have heard of the “birthday rule,” which KFF says exists in 16 states, including California, Illinois, Oregon and Virginia. It may sound like an annual free pass, but it is not for people without Medigap.

Those rules allow people who already have a Medigap policy to switch around their birthday each year to another policy with equal or lesser benefits.

KFF makes clear that they do not let someone without Medigap buy a policy for the first time. If you are coming from Medicare Advantage, you do not already have Medigap, so the birthday rule does not help.

What to do: Check your state’s rules before assuming anything. Some states go beyond federal law, and Medicare.gov says you may have additional rights under state law.

5. Get approved first, then make the move

This is the most important step, and it is the part that the “switching is easy” message leaves out.

You do not have to leave Medicare Advantage before applying for Medigap. According to Medicare’s guide, if you plan to return to Original Medicare, you can apply for Medigap while still enrolled in Medicare Advantage, and the insurer can sell it to you as long as you are leaving.

The guide also says to ask for the new policy to begin when your Medicare Advantage coverage ends so there is no gap. A Medigap policy cannot start until your Medicare Advantage coverage is over anyway.

That makes the decision much safer. If you are approved at a price you can afford, switch to Original Medicare by Dec. 7. If you are denied, or the premium is too high, you have lost nothing and can remain in Medicare Advantage.

Do not overlook drug coverage. If your Medicare Advantage plan included it, you will need to replace it. Medicare’s guide says that with Original Medicare, you can enroll in a separate drug plan for Part D coverage.

Get free help: Before making any move, contact your State Health Insurance Assistance Program, or SHIP.

SHIP provides free, local, one-on-one Medicare counseling, and you can find your office at shiphelp.org. KFF Health News reported that SHIP counselors can also point you toward ways to get coverage without underwriting.

The bottom line

The system is set up so that leaving Medicare Advantage looks like a simple checkbox, while the harder question — whether an insurer will cover you — is handled somewhere else, under someone else’s rules.

Reverse the order. Find out whether you have a guaranteed right, check your state’s rules, and apply for Medigap before you give up the plan you already have.

If you are still deciding whether to stay, see “Your $0 Medicare Advantage Plan Just Got Worse. Check These 5 Things Before Dec. 7,” and track the deadlines with “7 Medicare Enrollment Windows Every Retiree Must Know.”