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Locked Into a Medicare HMO

Find out whether you can get out of a Medicare HMO and back into traditional Medicare.

Q. I enrolled in a Medicare HMO at the beginning of this year and I’m now regretting it. Am I locked in? Or can I get back into traditional Medicare without waiting until the end of the year?

A. Maybe, but only in certain circumstances:

  • If you joined the Medicare health plan straight away during your initial enrollment period (when you turned 65) and this is your first year in the same plan, you can switch to traditional Medicare at any time within 12 months of joining the plan. This is regarded as a trial period. You can also enroll in a stand-alone Part D prescription drug plan at the same time. And you have a guaranteed right to buy Medigap supplementary insurance as long as you apply for it within 63 days of your health plan coverage ending.
  • If you dropped a Medigap supplementary insurance policy to enroll in a Medicare health plan for the first time, you’re entitled to switch back to traditional Medicare and be reinstated in your old Medigap policy on the same terms at any time within 12 months of joining the health plan. (However, you cannot do so if you were ever enrolled in a Medicare health plan before, no matter how long ago.) You can apply for the Medigap policy up to 60 days before, and no later than 63 days after, your health plan coverage ends.
  • If you receive Extra Help under the Part D drug program, or live in a nursing home, you can change health plans (including switching to traditional Medicare) at any time of the year.
  • If you move permanently out of your plan’s service area, you can use this opportunity to disenroll from your plan and switch to traditional Medicare instead of joining another health plan in your new home area, as explained in this previous question.

If you receive a special enrollment period (SEP), apart from those listed above, to disenroll from your current plan and switch to another partway through the year (that is, outside standard enrollment periods), you can use it to switch to traditional Medicare if you want. You can get a SEP if:

  • you lose eligibility for a Special Needs health plan,
  • your plan closes down,
  • it violates its contract with you,
  • you were tricked or misled into joining it,
  • a federal employee made a mistake in processing your enrollment or disenrollment, or
  • in other exceptional circumstances.

In most cases, all you need do to switch to traditional Medicare is disenroll from your health plan, which will check that you are entitled to a SEP. Once your plan coverage ends, traditional Medicare coverage automatically kicks in. You should then start using your Medicare card to receive services, instead of your plan’s card.

However, you need to apply for a SEP if you want to switch out of a plan that violated its contract or misled you into joining it, or if a federal employee made an error. To apply for this type of SEP, call Medicare at 1-800-633-4227 (or TTY 1-877-486-2048) and explain the circumstances. Medicare will investigate your complaint and decide whether or not to grant you an SEP.

(All these special enrollment periods may be used to switch to another Medicare health plan as well as to traditional Medicare, according to your preference.)

Patricia Barry is a senior editor at the AARP Bulletin.

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