Key Takeaways
- A 78-year-old in South Florida on Eliquis wants to leave her Medicare Advantage PPO for Original Medicare and a supplement during open enrollment, which ends Dec. 7.
- Her one-time Medigap window, when insurers can’t turn applicants down over their health, is almost surely closed, so a Medigap policy may not be available to her or may cost more.
- With no Medigap policy, she’d pay the $283 Part B deductible plus 20% of each covered bill with no yearly limit, or $4,226.40 on a procedure Medicare approves at $20,000.
- She can apply for Medigap before she leaves her Advantage plan, and if no insurer accepts her, a different Advantage plan with her doctors in network looks like the safer move.
If you’re in a Medicare Advantage plan and fed up with its network, you have until Dec. 7 to go back to Original Medicare. But the Medigap policy that would pick up your share of the bills afterward may no longer be yours to buy, and without one, that share has no yearly cap.
Her Advantage plan isn’t working for her
A poster in Reddit’s r/medicare forum asked for help this week on behalf of a 78-year-old woman in South Florida who wants to make exactly that move. She’s active and healthy overall, the poster wrote, but a hospital stay for pneumonia and an infection early last year left her on Eliquis and Trelegy long term, and she sees a cardiologist and a pulmonologist every few months. Her cardiologist has said a loop recorder, a small implanted heart monitor, could help her wean off Eliquis.
She’s in a UnitedHealthcare AARP Medicare Advantage PPO, and the poster says she’s “not happy with the choices of doctors in her network, dr visit copays and prescription copays.” She pays about $60 to see a specialist and up to $2,000 a year on prescriptions. So the poster is shopping for a supplement instead.
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Her Medigap window closed long ago
Medigap works only with Original Medicare, so it’s a second purchase on top of the switch. Federal law gives everyone a one-time, six-month Medigap Open Enrollment Period, starting the first month they have Part B and are 65 or older. During those six months, an insurer can’t use medical underwriting to turn an applicant down or deny coverage for pre-existing health problems. Once the window closes, she may not be able to buy a Medigap policy at all, or it may cost more.
At 78, unless she signed up for Part B within the past six months, her window is behind her, and it doesn’t come around again when she leaves the Advantage plan. My read: an insurer looking at a chronic blood thinner, a hospital stay last year and a planned heart-monitor implant could well say no, or quote a premium that stings.
One procedure could cost her $4,226.40
Back on Original Medicare with no supplement, she’d pay Part B’s $283 deductible for 2026, then usually 20% of the Medicare-approved amount for each covered service. And Part B has no yearly limit on what she pays out of pocket.
So let’s say Medicare approves $20,000 for her loop recorder procedure. She’d pay the first $283, then 20% of the remaining $19,717, or $3,943.40. That’s $4,226.40 out of her pocket between the deductible and her 20% share, for one procedure. Her bill could come in well under $20,000, and her share would shrink with it. But the specialist visits every few months and any second procedure each add their own 20% on top, and nothing stops the total.
Her Advantage plan has the ceiling she’d be giving up. Every Advantage plan has a yearly out-of-pocket limit, which varies by plan, and once she’s paid up to it, the plan pays 100% of covered health services for the rest of the calendar year. The post doesn’t give her plan’s limit.
Line up the supplement before Dec. 7
Changes made in open enrollment take effect Jan. 1. She can apply for a Medigap policy while she’s still in her Advantage plan, as long as she’s switching back to Original Medicare, and the policy can’t start until her Advantage coverage ends. Otherwise, it’s illegal for an insurer to sell a Medigap policy to someone in an Advantage plan. If her drug coverage comes through the Advantage plan (the poster wasn’t sure), she’d also pick a separate Medicare drug plan for her Eliquis and Trelegy in the same window.
If no insurer will take her, open enrollment also lets her switch to a different Advantage plan. One with her cardiologist and pulmonologist in network would fix the complaint that started all this, and it would come with a yearly cap of its own.
If I were in her shoes, I wouldn’t leave the Advantage plan until a Medigap insurer had said yes. Going back to Original Medicare without one trades a network she dislikes for bills with no ceiling, and with a procedure on the table, that’s a bad trade.
She has until March to change her mind
If she stays put past Dec. 7 while an insurer weighs her application, she isn’t locked in for all of 2027. From Jan. 1 to March 31, anyone already in an Advantage plan can drop it, return to Original Medicare and join a separate drug plan at the same time. Any switch would also put her on 2027’s Part B deductible, and CMS hasn’t published 2027’s figures yet. It released this year’s on Nov. 14 last year, so she should have the new deductible well before she’d have to pay it.
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Disclaimer:
Please note that the articles on TIKR are not intended to serve as investment or financial advice from TIKR or our content team, nor are they recommendations to buy or sell any stocks. We create our content based on TIKR Terminal’s investment data and analysts’ estimates. Our analysis might not include recent company news or important updates. TIKR has no position in any of the stocks mentioned. Thank you for reading, and happy investing!
