If you want out of Medicare Advantage, a 12-month calendar is your best friend

Seniors are finding that insurers are denying prior authorization for long-term care and rehabilitation. Are they trapped? Some are, but not everyone.

Seniors who signed up for Medicare Advantage at 65 and later wish they hadn’t have a federal escape hatch — but it closes after 12 months, and most consumers don’t know it exists until it’s too late. Find a more detailed guide to leaving Medicare Advantage on our ConsumerNews.ai site.

The protection is called the trial right. Under 42 U.S.C. § 1395ss(s), anyone who enrolled in a Medicare Advantage plan as their first-ever Medicare coverage has up to 12 months to change their mind, return to Original Medicare, and buy a Medicare Supplement (Medigap) policy without health questions, denials or surcharges.

A parallel right covers people who dropped a Medigap policy to try Medicare Advantage for the first time and now want their old policy back. Maine extends both versions to 36 months, AARP reports. Every other state stops at one year.

Outside the trial right, the door slams. In all but four states — Connecticut, Massachusetts, Maine and New York — insurers can refuse a Medigap policy or charge more based on a beneficiary’s health history once the 12 months elapse, the Kaiser Family Foundation found. Minnesota will add a limited annual window on Aug. 1, 2026, but only for ages 65 to 70 and with premiums that can run 15 to 35 percent above standard rates.

That asymmetry is the trap. A senior who enrolls when healthy, develops a chronic condition at 72, and tries to leave because the plan keeps denying long-term care may find no insurer will sell them a Medigap policy at any price.

The mechanics are simple but unforgiving. Five steps protect the right.

Call your free state counselor first. Every state runs a State Health Insurance Assistance Program — SHIPs — paid for by federal grants, staffed by trained volunteers, with no sales incentive. The national locator is 1-877-839-2675 or shiphelp.org. Ask the counselor four things: am I still inside my trial window, which Medigap plans must insurers issue to me in this state, what does my state add to federal protections, and what does the cheapest comparable Medigap policy cost?

Verify your state’s underwriting rules in writing. Sixteen states now operate “birthday rule” windows that let existing Medigap holders switch plans annually without underwriting, medicareresources.org reports — California, Oregon, Idaho, Illinois, Nevada, Louisiana, Maryland, Oklahoma, Kentucky, Utah, Virginia, Wyoming, plus Delaware and Indiana effective January 2026, West Virginia effective June 2026 and New Mexico beginning January 2027. None of those state windows replace the trial right for someone leaving Medicare Advantage. They only help if you already have Medigap.

Get Medigap quotes before disenrolling, not after. Pull quotes from at least three insurers for Plan G, the most comprehensive plan available to anyone newly eligible after January 2020 (Plan F is no longer sold to that group, per Medicare.gov). On every call, say: “I am exercising my federal 12-month trial right under 42 U.S.C. 1395ss(s) on a guaranteed-issue basis.” Get the agent’s name, the quote and the written application packet.

Sequence the paperwork. Submit the Medigap application first with a requested effective date that lines up with the first of the month after Medicare Advantage ends. Then disenroll from Medicare Advantage — by calling 1-800-MEDICARE, by enrolling in a standalone Part D drug plan (which automatically terminates Medicare Advantage), or by sending the plan a certified-mail disenrollment request. Do not file CMS Form 1763 by mistake — that form terminates Medicare itself, not a Medicare Advantage plan.

Plug the drug-coverage hole. Original Medicare does not include prescriptions. Enroll in a standalone Part D plan with a start date that matches the day Medicare Advantage drug coverage ends. More than 63 consecutive days without creditable drug coverage triggers a permanent late-enrollment penalty added to your Part D premium for life.

What to keep on file: your Medicare Advantage member ID showing the enrollment date that starts the 12-month clock; the Medigap insurer’s written confirmation that the policy was issued on a guaranteed-issue basis under the trial right; the disenrollment letter from your former Medicare Advantage plan with the last day of coverage; the Part D confirmation; and a call log with names and reference numbers. Keep all of it for seven years.

The most common ways consumers lose the right: disenrolling from Medicare Advantage without first applying for Medigap; applying in month 13; assuming a state birthday rule covers an MA-to-Medigap switch when it does not; and accepting a Medigap insurer’s claim that health questions can be used to deny coverage during a guaranteed-issue event. Federal law forbids that last one. If it happens, call your state insurance department and cite 42 U.S.C. 1395ss(s)(2)(A).

The HHS inspector general reported last week that the three largest Medicare Advantage insurers — UnitedHealthcare, CVS Health and Humana — deny prior authorization for long-term and rehabilitative care at rates ranging up to 80 percent, NBC News reported, and overturn 95 percent of those denials on appeal. For seniors who entered Medicare Advantage on the strength of zero-premium marketing and gym memberships and now find themselves fighting their insurer over a nursing-home stay, the 12-month clock is the only federal door that closes behind them in a way they can still walk back through. Use it before it shuts.

Find a more detailed guide to leaving Medicare Advantage on our ConsumerNews.ai site.

For one-on-one help: SHIP at 1-877-839-2675 (shiphelp.org); Medicare at 1-800-MEDICARE; the Medicare Rights Center at 1-800-333-4114.