Does switching Medicare plans affect my coverage?

1 answer | Last updated: Jun 28, 2010
Shoulder1 asked...

I will turn 65 in July 2009 and will be on Medicare Parts A and B. I want to get out of my HMO and go with Medigap policy. However, I broke my shoulder in April 2007 in a Workman's Compensation incident. It's healing but there's still a slight chance I could need surgery. Either way, I will need physical therapy. If I switch from my HMO to Medicare supplement policy, how does that affect treatment for my shoulder?

Expert Answers

When you turn 65 and enroll in Medicare Part B, you will have a six-month "guaranteed enrollment" eligibility period in which to purchase any Medigap (Medicare supplement) insurance policy available in your state. This means that you will be able to buy any Medigap policy, at the same rates as charged to others, regardless of your shoulder injury or any other preexisting medical condition.

Once you are enrolled in Medicare Part A, Part B, and a Medigap policy, together they will cover any medically necessary shoulder surgery and hospitalization, plus doctor-prescribed physical therapy whether or not you have surgery. But Medicare Part B has a yearly cap ($1,840) on physical therapy payments, and Medigap policies do not provide any coverage beyond that cap. Your current HMO, on the other hand, may provide more extensive physical therapy benefits. If so, you may want to consider keeping your HMO for awhile after you enroll in Medicare Part B, as long as you switch to a Medigap policy within six months. During the time you remain in your HMO, you can take advantage of its extra physical therapy coverage (if it offers better coverage than Medicare Part B), then switch to a Medigap policy before your six month guaranteed enrollment period is up.

Be aware, however, that once you are eligible for Medicare, your HMO may require that you switch coverage from your current plan to a special Medicare-eligible version of that plan. If so, you have to find out what the physical therapy coverage would be under that version of the plan, too.