Navigating Medicare & the Health Insurance Marketplace

Navigating Medicare & the Health Insurance Marketplace

Many people purchase their health insurance through the Health Insurance Marketplaces established by the Affordable Care Act in 2010. Yet when people become eligible for Medicare, there is little notification and thus much confusion on how and when to make the transition to this federal health care program. Below is some information with 3 main points and several action tips put together by the national SHIP Tech Center, the Senior Medicare Patrol National Resource Center and Medicare Rights Center on Health Insurance Marketplaces and how they affect Medicare. This information can help you can make informed decisions about your Medicare enrollment. For questions and/or assistance, contact your local Health Insurance Counseling and Advocacy Program (HICAP).


Point 1: Know what the Health Insurance Marketplaces are.

The Health Insurance Marketplaces were created by the Affordable Care Act (ACA). They allow people to buy insurance if they do not have insurance or do not have enough insurance. You can access the Marketplace online or over the phone. Some states have their own Marketplaces, and other states use the federal Marketplace to provide coverage. Plans sold through Marketplaces are also known as Qualified Health Plans, or QHPs.


Point 2: Understand how the Marketplace affects your Medicare coverage.

If you are eligible for Medicare, you should not use the Marketplace to get health and drug coverage, with two exceptions. If you are eligible for Medicare because you have End-Stage Renal Disease (kidney disease that requires dialysis or transplant) or you have to pay a premium for Medicare Part A (hospital insurance), you can choose to enroll in a Marketplace plan instead of Medicare.


You do not buy a Medicare Advantage Plan, Part D prescription drug plan, or Medicare supplemental insurance (known as Medigap) through the Marketplace. It is illegal for someone to sell you a Marketplace plan if they know you are enrolled in Medicare. If someone tries to sell you a Marketplace plan, let them know that you have Medicare and cannot enroll in a Marketplace plan.


Point 3: Know how to change from a Marketplace plan to Medicare.

If you are currently enrolled in Marketplace plan, you should most likely drop the Marketplace plan and enroll in Medicare when you are first eligible. There are a few reasons why:

  1. If you do not enroll in Medicare when you are first eligible, you may have a late enrollment penalty when you sign up later. You may also experience gaps in health insurance coverage.
  2. Marketplace plans do not work with Medicare. If you keep your Marketplace plan, it may not cover you once you are eligible for Medicare.
  3. Once you are eligible for premium-free Medicare Part A, you will no longer be eligible to receive cost assistance for your Marketplace plan. Although you may keep your Marketplace plan after becoming eligible for Medicare, it can be very expensive without cost assistance.


If you are enrolled in a plan through the federal Marketplace, contact the Marketplace at 800-318-2596 or visit to disenroll at least 14 days before you want your coverage to end. For Californians, contact Covered California at to learn how and when to disenroll from the plan. Keep in mind that you want your Marketplace plan to cover you up until your Medicare starts. You do not want any gaps in coverage, so timing is important.


Marketplaces also provide coverage through the Small Business Health Options Program (SHOP). This program lets small businesses provide health insurance. If you have a SHOP plan through a current employer, you may still need to enroll in Medicare. The timing depends on the size of your employer and how you qualify for Medicare. If you have a SHOP plan, talk with your employer or contact your local Health Insurance Counseling and Advocacy Program (HICAP) at 1-800-434-0222.


Actions to Take:

  1. If you are enrolled in a Marketplace plan and will soon be eligible for Medicare, contact Covered California, our state Marketplace to learn how to disenroll from the plan. You should disenroll before Medicare coverage begins.
  2. If you already have Medicare, you do not need to do anything with the Marketplace. Keep this information in mind in case it is helpful for a friend or family member.
  3. Contact HICAP if you have questions about how the Marketplace does or does not affect you.
  4. Contact your Senior Medicare Patrol (SMP) at 1-855-613-7080 if you suspect Medicare fraud, such as if someone tries to get you to enroll in a Marketplace plan while you are eligible for or enrolled in Medicare.
Karen Fletcher
Our blogger Karen J. Fletcher is CHA's publications consultant. She provides technical expertise, writing and research on Medicare, health disparities and other health care issues. With a Masters in Public Health from UC Berkeley, she serves in health advocacy as a trainer and consultant. See her current articles.

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