What a plan can and can't use to turn you down
| Can't be used | Can keep you out |
|---|---|
| Your health, past illnesses or pre-existing conditions | Not having both Part A and Part B |
| End-stage renal disease (allowed since January 1, 2021) | Living outside the plan's service area (in Ohio, plans are approved county by county) |
| Your age, if you have Medicare because of a disability | Applying outside an enrollment period you qualify for |
| How much care you used last year | Not meeting a special needs plan's eligibility rules |
The rules are in 42 CFR 422.50, and Medicare's booklet Understanding Medicare Advantage Plans says you can join "even if you have a pre-existing condition."
The timing rule is what stops most people
You can join or switch only at certain times:
- Initial Enrollment Period: the 7 months around your 65th birthday month (or when you first get Medicare because of a disability).
- Open Enrollment: October 15 to December 7 each year, for coverage starting January 1.
- Medicare Advantage Open Enrollment Period: January 1 to March 31, if you're already in a plan.
- Special enrollment periods: for example after moving, losing other coverage, getting Ohio Medicaid or Extra Help, or when your plan is ending. See can I change my plan after open enrollment.
Special needs plans have extra rules
A special needs plan can turn you down if you're not in the group it serves. A dual eligible plan (D-SNP) needs proof of Medicaid; a chronic condition plan (C-SNP) needs a qualifying condition, usually confirmed by your doctor; an institutional plan (I-SNP) needs nursing home residence or that level of care. In Ohio for 2027, the only D-SNPs are the plans tied to Next Generation MyCare Ohio. See what are special needs plans in Ohio.
If you have retiree coverage
A plan won't turn you down, but joining one can cost you other coverage. Enrolling in a new Medicare Advantage or Part D plan automatically ends your current one, and STRS Ohio says joining any other Part D plan cancels your STRS Ohio medical and prescription coverage. Check with your retirement system or former employer first; see Ohio public retirement systems and Medicare.
If you think a plan or agent refused you unfairly or misled you, call 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048). Complaints about an agent go to Ohio Department of Insurance Consumer Services at 1-800-686-1526. To compare plans from the companies they work with, you can request a call from a licensed insurance agent.
Related questions
What are special needs plans?
Who qualifies for each type.
Is Medicare Advantage in every county?
Yes for 2027.
How do I choose a plan?
Five steps to compare.
Sources
- eCFR — 42 CFR 422.50, eligibility to elect an MA plan
- eCFR — 42 CFR 422.74, disenrollment by the MA organization
- Medicare.gov — Understanding Medicare Advantage Plans (who can join; pre-existing conditions; ESRD)
- Medicare.gov — Joining a health or drug plan
- STRS Ohio — Medicare enrollment
More questions in this guide
- How do I choose a Medicare plan in Ohio?
- How many Medicare Advantage plans are available in Ohio for 2027?
- Is Medicare Advantage available in every Ohio county?
- What are Medicare special needs plans in Ohio?
Part of the guide: Medicare Advantage in Ohio · All questions
Frequently asked questions
Can I join Medicare Advantage in Ohio if I have end-stage renal disease?
Yes. Since 2021, people with ESRD can join any Medicare Advantage plan. Before you join, check that your dialysis center, kidney doctor and any transplant center you may need are in the plan's network.
Can a Medicare Advantage plan drop me?
Only for specific reasons Medicare allows, such as moving out of the service area, being away from it for more than 6 months in a row (unless the plan has a visitor program), not paying premiums after a grace period, or losing eligibility for a special needs plan.
Is Medigap different?
Yes. Outside your 6-month Medigap open enrollment period and federal guaranteed-issue situations, an Ohio Medigap company can ask health questions and turn you down. Ohio has no birthday rule.
Medicare in your Ohio county
Plans, local agents and help, county by county: Franklin · Cuyahoga · Hamilton · Summit · Montgomery · Lucas · Butler · Stark · Lorain · Warren · Delaware · Lake · Mahoning · Clermont · Trumbull · Licking · Medina · Greene · Fairfield · Portage · All 88 counties →
