Many seniors in California do not realize they have a special opportunity each year to change their Medicare Supplement plan without answering health questions. This opportunity is called the California Birthday Rule and it can be a valuable way to adjust coverage or reduce premiums if your needs have changed. Even if you are happy with your current plan, understanding the birthday rule can help you or someone you know make the most informed decisions about Medicare coverage.
What Is the California Birthday Rule?
The California Birthday Rule allows Medicare beneficiaries who are already enrolled in a Medicare Supplement plan to switch to a different Medigap plan during a specific time period each year without answering health questions or undergoing medical underwriting. Medical underwriting usually requires insurance companies to review your health history before approving a plan. If you have certain health conditions, you might be denied coverage or charged higher premiums. The birthday rule removes that barrier and gives seniors more flexibility.
Who Qualifies for the Birthday Rule?
To use the California Birthday Rule:
You must live in California
You must already have a Medicare Supplement plan
You can only use the rule during the 60 days following your birthday each year
During this window you can switch to a different Medigap plan with “equal or fewer” benefits. For example, someone could switch from Plan G to Plan G or from Plan G to Plan N. You cannot use this rule to switch from a plan with fewer benefits, such as Plan N, to a plan with greater benefits, such as Plan G.
Why This Rule Matters
The birthday rule can be very helpful for seniors who want to reduce their monthly premiums, adjust coverage to better match their current health needs, or gain more predictable out-of-pocket costs. Without this rule, switching plans outside of your initial Medigap enrollment period may require medical underwriting, which can limit your options or increase costs. Even if you are satisfied with your current plan, knowing about the birthday rule ensures that you or someone you know is aware of all available options.
By reviewing available plans, I can often save clients hundreds and sometimes even thousands of dollars on their premiums each year.
How to Use the California Birthday Rule
Mark your calendar because the rule applies during the 60 days following your birthday
Review available Medigap plans to compare premiums and coverage
Contact your insurance agent or insurance company to let them know you want to use the birthday rule to switch plans
Complete the application because no health questions will be asked
Confirm your coverage to make sure your new plan starts as expected
Planning ahead helps ensure you do not miss this opportunity because the window is limited.
Share This Information With Friends and Family
Many California seniors are unaware of the California Birthday Rule. Sharing this information with friends, family, or neighbors can help them avoid being denied coverage due to health conditions, reduce their premiums, or get a plan that better suits their needs. Providing this information is a valuable way to help others understand their Medicare options.
Need Help Understanding Your Options
Medicare rules can be confusing and every situation is a little different. If you or someone you know has a Medicare Supplement plan and wants to understand how the California Birthday Rule can help, I am always happy to answer questions and review options. Please feel free to share this article with friends or family who might benefit. Helping people understand their Medicare coverage is one of the most valuable things I can do for my clients.
Have Questions About Your Medicare Supplement Plan?
I’m here to help you understand your options and make the most of the California Birthday Rule. By reviewing available plans, I can often save clients hundreds and sometimes even thousands of dollars on their premiums each year.
If you found this article helpful, please feel free to share it with friends or family members who may have questions about their Medicare coverage.
Over the past several years, Medicare Advantage (MA) plans have become very popular. Millions of Americans have enrolled in them, often because the plans advertise low premiums and extra benefits such as dental, vision, or gym memberships.
However, a growing number of seniors are discovering that MA plans are not always the best fit for their healthcare needs. In fact, many people eventually decide to leave MA plans and return to Original Medicare (Part A and Part B), often paired with a Medicare Supplement (Medigap) plan.
If you or someone you know currently has an MA plan, it may be helpful to understand why some seniors decide to switch back. The goal of this article is not to criticize MA plans, but rather to explain some of the most common reasons people reconsider their coverage after experiencing it firsthand.
Below are several key reasons why some seniors choose to leave MA plans.
1. Doctor and Hospital Networks Can Be Limiting
One of the biggest differences between MA plans and Original Medicare is the use of provider networks. Most MA plans are HMOs and some are PPOs. This means members typically must receive care from doctors and hospitals within the plan’s network in order to receive the lowest cost coverage. While some plans offer limited out-of-network benefits, they are often more expensive.
Many people don’t realize how restrictive these networks can be until they actually need medical care. For example, a doctor you have seen for years may not be included in the plan’s network. Even more frustrating, doctors and hospitals can leave networks from one year to the next, meaning your trusted provider may suddenly no longer be covered.
Original Medicare works very differently. Patients can generally see ANY doctor or hospital in the United States that accepts Medicare, which includes the vast majority of providers, approximately 93%. For seniors who value flexibility and freedom in choosing their healthcare providers, this can be a major advantage.
2. Prior Authorization Requirements
Another issue that sometimes surprises MA members is the requirement for prior authorization. Prior authorization means the insurance company must approve certain procedures, tests, or treatments before they are performed. While this process is intended to control costs and ensure appropriate care, it can sometimes lead to delays or complications. For example, a physician may recommend a particular diagnostic test or treatment, but the MA plan may require additional approval before the service is covered. In some cases, this can delay care while paperwork is reviewed.
Original Medicare generally does not require prior authorization for most medically necessary services. This can make the process of receiving care simpler and more straightforward for patients and their doctors.
3. Referrals to Specialists
Most MA plans require members to obtain referrals before seeing a specialist. This means that if you want to see a cardiologist, dermatologist, or other specialist, you may first need to visit your primary care physician and obtain a referral. While some people are comfortable with this system, others find it inconvenient.
With Original Medicare, referrals are typically not required. Patients can schedule appointments with specialists directly, provided the specialist accepts Medicare. For seniors who want greater control over their healthcare decisions, this difference can become an important factor.
4. Coverage When Traveling
Travel is another area where some MA members encounter unexpected limitations. Many MA plans are designed around regional networks. If you travel outside your local area for an extended period of time, you may find that accessing routine medical care becomes more complicated.
While emergency care is usually covered nationwide, non-emergency services may be limited to the plan’s network. Original Medicare, on the other hand, is accepted by doctors and hospitals across the country. This makes it much easier for retirees who travel frequently, spend part of the year in another state, or simply want peace of mind while away from home.
5. Costs Can Be Less Predictable
MA plans often advertise low monthly premiums, and in some cases the premium may even be zero. While this can sound very appealing, it’s important to look at the total potential cost of care.
Many MA plans require co-payments for services such as:
Doctor visits
Specialist visits
Diagnostic tests
Outpatient procedures
Hospital stays
These costs can add up quickly if someone experiences serious health issues. In contrast, many people who choose Original Medicare also purchase a Medicare Supplement plan. These plans help cover many of the out-of-pocket expenses that Original Medicare does not pay, such as deductibles and coinsurance. As a result, healthcare costs can be more predictable from year to year.
6. MA Plans Have Maximum Out-of-Pocket Limits
Another factor many people overlook is the maximum out-of-pocket limit in MA plans. Each MA plan must set a maximum amount that a member could potentially pay during the calendar year for covered medical services. In 2026, that limit can be as high as $9,350 for in-network services, although some plans may set lower limits.
IMPORTANT:If you go out of network, you usually pay all costs!
While reaching that amount may not happen every year, it is possible if someone experiences a serious illness, hospitalization, or multiple medical procedures during the year. Also, if someone gets seriously ill in the last part of the year and they have met their annual deductible but are still requiring expensive care in the beginning of the following year, their annual deductible starts all over again every January, and they could potentially have to pay $9,350, etc. twice in a 12 month period!
By comparison, many people who combine Original Medicare with a comprehensive Medicare Supplement plan have much lower out-of-pocket exposure for Medicare-approved services. This can make healthcare costs far more predictable for retirees who want peace of mind. For example, with a Plan G Medicare Supplement, the maximum out-of-pocket cost for all of 2026 is the Medicare Part B deductible, which is only $283.
7. Switching Back Can Be Difficult Later
One of the most important facts many people don’t realize is that switching from MA to a Medicare Supplement plan later in life can sometimes be difficult.
When people first enroll in Medicare, they have a six-month Medicare Supplement open enrollment period. During this time, they can purchase any Medicare Supplement plan that they want without answering health questions. However, if someone decides to leave an MA plan later and apply for a Medicare Supplement plan, they are required to go through medical underwriting in most states. This means the insurance company can review health history and potentially decline coverage.
Because of this rule, some people feel “stuck” in their MA plan if their health has changed over time. There are a few exceptions in certain states that provide additional consumer protections, but the rules can vary significantly depending on where someone lives.
Making an Informed Decision
It is important to understand that both MA and Original Medicare with a Medicare Supplement plan can be appropriate depending on an individual’s preferences, budget, and healthcare needs.
Some people are perfectly happy with their MA plan and appreciate the additional benefits and lower premiums. Others prefer the flexibility and predictability offered by Original Medicare combined with a Medicare Supplement. The key is making an informed decision and understanding how the two types of coverage work before enrolling.
Final Thoughts
Healthcare coverage is one of the most important decisions people make during retirement. While MA plans work well for some individuals, others eventually decide that the flexibility and simplicity of Original Medicare better meets their needs.
If you have friends or family members enrolled in an MA plan who are experiencing frustrations with networks, referrals, or prior authorization requirements, it may be helpful for them to learn about the differences between these options. Everyone’s situation is unique, and the best coverage depends on personal circumstances. However, understanding how Medicare works can help seniors make confident decisions about their healthcare coverage for the future.
If you or someone you know currently has an MA plan and would like to better understand how it compares to Original Medicare with a Medicare Supplement plan, feel free to contact me. I’m an independent Medicare agent and I’m happy to help you review your options.
And if you found this article helpful, please feel free to share it with friends or family members who may have questions about their Medicare coverage.
If you have noticed that some insurance agents no longer offer Medicare Advantage or Medicare Part D plans, you are not imagining it.
Over the past several years, the rules governing the marketing and sale of Medicare Advantage and Part D plans have become increasingly detailed. Agents and brokers who sell these plans must meet annual training and testing requirements, follow Medicare marketing rules, comply with requirements imposed by the insurance companies they represent, and maintain appropriate documentation.
For some independent agents, the additional time, expense and responsibility have made these products less attractive to sell. I am one of those agents. I have made the decision to focus my business primarily on Medicare Supplement insurance rather than selling Medicare Advantage and Part D plans.
This does not mean that Medicare Advantage or Part D plans are bad coverage. These plans can be a good fit for many people. It simply means that I believe I can provide better service by specializing in Medicare Supplement insurance rather than trying to sell every type of Medicare product.
Why Have the Rules Become More Complicated?
Medicare Advantage and Part D plans are regulated by the Centers for Medicare & Medicaid Services, commonly called CMS.
CMS has established detailed requirements governing how these plans can be marketed and sold. The requirements are designed to protect Medicare beneficiaries and help ensure that people receive accurate information when making important coverage decisions.
Agents who sell Medicare Advantage and Part D plans must complete annual training and testing covering Medicare rules, regulations and the specific products they sell. Insurance companies and other organizations that work with agents also have their own certification and compliance requirements. For an independent agent who wants to represent multiple insurance companies, keeping up with all of these requirements can take a substantial amount of time.
Call Recording Adds Another Layer of Compliance
One of the requirements that has received considerable attention is the recording of certain calls involving Medicare Advantage and Part D sales and enrollment activities.
CMS requires organizations and individuals who meet the definition of a Third Party Marketing Organization, or TPMO, to record marketing, sales and enrollment calls in their entirety. Calls that do not involve marketing, sales or enrollment activities do not have to be recorded under this requirement.
This is an important distinction because the requirement is not simply that an agent must record every telephone conversation with every client. However, when an independent agent is conducting activities that fall under the Medicare marketing and enrollment rules, the recording and recordkeeping requirements can add another layer of technology, administration and compliance responsibility.
For a large organization or call center, these systems may be relatively easy to manage. For a small independent insurance practice, they can be much more burdensome.
Annual Training and Certification Take Time
Selling Medicare Advantage and Part D plans also requires ongoing training and testing. CMS requires agents and brokers who sell Medicare products to complete annual training and testing on Medicare rules and regulations as well as the specific benefits of the plans they sell.
An independent agent who represents several insurance companies may also need to complete separate certification requirements for those companies. That means an agent who wants to offer a broad selection of Medicare Advantage and Part D plans has to invest considerable time each year simply to remain qualified to sell and service those products.
There is nothing wrong with these requirements. In fact, I believe it is important that anyone helping a Medicare beneficiary choose coverage understand the products and the rules. The question for an independent agent is whether the time and resources required to remain active in this part of the business make sense for the practice.
Compensation Is Only One Part of the Equation
Compensation is another consideration, although it is not the only reason some agents have left this part of the Medicare business. CMS publishes compensation information for Medicare Advantage and Part D plans. Generally, independent agents receive an initial payment when a beneficiary enrolls and a lower renewal payment in subsequent years when applicable.
The amount an agent receives can vary depending on the type of enrollment, the plan, the state and other factors. For an independent agent, however, compensation has to be considered together with the time required for training, certification, compliance, documentation, technology and ongoing client service. An agent may decide that the overall economics simply do not make sense for the way he or she wants to operate a business. That is one of the reasons I decided to focus my practice on Medicare Supplement insurance.
Why I Chose to Specialize in Medicare Supplement Insurance
My decision is not based on the belief that Medicare Advantage or Part D plans are inherently bad. It is based on the type of service I want to provide.
As an independent Medicare Supplement insurance specialist, I can focus my time on helping clients compare Medicare Supplement plans from the insurance companies I represent. I can help clients compare premiums, benefits and other factors that are important when choosing a Medicare Supplement.
I also work with people who already have Medicare Supplement coverage and want to see whether they may be able to reduce their premiums while keeping the same benefits. That specialization allows me to concentrate on one area of Medicare rather than trying to be an expert in every type of Medicare insurance product.
There Is Another Important Consideration for Consumers
There is also a practical reason why I believe consumers should understand why some agents do not sell every Medicare plan available in their area. An insurance agent can generally only sell or enroll a beneficiary in the Medicare Advantage and Part D plans that the agent is properly licensed, appointed and certified to represent. That means an agent may represent several insurance companies but still not represent every Medicare Advantage or Part D plan available in a particular ZIP code. This does not necessarily mean the agent is doing anything wrong. It is simply a limitation that consumers should understand.
If you ask an agent to help you choose a Part D plan, for example, you may not necessarily be comparing every Part D plan available to you. That is one reason I created my separate guide explaining how to use Medicare’s Plan Finder.
How I Recommend Comparing Part D Plans
Because I do not sell Part D plans, I do not have a financial interest in recommending one Part D plan over another. Instead, I recommend using Medicare’s official Plan Finder to compare the plans available in your area based on your actual medications and the pharmacy you use.
For 2027, I have created a separate guide that walks through this process:
The important thing is to compare the plans using your own prescriptions and pharmacy information rather than choosing a plan simply because it has the lowest monthly premium. A plan with a slightly higher premium could potentially have lower overall prescription costs for your particular medications.
What About Medicare Advantage Plans?
The same general principle applies to Medicare Advantage plans. Medicare Advantage plans can be a good choice for some beneficiaries, but they are different from Original Medicare combined with a Medicare Supplement.
If you are considering a Medicare Advantage plan, it is important to look at the plan’s provider network, prescription drug coverage, costs, rules for seeing specialists, prior authorization requirements and maximum out of pocket costs. You should also consider whether your doctors, hospitals and other providers participate in the plan.
Medicare Advantage plans can change from year to year, which is why reviewing your coverage during the Annual Election Period is important. However, reviewing your options does not automatically mean you should change plans.
Why I Am Comfortable Not Selling These Plans
Some people have asked me why I do not simply maintain appointments with more insurance companies so I can sell Medicare Advantage and Part D plans again.
For me, it comes down to specialization. I would rather focus my time on Medicare Supplement insurance and provide personal service to the clients I serve than spend a significant amount of time maintaining certifications and compliance requirements for products that are not the primary focus of my business.
I also believe consumers should know when an agent does not represent every plan available in their area. If I were helping someone select a Part D plan, for example, I would not want that person to assume that the plans I could offer represented every available option. That is why I would rather point people toward Medicare’s Plan Finder and show them how to compare the available plans for themselves.
What This Means for You During AEP
If you have Medicare Advantage or Medicare Part D coverage, you may notice that some agents who previously helped people with these plans are no longer doing so. That does not necessarily mean that those agents no longer care about their clients. For some independent agents, the combination of annual training, certification, compliance, documentation, call recording and other requirements has simply made these products less practical to offer.
At the same time, these requirements are intended to protect Medicare beneficiaries and promote accurate information when people are making important Medicare decisions. CMS continues to maintain detailed requirements for agents and brokers who sell Medicare Advantage and Part D plans.
If you need help reviewing your Part D coverage, you do not have to rely solely on an insurance agent. You can use Medicare’s Plan Finder to compare the plans available in your area, and you can also contact the California Health Insurance Counseling & Advocacy Program (HICAP) for free, unbiased Medicare counseling.
My Role as an Independent Medicare Supplement Specialist
My business is focused on Medicare Supplement insurance. I work with most of the major insurance carriers offering Medicare Supplement plans in the states where I am licensed. If you already have a Medicare Supplement, I can help you review your current premium and compare other available Medicare Supplement options. If you are turning 65, I can also help you coordinate your Medicare enrollment with your Medicare Supplement coverage.
For Medicare Advantage and Part D plans, my goal is different. I want to make sure you have access to the information and tools you need to understand your options, even though I do not sell those plans. That is why I created my Part D guide and why I recommend using Medicare’s own Plan Finder when comparing prescription drug plans.
The Bottom Line
Medicare Advantage and Part D plans are important parts of the Medicare program, and they can be a good fit for many people. At the same time, the business of selling these plans has become more regulated and more complicated for independent insurance agents. Annual training and testing, carrier certifications, marketing requirements, documentation, call recording and other compliance responsibilities all require time and resources. For some agents, including me, the decision has been to focus on Medicare Supplement insurance instead.
If you have Medicare Advantage or Part D coverage, do not assume that you need to change plans simply because AEP arrives. Review your options, compare the coverage and costs that apply to your own situation, and make the decision that is right for you.
For more information about the 2026 Annual Election Period, see:
Disclaimer:This article is for educational purposes only and is not intended to provide individual insurance, legal or financial advice. Medicare rules, benefits, costs and plan information can change. Always verify current information with Medicare or your State Health Insurance Assistance Program before making a Medicare coverage decision.
About the Author
I’m an independent Medicare Supplement insurance specialist working with most of the major insurance carriers throughout California, Nevada, and Arizona.
I help people turning 65 coordinate their Medicare enrollment so their Medicare Supplement and prescription drug coverage begin at the same time as Medicare.
I also work with many people who already have Medicare Supplement plans and would like to review their options. In California, there is a law called the California Birthday Rule, which allows Medicare Supplement policyholders to change their plans each year during the 60 days following their birthday without answering health questions or going through medical underwriting. During this annual 60-day open enrollment period, you cannot be turned down for coverage when changing to a Medicare Supplement plan with the same or fewer benefits.
I regularly help clients lower their Medicare Supplement premiums while keeping the same benefits and coverage.
Over the years, I have helped many clients save hundreds and sometimes even thousands of dollars on their annual premiums.
There is never a fee for my services because I am compensated by the insurance companies, not my clients. My goal is to help you find competitive premiums while providing dependable, personal service year after year.
If you’re turning 65 or already have a Medicare Supplement plan and would like to review your options, I’m happy to help.
This website is operated by a licensed insurance agent and is intended for educational purposes only. I am not affiliated with or endorsed by Medicare or any government agency.
