A couple in their late 60s spends April through October at a lake house near Cleveland and November through March in a condo outside Naples. Their Medicare Advantage plan, chosen five years ago for its $0 premium and included dental, lists a primary care doctor and cardiology network in Cuyahoga County.
In Florida, the HMO covers emergency care, urgent care, and certain other required services, but routine cardiology appointments may be outside the network. Unless the plan offers a visitor benefit or authorizes the care, it may pay nothing. This is the retirement many Medicare Advantage HMOs were not built for, and the trap tightens the longer the couple remains enrolled.
The County-Based Network Nobody Mentions
Medicare Advantage service areas are generally built around counties or groups of counties. A plan sold in Cuyahoga County contracts with a specific network of hospitals and physicians. When the enrollee arrives in Collier County, the plan treats him as a traveler.
Federal rules require coverage for emergency and urgently needed care anywhere in the U.S. Routine care is different. A scheduled echocardiogram, dermatology visit, or physical therapy series may not be covered outside the network unless the plan provides a national network, visitor program, point-of-service benefit, or PPO coverage.
Original Medicare works differently. A beneficiary can use any doctor or hospital that takes Medicare anywhere in the country. A cardiologist in Naples and one in Cleveland operate under the same federal program, although the patient may pay more when a provider does not accept Medicare assignment.
Add Medigap Plan G, and the couple generally pays the $283 Part B deductible in 2026 before the policy covers Part B coinsurance for Medicare-approved services. The same coverage follows them between states.
The Math in a Sick Year
Suppose the husband needs $60,000 in scheduled, nonemergency care while in Florida, including imaging, specialist visits, a procedure, and follow-up. If his Ohio-based HMO does not cover or authorize that out-of-network care, he can be responsible for the billed charges. Services the plan denies as noncovered generally do not count toward its out-of-pocket maximum.
Under Original Medicare with Plan G, Medicare pays its portion of approved services and the supplement generally covers the Part B coinsurance after the annual deductible.
The Medigap premium is the price of that portability. Each spouse needs a separate policy, and rates vary by age, zip code, carrier, and rating method. In a healthy year, the $0-premium Advantage HMO may remain considerably cheaper. One major episode away from home can reverse that arithmetic quickly.
The Switch-Back Trap
Anyone can leave Medicare Advantage during an eligible enrollment period and return to Original Medicare. Buying the Medigap policy that closes Original Medicare’s cost-sharing gaps is the harder step.
The federal six-month Medigap Open Enrollment Period began when each spouse was 65 or older and first enrolled in Part B. Five years later, it is gone. Outside that period or another guaranteed-issue right, insurers in most states may use medical underwriting.
States offer different protections, but spending part of the year in Florida or owning a second home does not create a federal Medigap right. Ohio and Florida both permit underwriting outside protected circumstances. A stent, cancer history, or diabetes could result in a denial or higher premium.
High-deductible Plan G does not solve the underwriting problem. It carries a larger deductible and lower premium, but applicants outside protected windows can face the same health screening.
The Advantage choice at 65 is not irreversible. It can become difficult to unwind once health changes.
What to Do Next
Three checks belong on the snowbird calendar:
- Ask the current plan about travel coverage. Confirm whether it offers a national network, visitor program, HMO point-of-service benefit, or PPO coverage. Get the out-of-network cost-sharing and maximum in writing.
- Secure Medigap acceptance before leaving Advantage. Apply and obtain written approval before dropping the existing plan. Coordinate Original Medicare, Medigap, and standalone Part D effective dates.
- Build care around both addresses. If Medigap is unavailable, compare Advantage PPOs during the October 15 to December 7 enrollment period. Confirm cardiologists, hospitals, and imaging facilities near both homes, and schedule predictable care in the primary network when possible.
A 2.8% Social Security cost-of-living adjustment (COLA) leaves little room for a five-figure medical surprise. Portability carries a monthly premium. Discovering that the network stopped at the state line, however, can carry a much larger bill.
Contact [email protected] for any questions or corrections.
Top Gaining Stocks
Top Losing Stocks