Guide to Switching Back to Traditional Medicare: Addressing Provider Network and Care Coverage Issues in Advanced Wound Care

Many Medicare beneficiaries initially enroll in a Medicare Advantage (MA) plan for its

low premiums and additional benefits. However, some find that their MA plan’s provider

network and coverage limitations do not adequately meet their healthcare

needs—particularly when it comes to specialized care like advanced wound treatment.

If you’re facing challenges accessing wound care specialists or the necessary

treatments under your current plan, switching back to Original Medicare may be a

solution.

This guide explains when and how to transition from Medicare Advantage to Traditional

Medicare, with a focus on ensuring access to advanced wound care services.

Common Reasons for Switching Back to Original Medicare

1. Inadequate Provider Network: Many MA plans have limited networks that may not

include wound care specialists or facilities offering advanced wound treatment options.

2. Coverage Denials for Essential Care: Some beneficiaries experience denials or

excessive prior authorization requirements for specialized treatments, including skin

grafts, biologics, and hyperbaric oxygen therapy.

3. Referrals and Access Delays: Medicare Advantage plans often require referrals from

primary care providers before seeing a specialist, leading to delays in critical wound

care treatment.

4. Changing Health Needs: As wound care needs become more complex, beneficiaries

may find that their MA plan does not provide the flexibility or comprehensive coverage

necessary for chronic wound management.

5. Desire for Nationwide Access: Traditional Medicare allows beneficiaries to see any

provider that accepts Medicare, offering greater access to wound care centers across

the country.

How to Switch Back to Traditional Medicare

1. Understand the Enrollment Periods

Switching from a Medicare Advantage plan to Traditional Medicare is only allowed during

specific periods:

- Medicare Advantage Open Enrollment Period (January 1 – March 31)**: You can

switch from an MA plan to Original Medicare and enroll in a Part D prescription drug

plan if needed.

- Annual Election Period (October 15 – December 7)**: You can leave your MA plan

and return to Original Medicare, with coverage beginning January 1 of the following

year.

- Special Enrollment Periods (SEPs)**: If your plan’s provider network no longer

includes your wound care provider, or if you move out of your plan’s service area, you

may qualify for a SEP.

2. Enroll in Traditional Medicare (Parts A & B)

If you are leaving an MA plan, you must ensure that you are re-enrolled in Traditional

Medicare. You can do this by contacting Medicare directly at 1-800-MEDICARE or

visiting:

[Social Security Administration] https://secure.ssa.gov/iClaim/rib or

[Medicare.gov] https://www.medicare.gov

3. Consider Adding a Medigap Policy

Medigap (Medicare Supplement Insurance) helps cover out-of-pocket costs such as

deductibles and coinsurance. If you are switching back to Traditional Medicare and want

predictable healthcare costs, applying for Medigap is advisable. However, depending on

your state and enrollment timing, you may be subject to medical underwriting.

4. Sign Up for a Medicare Part D Plan

Since Traditional Medicare does not include prescription drug coverage, enrolling in a Part D plan will ensure continued access to necessary medications, including those used in wound care treatment.

5. Verify Provider Acceptance

Before switching, confirm that the wound care specialists and facilities you plan to use

accept Traditional Medicare. Most advanced wound care providers participate in Medicare, but it’s always best to check.

6. Coordinate the Transition to Avoid Coverage Gaps

Ensure your switch is processed before discontinuing your current MA plan to avoid any

gaps in healthcare coverage. Keep records of all correspondence related to the

transition.

Additional Considerations for Wound Care Patients

- Access to Specialized Treatments: Traditional Medicare covers advanced wound care

procedures, including debridement, negative pressure wound therapy, biologic

dressings, and hyperbaric oxygen therapy when deemed medically necessary.

- Home Health Coverage: If wound care is required at home, Traditional Medicare provides coverage for eligible home health services without restrictive network limitations.

- Flexibility to See Specialists: Beneficiaries with complex wound care needs can visit

any Medicare-accepting specialist without prior authorization, reducing treatment

delays.

Conclusion

If your Medicare Advantage plan’s network or coverage restrictions prevent you from

receiving necessary advanced wound care, switching back to Traditional Medicare may be the best option. By carefully planning your transition and enrolling in the appropriate

supplemental coverage, you can regain access to the specialized wound care services

you need. Consider your healthcare needs, provider preferences, and financial situation

to make an informed decision about your Medicare coverage.