How You Can Lose Your Medicare Benefits

WDC NEWS 6 STAFF March 7, 2025

17 4 minutes read

If you have Medicare, losing your health coverage is still possible. You can lose Medicare coverage through your own actions or for reasons outside of your control, such as an insurance provider deciding to discontinue a plan.

If you lose your Medicare coverage, you can reapply. Depending on circumstances, you may be able to apply outside of the Medicare open enrollment period, which runs from October 15 to December 7 each year. You can reapply outside of that window if you’ve experienced what is considered to be a qualifying life event. In order to do this, you would typically qualify for a Special Enrollment Period (SEP).

Here’s a look at the ways you can lose your Medicare benefits.

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1. Failure to pay your premiums

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Not paying your premiums is an easy way to lose your Medicare coverage. Everyone enrolled in an Original Medicare/Medicare Advantage plan must pay a monthly premium for Part B, which is $185 for 2025. If you haven’t paid Medicare taxes for 40 quarters or more, you will also pay premiums for Part A. In 2025, the monthly premium is either $285 or $518, depending on how long you or your spouse worked and paid Medicare taxes.

Due on the 25th of every month, failure to make your premium payments for a month will result in a second notice. This notice will give you a deadline by which you must make your payment. Continuing to not pay will result in a third delinquent notice.

Your third delinquent notice will include the past-due amount (amount owed from prior billing notice) plus premiums for the next month. If you don’t pay the past-due amount or if a partial payment leaves a balance of more than $10.00, your Medicare coverage will terminate by the billing due date.

If you Medicare coverage is terminated, so will your Medigap, and Part D prescription drug coverage. These insurance policies work in tandem with your Medicare coverage.

2. Committing Medicare fraud or engaging in “disruptive behavior”

Medicare Fraud Text With Magnifying Glass and Stethoscope

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Defrauding Medicare in any way will get your coverage terminated. For instance, if you let someone else use your Medicare card, you can lose coverage.

Other types of patient fraud:

Kickbacks. If you receive money or other benefits in exchange for referring patients to a specific provider or facility
Phantom billing. If If you receive money or other benefits when you agree to receive unnecessary medical treatment or attest to care not actually received allowing a provider to bill Medicare for or services or procedures they did not give or were unnecessary
Upcoding. If you receive money or other benefits in exchange for involvement in billing schemes that inflate the cost of procedures

Medicare Advantage plans and Part D plans. You may also lose coverage for “disruptive behavior,” which varies from plan to plan and will be defined by your insurance company. To be clear, this does not have to do with the use of medical services or whether or not you’re listening to your doctor’s advice.

An MA plan enrollee is considered disruptive if their behavior substantially impairs the plan’s ability to arrange for or provide services to the individual or other plan members. Generally, it means substantially interfering with your plan’s ability to render services or provide care for you or other plan members; it is a lengthy process that requires three written notices.

3. Lying on your application

Truth and Lies Conceptual Signpost.

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Medicare Advantage and Part D prescription drug plans. If you provide misleading information on your plan application, you risk losing your Medicare Advantage of Part D coverage. An enrollment is not legally valid if a plan sponsor or CMS determines at a later date that an incorrect permanent address was provided at the time of enrollment to get access to a plan that is outside the service area.

Medigap or Supplemental Insurance. If you provide dishonest information on your application in an attempt to get a lower premium, you could lose your coverage when the insurance provider confirms/investigates. Dishonest information includes falsely claiming you have a lower income or that you’re a nonsmoker.

4. Moving outside your plan area

Happy Senior Couple With Cardboard Boxes in New House at Moving Day Drinking Coffee

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If you move, your current plan may not cover you at your new address.

You can switch to a new Medicare Advantage Plan or to Original Medicare and a Part D drug plan if you move outside your plan’s service area. This rule also applies if you move to a new address in your plan’s service area but have new plan options in your new location.

5. Medicare doesn’t renew or terminates your Medicare Advantage plan

Cancelled sign

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If your Medicare Advantage Plan or Medicare Part D drug plan is not renewed or is terminated by Medicare, you will need to select a new provider or switch to Original Medicare. It may also be the case that your MA provider decides not to renew their contract with Medicare.

If you plan is sanctioned and not cancelled by Medicare, you also have the option to select a new MA provider or enroll in Original Medicare.

What is a Special Enrollment Period (SEP)?

If you lose your coverage due to many of the reasons discussed above, such as moving or losing other insurance coverage, you may be able to use a Special Enrollment Period (SEP) to get new coverage.

A SEP is a time outside of the regular enrollment periods during which Medicare beneficiaries have an opportunity to enroll in or make changes to their Medicare coverage. SEPs are available to individuals who experience certain qualifying life events or meet specific criteria.

Bottom line

If you’ve suffered a disruption to your Medicare benefits, you can call Medicare directly at 1-800-MEDICARE (1-800-633-4227) to get more information and possible solutions to your issues. Help from Medicare is available 24 hours a day, 7 days a week, except some federal holidays. TTY users can call 1-877-486-2048.

The State Health Insurance Assistance Program (SHIP) is a national program that offers one-on-one assistance and counseling to Medicare beneficiaries about their Medicare rights and billing problems. It can also help beneficiaries compare plans, get enrolled, and find financial assistance to pay for health care premiums and costs.

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