Original
Medicare pays for many, but not all, health care services and supplies.
A Medigap policy, sold by private insurance companies, can help pay some of
the health care costs ("gaps") that Original Medicare doesn't cover,
like copayments, coinsurance, and deductibles. Some Medigap policies also
offer coverage for services that Medicare doesn't cover, like medical care when
you travel outside the U.S. If
you have Original Medicare and you buy a Medigap policy, both plans will pay
their share of Medicare approved amounts for covered health care costs.
Medicare doesn't pay any of the costs for a Medigap policy. Every
Medigap policy must follow Federal and state laws designed to protect you, and
it must be clearly identified as "Medicare Supplement Insurance."
Medigap insurance companies can sell you only a "standardized" Medigap
policy identified in most states by letters (A through L). Each standardized
Medigap policy must offer the same basic coverage, no matter which insurance
company sells it. Cost is usually the only difference between Medigap
policies sold by different insurance companies. Medigap
Advisors works with several of the nation's leading providers of Medigap plans,
including:
The 12 Medicare Supplement Plans and How They Work
Medicare
Supplement insurance can be sold in only ten standard plans: A, B, C, D, E,
F, G, H, I, and J. Plan
A: Basic Benefits The
basic benefits (also known as the "core benefits" or
Plan A) are the minimum Medicare Supplement coverage you may buy. These
are the only benefits in Plan A. Every other plan contains these
three Medicare Supplement benefits as the "core" and then adds one
or more additional benefits. -
Hospitalization:
Medicare Part A pays for hospitalizations for the first 60 days, but only
pays a portion of the daily costs from the 61st day through the 150th day.
You must pay the coinsurance amounts for those days. This Medicare Supplement
benefit pays the coinsurance amount for those days, and the total Medicare
reimbursement amount for an additional 365 lifetime days.
-
Blood:
Medicare pays for all blood that is medically necessary except for the first
three pints in each calendar year. This Medicare Supplement benefit
pays for the first three pints of blood not paid for by Medicare.
-
Medical
Expenses: Generally Medicare Part B pays for 80% of a predetermined
amount (called the "Medicare approved" amount) for each procedure,
supply, or service billed by your doctor or other provider that is not a hospital.
This Medicare Supplement benefit pays the coinsurance (generally 20% of the
"Medicare approved" amount) under Medicare Part B.
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Note:
Plan A contains only these 3 core benefits. Although Plan
A is the least expensive policy, it may not be a good choice for low-income
individuals who may not be able to afford the Medicare Part A hospital deductible
when they are hospitalized.
| | Plans
B through J There
are seven additional Medicare Supplement benefits that are combined with the
basic benefits in various ways to make up the nine remaining plans called Medicare
Supplement Plan B through Plan J. Medicare Supplement plans do not cover
Prescription drugs. For Prescription drug coverage, see Medicare
Part D.
-
The Part A Deductible: The Medicare Part A deductible is the
expense for which you are obligated to pay when you are admitted to a hospital
as an inpatient. Medicare pays eligible benefits above that amount.
(The Medicare Part A deductible amount may change yearly, so check the current
Medicare
brochure). This Medicare Supplement benefit reimburses you the deductible
amount, no matter what the amount may be. This supplemental benefit
is included in Plans B through J.
- Skilled
Nursing Coinsurance: Medicare Part A pays for the first 20 days
of care in a skilled nursing facility following hospitalization, but requires
you to pay a coinsurance beginning on the 21st day through the 100th day.
This Medicare Supplement benefit pays the coinsurance amount beginning on
the 21st day. This supplemental benefit is included in Plans C through
J.
- Part
B Deductible: The Medicare Part B deductible is the amount you must
pay each year for medical expenses (such as doctor fees) before Medicare begins
paying. (The Part B deductible amount may change per year). This
Medicare Supplement benefit reimburses you the deductible amount. This
supplemental benefit is included in Plan C, Plan F, and Plan J.
- Part
B Excess Charges: Medicare Part B pays 80% of a predetermined amount
(called the "Medicare approved" amount) for each procedure performed
by your doctor or other medical care provider. If your doctor accepts
Medicare "assignment," the provider may only bill you for the difference
between the amount paid by Medicare and the amount approved
by Medicare.
If your doctors do not accept Medicare assignment, they may bill you
for the difference between the amount paid by Medicare and the amount they
can legally charge you (called the "limiting charge"). If
you have a Medicare Supplement Policy with the following:
-
Foreign Travel Emergency: The original Medicare plan does not
pay for medical care outside of the United States, but some Medicare managed
care plans, private Fee-for-Service plans, and some Medicare Supplement plans
do. This Medicare Supplement benefit will pay 80% of your expenses for
most emergency medical care in a foreign country during the first 60 days
of a trip abroad after you pay a $250 deductible. There is a lifetime
maximum benefit, so check the current Medicare
brochure for the dollar amount. This supplemental benefit is
in Plan C through Plan J. Check your insurance coverage before you
travel.
- At-Home
Recovery: Under the home health care benefit, Medicare pays for
intermittent visits by a nurse or other skilled care provider in your
home during recovery from an acute illness. Medicare does not
pay for custodial care in your home such as homemaker services (such
as help with bathing, dressing, laundry, or shopping). This Medicare
Supplement benefit pays per home visit. Check the Medicare
brochure for current benefits for medically necessary custodial care while
you are recovering from an illness, injury, or surgery. An insurance
company may limit the number of visits to equal the number of Medicare home
health care visits. This supplemental benefit is in Plan D, Plan
G, Plan I, and Plan J.
- Preventive
Care: Medicare pays for some testing for diagnostic purposes.
This Medicare Supplement benefit pays up to $120 per year for certain tests
done for screening purposes, routine physical exams, patient education, and
other medically appropriate tests or preventive measures not covered by Medicare.
This supplemental benefit is included in Plan E and Plan J. There
are eight additional benefits that are combined with the basic benefits in
various ways to make up the nine remaining plans called Plan B through Plan
J.
The chart below shows
the benefits included in each plan.
|
Features
|
A
|
B
|
C
|
D
|
E
|
F*
|
G
|
H
|
I
|
J*
|
K**
|
L**
| |
Basic
Benefits
|
|
|
|
|
|
|
|
|
|
|
50%
|
75%
| |
Skilled
Nursing
Coinsurance
|
-
|
-
|
|
|
|
|
|
|
|
-
|
50%
|
75%
| |
Part
A
Deductible
|
-
|
|
|
|
|
|
|
|
|
|
50%
|
75%
| |
Part
B
Deductible
|
-
|
-
|
|
-
|
-
|
|
-
|
-
|
-
|
| | | |
Part
B Excess
|
-
|
-
|
-
|
-
|
-
|
100%
|
80%
|
-
|
100%
|
100%
| | |
|
Foreign
Travel
Emergency
|
-
|
-
|
|
|
|
|
|
|
|
| | | |
At-Home
Recovery
|
-
|
-
|
-
|
|
-
|
-
|
|
-
|
|
| | |
|
Preventive
Care
|
-
|
-
|
-
|
-
|
|
-
|
-
|
-
|
-
|
| | | |
*
Plan F and Plan J also have high deductible options, which some companies
may offer. These high deductible plans pay the same benefits as Plan F
and J after one has paid a calendar year $2000 deductible. Benefits from
high deductible Plans F and J will not begin until out-of-pocket expenses exceed
$2000. **
Plans K and L provide for different cost-sharing for items and services than
Plans A through J. With either of these plans, once you reach your annual
"out-of-pocket limit," the plan will then pay 100% of the Medicare
co-payment, co-insurance and deductibles for the rest of the calendar year.
The out-of-pocket limit does not include charges for any provider that exceeds
Medicare-approved amounts, known as "excess charges." The annual
out-f-pocket limits for these plans in 2009 are $4620 for Plan K, and $2310
for Plan . After
the Medicare Supplement policy is mailed or delivered, you have a 30-day free
look to examine the policy and to decide if you want to keep it. If you
return the policy within 30 days, all of your money will be refunded. 
How
to Qualify for Medicare Supplement Plans
To
qualify for a Medicare Supplement policy, you must be age 65 or older (may vary
by state), enrolled in Medicare parts A and B, and you must reside in the state
in which you are applying for supplemental coverage.Open
Enrollment: Your open enrollment period that lasts for 6 months
and begins on the first day of the month in which you are age 65 or older and
enrolled in Part A and B of Medicare. Some states have additional open
enrollment periods. There are no other qualifying questions during open
enrollment, insurance companies can not use medical underwriting, and pre-existing
health conditions do not matter. This is great news for anyone desiring
to enroll in a Medicare Supplement plan. During this time, an insurance
company must sell you any Medicare Supplement plan they offer, they can not
make you wait for coverage to begin (even for pre-existing conditions) and they
can not add extra charges because of any health problems, past or present. IMPORTANT:
If you do not apply during your open enrollment period, you application will
be subject to an approval process called “underwriting.”
Because health insurance is designed primarily to cover you for the unexpected,
a company may put an exclusion on pre-existing health conditions. If you
have cancer, heart disease, or other serious health conditions you will likely
be declined. Some companies also reserve the right to rate the premium
up (charge more) to cover the cost of current medications. IT IS VERY
IMPORTANT THAT YOU APPLY DURING YOUR OPEN ENROLLMENT PERIOD IF POSSIBLE,
at which time your application will NOT be subject to this underwriting process.
This means the insurance company must accept your application, and can not raise
your premium or exclude coverage because of any pre-existing conditions you
may have. After
Open Enrollment: To help control rising costs, carriers apply
the pre-existing condition clause to newly issued Medicare Supplement
plans in most states. Expenses resulting from a condition existing
six months prior to the supplemental policy effective date are not covered unless
they are incurred three months after the supplemental policy effective date.
If
the supplemental policy replaces another creditable individual or group insurance
coverage due to a person's eligibility for Medicare, this Pre-Existing Conditions
Limitation will be reduced by the number of months that coverage was in force.
If this supplemental policy replaces another Medicare Supplement policy, this
Pre-Existing Conditions Limitation will be reduced by the number of months that
the coverage was in force. The
medical questions on the supplemental enrollment application address health
conditions that would result in a rejected application. If you
have one of these conditions or have been advised by a doctor to treat these
conditions using medications, X-rays, a surgical procedure (in-patient or outpatient),
therapy, rehabilitation or doctor's visits, you should not apply for a Medicare
Supplement plan until your next open enrollment period.
Frequently
Asked Questions Q:
Does the member receive coverage while out of the country? A:
If the member is enrolled in plans C, F and High F, then the member will receive
out of country coverage. Q:
How often do rates change on Medicare Supplement plans? A:
In most states, plans are age-rated and are in age bands, i.e., 65, 66-67, 68-69,
70-74 etc., so rates do change once the member reaches a higher age bracket.
Rates may also increase each year, based on market factors. Any rate increases
to Medicare Supplement plans must be approved by the Division of Insurance or
regulating agency. Q:
Does the applicant need to answer the medical questions on the application form? A:
Yes, unless they answered "Yes" to either of the questions under the
Guaranteed Acceptance Determination section. If not applying during a time of
open enrollment, a yes answer on any of the medical questions will result in
an application being denied. Q:
After enrolling, may they switch from one plan to another? A:
The member may downgrade (i.e., reduce their coverage) at any time upon request.
A new application must be taken in order to upgrade their plan. All underwriting
questions must be answered in order to request an upgrade. Q:
Does a member need to send in the first month's premium with an application? A:
Yes, the first month's premium is required to process the application Q:
Where can I obtain a copy of the government publication on Medicare? A:
A current handbook on Medicare is available from your local Social Security
office or by calling the Social Security Administration toll-free at 800-633-4227
or via the website at: http://www.medicare.gov
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