Medigap

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Medicare Medigap Insurance

Medigap is extra health insurance the help pay for some costs not covered by Original Medicare Part A and Part B. You buy Medigap coverage from a private insurance company to pay costs such as copayments and deductibles. You pay a monthly premium for a Medigap policy.

Two requirements to getting Medigap is having Medicare Part A and Medicare Part B. Medicare Part A helps pay for hospital services while Medicare Part B covers the cost for doctor services.

Also, people who have a Medicare Advantage plan (medicare Part C) cannot get a Medigap plan.

Types of Medigap Insurance

There are currently 10 standardized Medigap plans as well as one high-deductible plan available in most states. Each plan is named with a letter. There is: Plan A, B, C, D, F, G, K, L, M, N, and a high-deductible version of Plan F. Picking the right plan for you can take a lot of research.

Medicare Part A costs covered by Medigap policies

  • The cost of hospital coinsurance for up to a year after your Medicare Part A hospital benefits end
  • Medicare supplement plans also cover Part B coinsurance / copayments
  • 50-100% of Skilled nursing facility stay coinsurance
  • Medigap plans might cover up to 50-100% of your hospice care coinsurance/copayment
  • Medigap plans can cover up to 50-100% of the Medicare Part A deductible costs

Medicare Part B costs covered by Medigap policies

  • 50-100% of your Medicare Part B copay/coinsurance can be covered by Medigap
  • Medigap Plan C and Plan F are the only plans that help pay for Medicare Part B deductible
  • Plan F and Plan G Medigap policies cover the Medicare Part B excess charges

Things not covered by Medigap policies

  • Long-term care (care in a nursing home)
  • Routine vision or dental care
  • Hearing aids
  • Eyeglasses
  • Private-duty nursing

When you buy a Medigap plan, you get your benefits from Original Medicare (Part A and Part B), and the Medigap plan covers the out-of-pocket costs associated with Original Medicare benefits. When you are part of a Medicare Advantage (Part C) plan, you get your benefits from that plan instead of the federal Medicare program. These plans must provide at least the same amount of coverage as Original Medicare (Part A and Part B), but may offer additional benefits.

Foreign Travel

Medigap Plans C, D, F, G, N, or M provide coverage if you go abroad.

Medigap Pros and Cons

If you have Medigap insurance you are able to visit any provider that allows Original Medicare patients. Medigap policies may have low monthly premiums, additional benefits like dental or vision, doctor supervision, and are available to all entitled individuals.

These plans must provide at least the same amount of coverage as Original Medicare (Part A and Part B), but may offer additional benefits. Plan benefits and pricing vary widely.

It may be important for some Medicare beneficiaries to have access to senior home care. Finding out how to get this care through private medical insurance is important. Investigate coverage on home medical equipment and senior assisted living. In-home care and home medical equipment are covered under Medicare Part B (along with doctor’s visits and other preventive services). There are, however, limitations to this coverage.

Currently, there are 10 standardized Medigap plans and one high deductible plan, each represented by a letter (A, B, C, D, F, G, K, L, M, N, and high deductible F) sold in most states. Benefits and coverage rates vary with each policy, but details of each plan remain the same despite the plan provider or location. For example, Plan A details are the same in New Jersey as they are in Oregon.

The Benefits of a Medicare Supplement plan can include

  • Minimal to no cost for Medicare-covered services, depending on the plan
  • Freedom to use the plan nationwide (except for Medicare SELECT plans)
  • No medical underwriting if the plan is purchased during the Medigap Open Enrollment Period.
  • Drug coverage is included with most of these plans
  • Managed care, such as supervision of doctors by the plan, possible case management, sometimes a 24-hour nurse hotline
  • Availability to all individuals entitled to Medicare Part A and enrolled in Medicare Part B who reside within the service area
  • Possible additional benefits, such as routine dental and vision, and health club membership
  • Medicare Part A coinsurance and hospital costs (up to an additional 365 days after Medicare benefits are used)
  • Medicare Part B coinsurance or copayment*
  • Blood (first 3 pints)*
  • Part A hospice care coinsurance or copayment*

*Coverage may be partial for some plans

Some Medigap Plans Can Also Include

  • Skilled nursing facility care coinsurance
  • Medicare Part A deductible
  • Medicare Part B deductible
  • Medicare Part B excess charges
  • Foreign travel emergency

The Disadvantages of a Medicare Supplement plan can include

  • Drug coverage isn’t included, but you can add this through a separate Medicare Part D plan
  • Medical underwriting can be required, except during the Medigap Open Enrollment Period, with some exceptions
  • Depending on the state, plan choices may be limited and more expensive for individuals under 65
  • Cost sharing and copayments for most many services
  • Physician network restrictions
  • Possible geographic restrictions
  • Possible requirement of referrals for specialist visits

Medicare vs Medigap

Medicare Part B covers medically necessary part-time nursing care.

  • It also covers physical therapy, speech/language therapy, and on-going occupational therapy
  • A health care provider (physician or other) that is enrolled in Medicare must order such care, and it must be provided by a Medicare-certified home health agency
  • To get this coverage, you must be homebound, meaning it is extremely difficult for you to leave your home
  • If you are homebound you pay nothing for these services

Other Medicare Part B-covered services can also include:

  • Medical social services
  • Part time home health aide services
  • Durable medical equipment and medical supplies

Who can get Medicare-covered home health care and what services does Medicare cover?

If you have Medicare, home health care services are covered if you meet all the following conditions:

  • Your doctor must decide that you need medical care at home, and make a plan for you care at home
  • You must need intermittent skilled nursing care, physical therapy, speech-language therapy or to continue occupational therapy
  • The home health agency caring for you must be approved by the Medicare program (Medicare-certified)
  • You must be homebound, or normally unable to leave home without help
  • To be homebound means that leaving home takes considerable and taxing effort
  • You can be homebound and still leave home for medical treatment or short, infrequent absences for non-medical reasons, such as trips to a barber or church
  • A need for adult day care doesn’t keep you from getting home health care

If you meet the conditions above, Medicare will cover the following types of home health care:

  • Skilled nursing care on a part-time or intermittent basis
    1. Skilled nursing care includes services and care that can only be performed safely and correctly by a licensed nurse (either a registered nurse or a licensed practical nurse).
    2. Home health aide services on a part-time or intermittent basis. A home health aide doesn’t have a nursing license, but supports the nurse by providing services such as help with bathing, using the bathroom, dressing or other personal care. These types of services don’t need the skill of a licensed nurse.
    3. Medicare doesn’t cover home health aide services unless you are also getting skilled care such as nursing care or other therapy. The home health aide services must be part of the home care for you illness or injury.
  • Physical therapy, speech-language therapy, and occupational therapy for as long as your doctor says you need it
    1. Physical therapy includes exercise to regain movement and strength in a body area, and training on how to use special equipment or do daily activities, like how to get in and out of a wheelchair or bathtub.
    2. Speech-language therapy (pathology services) includes exercise to regain and strengthen speech skills.
    3. Occupational therapy includes exercise to help you do usual daily activities by yourself. You might learn new ways to eat, put on clothes, comb your hair, and perform other usual daily activities. You may continue to receive occupational therapy if ordered by your doctor even if you no longer need other skilled care.

Medical social services to help you with social and emotional concerns related to your illness. This might include:

  • Counseling or help in finding resources in your community
  • Certain medical supplies, like wound dressings (but not prescription drugs or biologicals)
  • Durable medical equipment, such as a wheelchair or walker. It also includes oxygen equipment, hospital beds and other items that are “durable”. That is, you don’t use them once and throw them out.

Currently, Medicare does not cover (does not pay for) any of the following:

  • 24-hour-a-day care at home
  • Meals delivered to your home
  • Homemaker services like shopping, cleaning, and laundry
  • Personal care given by home health aides like bathing, dressing, and using the bathroom when this is the only care you need

Most of the time, your doctor, a social worker, or a hospital discharge planner will help arrange for Medicare-covered home healthcare. However, you have a say in which home health care agency you use.

You will pay $0 for all covered home health visits. It should also be noted that if you only have Medicare Part B, then these services will be covered under Part B. It is important to also understand that Medigap policies (Medicare Supplement Insurance) no longer cover “At-home Recovery” or “Preventive Care Not Covered by Medicare.” However, Part A Hospice Care is included in all Medicare Supplement Insurance plans.

Durable medical equipment refers to items like oxygen equipment, wheelchairs, walkers, hospital beds, and other items that are “durable.” You don’t use them once and throw them out. You also use most of these items as part of in-home care. Durable medical equipment must also be ordered by a medical professional enrolled in Medicare. In some cases, equipment must be rented. You have to pay for 20 percent of Medicare-approved amount (Part B deductible also applies here). Medicare is also beginning a new competitive bidding program that will save money and limit fraud. In some states you will need to get certain equipment from specific suppliers or Medicare will not pay, leaving you with the full bill. This program began January 1, 2011, in several metropolitan areas in California, Florida, Indiana, Kansas, Kentucky, Missouri, North Carolina, Ohio, Pennsylvania, South Carolina and Texas. It is scheduled to include areas in all 50 states by 2016.

Other items are considered durable medical equipment. These include: air fluidized beds, blood glucose monitors, bone growth stimulators, canes, commode chairs, crutches, infusion pumps (and even some medicines used in such pumps), Lymphedema pumps/pneumatic compression devices, scooters, nebulizers (and some medicines used), patient lifts, suction pumps, traction equipment, transcutaneous electronic nerve stimulators, and ventilators. This list is not comprehensive. A number of prosthetic and orthotic items are also considered “durable” and are covered.

You should note that Medicare will not cover motorized scooters and wheelchairs which are primarily used outside the home. Your doctor needs to verify that you need such a scooter for a medical condition. You must have a “certificate of medical necessity” to get any of these items or other durable medical equipment. Medicare usually pays 80% of costs of such equipment. Note that this is figured on the Medicare-approved amount for these items so the payment might actually be less than 80%. Different durable goods are covered in different ways as well. Some, for instance, may be rented.

Depending on your Medigap plan you should be able to get help paying for your share of these items. In some cases, the Medigap plan will fully cover your portion of the bill for durable medical equipment. Contact your insurance company and ask them specifically what is covered. When it comes to durable medical equipment, be sure to find out if your Medigap plan pays for 20% of the Medicare-approved amount, or if it covers any amount over what is covered by Medicare.

Medigap policies fill in the coverage gaps

Original Medicare (Parts A and B) pays for many of your health care services and supplies, but it doesn’t pay for everything. That’s why you may want to consider getting a Medicare Supplement Insurance policy, also called Medigap. A Medigap policy is health insurance sold by private insurance companies. They help pay some of the costs that Original Medicare doesn’t cover, such as copayments, coinsurance, and yearly deductibles. Some Medigap policies also help pay for services that Original Medicare doesn’t cover at all. Basically, a Medigap policy fills the “gaps” in Original Medicare coverage.

How do Medigap policies work with Medicare?

Medigap policies supplement your Original Medicare benefits, which is why these policies are also called Medicare Supplement plans. If you have Original Medicare and a Medigap policy, Medicare will pay first and your Medigap policy will fill in the gaps. For example, suppose you have a $5,000 ambulance bill and have not yet met the yearly Part B deductible ($140 in 2012). Medicare Part B will pay 80 percent of your bill, minus the deductible amount. Your Medigap policy will then pay the remaining 20 percent plus the deductible amount.

Medigap policies protect you from big medical bills.

Your cost with a Medigap policy* Your cost without a Medigap policy*

  • Ambulance charge: $5,000 Ambulance charge: $5,000
  • Part B yearly deductible: $140 Part B yearly deductible: $140
  • Medicare Part B pays: $3,860 Medicare Part B pays: $3,860
  • Medigap policy pays: $1,140
  • You pay: $0 You pay: $1,140

*Costs shown are examples only and do not represent exact calculations.

Plans that don’t supplement Medicare coverage (Aren’t Medigap policies)

    Advantage plans (like an HMO or PPO)
  • Medicare Prescription Drug plans (Part D)
  • Medicaid
  • Employer’s or union’s plans
  • TRICARE
  • Veterans’ benefits
  • Long-term care insurance policies

Additional facts about Medigap policies

You must have Medicare Part A and Part B to get a Medigap policy.

Every Medigap policy must be clearly identified as “Medicare Supplement Insurance.”

A Medigap policy can only cover one person, so if you are married, both you and your spouse must buy separate policies.

Not all types of Medigap policies may be available in your state.