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Medigap (Medicare Supplement Insurance). Module 3. Lesson 1: Medigap Basics Lesson 2: Medigap in Detail. Medigap Basics. Module 3—Lesson 1. Session Topics. Overview Medigap benefits Medigap plans Medigap costs. Session Topics. Overview Medigap benefits Medigap plans Medigap costs.

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medigap basics

Lesson 1: Medigap Basics

Lesson 2: Medigap in Detail

Medigap Basics

Module 3—Lesson 1

session topics
Session Topics
  • Overview
  • Medigap benefits
  • Medigap plans
  • Medigap costs
session topics4
Session Topics
  • Overview
  • Medigap benefits
  • Medigap plans
  • Medigap costs
what is medigap

Overview

What Is Medigap?
  • Health insurance policies
    • Sold by private insurance companies
    • Cover “gaps” in Original Medicare
    • Follow Federal and state laws that protect you
    • Must say “Medicare Supplement Insurance”
what is medigap continued

Overview

What Is Medigap?(continued)
  • Health insurance policies
    • 12 standardized policies in most states
      • Plans A – L
    • Non-standard policies
      • Massachusetts
      • Minnesota
      • Wisconsin
    • Costs may vary
      • By plan
      • By company
      • Where you live
how medigap works

Overview

How Medigap Works
  • Only works with Original Medicare
    • Don't need Medigap policy in
      • Medicare Advantage Plan
      • Other Medicare plans
  • Can go to any doctor, hospital, or provider that accepts Medicare
    • Unless you have Medigap SELECT policy
medigap is not

Overview

Medigap Is Not
  • Medicare Advantage Plans
  • Medicare Part B
  • Medicare Prescription Drug Plans
  • Medicaid
  • Employer or union plan
  • TRICARE
  • Veterans’ benefits
who can buy medigap

Overview

Who Can Buy Medigap?
  • Must have Medicare Parts A and B
  • May not be able to buy Medigap under 65
    • People with a disability
    • People with End-Stage Renal Disease
  • Guaranteed right to buy a Medigap policy
    • In your Medigap open enrollment period
    • Covered under a Medigap protection
session topics10
Session Topics
  • Overview
  • Medigap benefits
  • Medigap plans
  • Medigap costs
why buy medigap

Medigap Benefits

Why Buy Medigap?
  • Original Medicare does not pay all costs
  • Medigap policy may help you
    • Lower your out-of-pocket costs
    • Get more health insurance coverage
gaps in original medicare
Hospital Stays

Skilled Nursing

Blood

$1,024 deductible for days 1 – 60

$256 per day for days 61 – 90

$512 per day for days 91 – 150

$0 for first 20 days

$128 per day for days 21 – 100

100% after day 100

100% for first 3 pints

20% for additional pints

Medigap Benefits

Gaps in Original Medicare

What you pay in2008—Part A

gaps in original medicare13
Home Health Care

Hospice Care

$0 for home health care services

20% for durable medical equipment

Up to $5 copayments for outpatient prescription drugs

5% for inpatient respite care

Room and board, in some cases

Medigap Benefits

Gaps in Original Medicare

What you pay in2008—Part A

gaps in original medicare14
Part B Deductible

Part B Services

$135 per year

20% coinsurance for most covered services

50% coinsurance for outpatient mental health

Copayments for hospital outpatient services

Medigap Benefits

Gaps in Original Medicare

What you pay in2008—Part B

medigap coverage

Medigap Benefits

Medigap Coverage
  • Plans A – J
    • All cover basic benefits
      • Part A coinsurance for inpatient hospital care
      • Cost of 365 extra days of inpatient hospital care
      • Part B coinsurance after deductible
      • First 3 pints of blood each year
    • Some plans cover more
other medigap benefits

Medigap Benefits

Other Medigap Benefits
  • Most plans have extra benefits
  • Some Medigap policies cover
    • Part A deductible
    • Part B deductible
    • At-home recovery
    • Medicare Part B excess charges
      • Subject to the “limiting charge”
    • Other services
medigap plans k l

Medigap Benefits

Medigap Plans K & L
  • Basic benefits
    • Part A coinsurance for inpatient hospital care
    • Cost of 365 extra days of inpatient hospital care
    • Plan K pays 50% and Plan L pays 75% of
      • Part A deductible
      • Part B coinsurance after deductible
        • Except 100% for covered preventive services
      • First 3 pints of blood each year
      • Hospice care
medigap benefits comparison
Medigap Benefits Comparison

Medigap Benefits

02-13-08

18

items not covered

Medigap Benefits

Items Not Covered
  • Long-term care
  • Vision and dental care
    • Including eyeglasses
  • Hearing aids
  • Private-duty nursing
  • Outpatient prescription drugs
session topics20
Session Topics
  • Overview
  • Medigap benefits
  • Medigap plans
  • Medigap costs
special types of medigap plans

Medigap Plans

Special Types of Medigap Plans
  • Medigap plans with drug coverage
  • High deductible plans
    • Plans F, J
  • Medigap plans with hospice care
    • Plans K, L
  • Massachusetts, Minnesota, and Wisconsin
  • Medicare SELECT
drug coverage and medigap

Medigap Plans

Drug Coverage and Medigap
  • Medigap policies covering prescription drugs
    • May not be sold after January 1, 2006
    • Same policies may be sold without drug coverage
  • If your Medigap policy covers drugs
    • Should have received information from company
      • Explains how drug coverage affects your policy
medigap plans with drug coverage

Medigap Plans

Medigap Plans With Drug Coverage
  • Standardized plans H, I, J
    • Sold before January 1, 2006
  • Some policies
    • Massachusetts
    • Minnesota
    • Wisconsin
  • Some pre-standardized plans
  • Others
f and j high deductible option

Medigap Plans

F and J High Deductible Option
  • $1,900 deductible for 2008
    • Amount can go up each year
  • Often have lower premium
  • Out-of-pocket costs may be higher
  • May not be able to change plans
  • Additional deductibles
    • Prescription drugs
    • Foreign travel
plans k and l

Medigap Plans

Plans K and L
  • Pay only partial costs after Medicare pays
  • Have annual out-of-pocket maximum
  • Plan K
    • 50% for most services
    • $4,440 out-of-pocket limit in 2008
  • Plan L
    • 75% for most services
    • $2,220 out-of-pocket limit in 2008
session topics26
Session Topics
  • Overview
  • Medigap benefits
  • Medigap plans
  • Medigap costs
how much does medigap cost

Medigap Costs

How Much Does Medigap Cost?
  • Depends on
    • Your age (in some states)
    • Where you live
    • Company selling the policy
  • Can be big differences in premiums
    • For exactly the same coverage
  • Compare the same Medigap policies
what is underwriting

Medigap Costs

What is Underwriting?
  • Review
    • Health status
    • Medical history
  • Insurance company determines
    • Whether to accept your application
    • How much to charge you
    • Whether to make you wait for some benefits
  • Application
    • Usually includes medical questions
    • Fill out carefully
buying a medigap policy

Medigap Costs

Buying a Medigap Policy
  • May be able to buy a policy any time
  • Best time is during open enrollment period
    • Lasts for 6 months
    • Starts on first day of the month you are
      • Age 65 or older AND
      • Enrolled in Medicare Part B
  • Once 6-month Medigap open enrollment period starts, it can't be changed
open enrollment period

Medigap Costs

Open Enrollment Period
  • Insurance company can’t
    • Deny you coverage
    • Make you wait for coverage to start
      • But may make you wait for coverage of pre-existing conditions
        • Unless you have creditable coverage
    • Charge you more for a policy
      • Because of your health problems
let s look at a case study

Medigap Costs

Let’s look at a case study…
  • It is October 1, 2008, and Sam (who is 65) wants to buy a Medigap policy. He needs to know if he is in his open enrollment period. He looks at his Medicare card. His Medicare Part B coverage started August 1, 2008.
    • Is Sam in his Medigap open enrollment period?
    • Can the company deny him coverage?
medigap in detail

Lesson 1: Medigap Basics

Lesson 2: Medigap in Detail

Medigap in Detail

Module 3—Lesson 2

session topics34
Session Topics
  • Prior creditable coverage
  • Under age 65
  • Medigap and Medicaid
  • Guaranteed issue
  • More information
session topics35
Session Topics
  • Prior creditable coverage
  • Under age 65
  • Medigap and Medicaid
  • Guaranteed issue
  • More information
pre existing condition

Medigap Coverage

Pre-Existing Condition
  • Health problem before new policy starts
  • Medigap company can refuse to cover that condition
    • If diagnosed or treated during the 6 months before the policy starts
    • For up to 6 months in some cases
    • Called “pre-existing condition waiting period”
creditable coverage

Medigap Coverage

Creditable Coverage
  • Coverage you had before applying for Medigap
    • Can avoid or shorten waiting period for a pre-existing condition
    • Medigap company cannot refuse to cover pre-existing conditions
      • If at least 6 months creditable coverage
        • With no break in coverage of more than 63 days
examples of creditable coverage
Union/employer group health plan

Some health insurance policies

Medicare Part A or B

Medicaid

IHS or tribal organization

A state health benefits risk pool

TRICARE

FEHBP

Public health plan

Health plan under the Peace Corps Act

COBRA

SCHIP

Medigap Coverage

Examples of Creditable Coverage
not creditable coverage

Medigap Coverage

Not Creditable Coverage
  • Hospital indemnity insurance
  • Specified disease insurance
    • For example, cancer insurance
  • Vision or dental policies
  • Long-term care policies
let s look at a case study40

Medigap Coverage

Let’s look at a case study…
  • Harry is 65 and was diagnosed with heart disease early in 2007. His Medicare Part A and Part B started November 1, 2007. Before that date, he had no health insurance coverage. Harry buys a Medigap policy with coverage starting March 1, 2008.
    • Can the Medigap insurance company refuse to cover Harry’s heart condition for 6 months?
    • Does Harry have prior creditable coverage?
    • What if Harry’s heart condition hadn’t been diagnosed?
session topics41
Session Topics
  • Prior creditable coverage
  • Under age 65
  • Medigap and Medicaid
  • Guaranteed issue
  • More information
medigap for people under 65

Under Age 65

Medigap for People Under 65
  • Federal law does not require coverage
  • May not be able to buy a Medigap policy
  • Some state laws are different
  • At age 65
    • Can choose and buy any Medigap policy
    • Companies cannot refuse to sell Medigap
    • 6-month open enrollment period
    • Already have Medigap
      • May reapply to get a better rate
medigap for people under 6543

Under Age 65

Medigap for People Under 65
  • Some companies sell to people under 65
    • Policies may cost more
  • Some states require Medigap be offered
    • See Guide to Health Insurance for People with Medicare
  • Another open enrollment period at 65
right to suspend medigap

Under Age 65

Right to Suspend Medigap
  • Under 65 and entitled due to a disability
    • Right to suspend your Medigap policy
      • While enrolled in employer group health plan
      • Without penalty
    • Get your Medigap policy back at any time
    • Must notify Medigap insurer within 90 days of losing employer group coverage
session topics45
Session Topics
  • Prior creditable coverage
  • Under age 65
  • Medigap and Medicaid
  • Guaranteed issue
  • More information
medigap and medicaid

Medigap and Medicaid

Medigap and Medicaid
  • If you have both Medicare and Medicaid
    • Most health care costs are covered
    • Can suspend Medigap policy for up to 2 years
    • An insurance company can sell you a Medigap policy only in certain situations
  • For information, call state Medicaid office
suspending medigap

Medigap and Medicaid

Suspending Medigap
  • Right to suspend Medigap
    • Within 90 days of getting Medicaid
    • Do not pay premiums
    • Policy will not pay benefits
    • Can suspend policy for up to 2 years
    • Can start it up again
      • No new medical underwriting
      • No pre-existing condition waiting periods
  • Call state Medicaid office
session topics48
Session Topics
  • Prior creditable coverage
  • Under age 65
  • Medigap and Medicaid
  • Guaranteed issue rights
  • More information
medigap rights and protections

Guaranteed Issue Rights

Medigap Rights and Protections
  • Also called “guaranteed issue rights”
  • Special rights to buy Medigap
  • Keep
    • Letters
    • Claim denials
    • Postmarked envelopes
  • Protections are in Federal law
    • Many states provide more Medigap protections
    • Call your SHIP or state insurance department
summary of medigap protections

Guaranteed Issue Rights

Summary of Medigap Protections
  • Guaranteed issue rights in some situations
    • Right to buy a Medigap policy
    • Apply within 63 days from other coverage ending
  • In these situations, an insurance company
    • Must sell you a Medigap policy
    • Must cover all pre-existing conditions
    • Can’t charge more because of past or present health problems
guaranteed issue rights

Guaranteed Issue Rights

Guaranteed Issue Rights
  • Rights to purchase plans A, B, C, F, K, or L, if
    • Medicare Advantage or PACE coverage ends
    • Employer group health plan coverage that pays secondary to Medicare ends
    • You move out of the plan's service area
    • You joined a Medicare Advantage or PACE plan
      • First eligible for Medicare at age 65 and leave within 12 months
guaranteed issue rights continued

Guaranteed Issue Rights

Guaranteed Issue Rights(continued)
  • You dropped a Medigap policy and enrolled in Medicare Advantage Plan for first time
    • Stayed in the plan less than a year and
    • Want to switch back
  • Medigap coverage ends through no fault of your own
  • Plan or insurance company committed fraud
let s look at a case study53

Guaranteed Issue Rights

Let’s look at a case study…
  • Jennie is 69 and joined a Medicare Advantage Plan when she first was eligible for Medicare at age 65. She decides she would like to drop her Medicare Advantage Plan and go to Original Medicare.
    • Does Jennie have a guaranteed issue right to a Medigap policy?
session topics54
Session Topics
  • Prior creditable coverage
  • Under age 65
  • Medigap and Medicaid
  • Guaranteed issue
  • More information
information sources for medigap
Information Sources for Medigap
  • 2008 Choosing a Medigap Policy: A Guide to Health Insurance for People With Medicare
    • Available on www.medicare.gov
  • SHIP
  • State insurance department
  • 1-800-MEDICARE
    • 1-800-633-4227
    • 1-877-486-2048 for TTY users