AHIP Medicare - Module 1 - Overview of Medicare Program Basics: Choices, Eligibility, and Benefits - MEDIGAP COVERAGE

Medigap insurance:

Works only with Original Medicare.

Is sold by private insurance companies to fill “gaps” in Original Medicare coverage, such as all or part of the deductibles or coinsurance amounts.

It coordinates with original Medicare coverage.

Some Medigap policies cover limited benefits not covered by Part A or Part B of Original Medicare, Such as extra days of coverage for inpatient hospital care or foreign travel emergency care. Generally, Medigap doesn’t cover long-term care (like care in a nursing home), vision or dental services, hearing aids, eyeglasses, or private-duty nursing.

Generally, Medigap doesn’t cover long-term care (like care in a nursing home), vision or dental services, hearing aids, eyeglasses, or private-duty nursing.

-Medigap is NOT a Medicare Advantage (Part C) plan or other Medicare health plan.

• Medigap is NOT Original Medicare. Medigap supplements Original Medicare benefits only.

-In addition,
--A Medigap plan cannot be used with a Medicare Advantage health plan. -- It is illegal to sell a Medigap plan to someone who is already in a Medicare Advantage health plan.

Medigap policies are available in standardized benefit plans, identified by certain letters between A and N
(however, different plans are offered in Massachusetts, Minnesota, and Wisconsin).

Turning age 65 and signing up for Part B triggers a six-month Medigap open enrollment period when Medigap insurers must issue you a policy, regardless of any pre-existing conditions. This is called a guaranteed issue right.

Yes. In certain limited instances, leaving a Medicare Advantage plan may trigger a guaranteed issue right. Some states have additional guaranteed issue periods for Medicare beneficiaries. Agents should look into state-specific Medigap laws.

All Medigap plans pay for some or all of the following costs:

• Part A coinsurance

• Coverage for 365 additional hospital days when Medicare coverage for hospitalization ends

• Part B coinsurance or copayment

• Blood (First 3 Pints)

• Hospice care coinsurance or copayment

Yes, Medigap pays for some or all of Part A coinsurance.

Yes, Medigap pays for some or all of 365 additional hospital days when Medicare coverage for hospitalization ends

Yes. Medigap pays for some or all of Part B coinsurance or copayment.

Yes. Medigap pays for some or all of the cost for the first 3 pints of blood.

Yes. Medigap pays for some or all of hospice care coinsurance or copayment.

• Medigap plans H, I, and J offer non-Medicare drug coverage. These plans could no longer be sold as of January 1, 2006. However, some beneficiaries may have decided to keep their H, I, or J policy with the drug coverage they had before January 1, 2006

• Individuals who are enrolled in Medigap plans may only obtain Medicare drug coverage (Part D) through a stand-alone prescription drug plan.

• To enroll in Part D, individuals who have Medigap plans H, I, or J may:
  – keep their Medigap coverage with the drug portion of the coverage removed and enroll in a Part D PDP plan; or
  – drop their Medigap coverage and enroll in an MA-PD or other health plans with a PDP.

Medigap plans H, I, and J offer non-Medicare drug coverage. These plans could no longer be sold as of January 1, 2006. However, some beneficiaries may have decided to keep their H, I, or J policy with the drug coverage they had before January 1, 2006

Individuals who are enrolled in Medigap plans may only obtain Medicare drug coverage (Part D) through a stand-alone prescription drug plan.

To enroll in Part D, individuals who have Medigap plans H, I or J may do either one of the following:

1. keep their Medigap coverage with the drug portion of the coverage removed, and enroll in a Part D PDP plan; or

2. Drop their Medigap coverage and enroll in an MA-PD or other health plans with a PDP.

–Non-Medicare insurers (including Medigap plans) are required to notify beneficiaries annually whether or not the prescription drug coverage they have is creditable (coverage that expects to pay, on average, at least as much as Medicare’s standard Part D coverage expects to pay).

– All beneficiaries who do not maintain creditable coverage must pay a Part D late enrollment penalty if they wish to enroll in Part D unless they qualify for “Extra Help” or enroll in Part D during the special enrollment period for loss of creditable coverage.

– Beneficiaries who previously had creditable coverage and are informed that their non-Medicare drug coverage is no longer creditable will have a special enrollment period to enroll in a Part D plan without the obligation to pay a Part D late enrollment penalty.

Yes. Non-Medicare insurers (including Medigap plans) are required to notify beneficiaries annually whether or not the prescription drug coverage they have is creditable.

Creditable coverage is coverage that expects to pay, on average, at least as much as Medicare’s standard Part D coverage expects to pay.

All beneficiaries who do not maintain creditable coverage must pay a Part D late enrollment penalty if they wish to enroll in Part D unless they qualify for “Extra Help” or enroll in Part D during the special enrollment period for loss of creditable coverage.

Beneficiaries who previously had creditable coverage and are informed that their non-Medicare drug coverage is no longer creditable will have a special enrollment period to enroll in a Part D plan without the obligation to pay a Part D late enrollment penalty.

The “Extra Help” program is a Medicare initiative designed to assist individuals with limited income and resources in paying for Medicare drug coverage, also known as Part D. The program helps cover costs such as premiums, deductibles, coinsurance, and other expenses associated with Part D.

Here are some key points about the “Extra Help” program:

You won’t have to pay a Part D late enrollment penalty while you get Extra Help.
Some people qualify for Extra Help automatically, while others have to apply.

The program isn’t available in Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, or American Samoa. However, other programs are available in those areas to help people with limited income and resources.
If you qualify for Extra Help, you’ll be automatically enrolled in a Medicare drug plan (Part D), if you don’t have one already.
You can apply for Extra Help at any time before or after you enroll in Part D.

Please note that the level of help you receive depends on your income and assets. If you’re interested in applying for the “Extra Help” program, you can do so through the Social Security Administration.

–Individuals who attained age 65 on or after January 1, 2020, or first become eligible for Medicare due to age, disability, or end-stage renal disease on or after January 1, 2020, may not purchase a Medigap plan that pays the Part B deductible (generally plans C, F or high deductible F, but the prohibition also applies in waiver states with non-standard packages).

– Individuals previously enrolled in plans that cover the Part B deductible may remain enrolled in those plans.

– Individuals who became eligible for Medicare before 2020 may enroll in plans that cover the Part B deductible.

The Medigap plans are:

A, B, D, G, K, L, M, N, C, and F

All of these plans pay 10% of Original Medicare’s Part A Coinsurance and Hospital Benefits

Medigap plans A, B, D, G, M, N C, and F pay 100% of Original Medicare's Part B coinsurance or copayment costs.

NOTE: Medigap plan K pays 50% of Original Medicare's Part B coinsurance and copayment costs; and,

Medigap plan L pays 75% of Original Medicare's Part B 75% coinsurance and copayment costs.

Medigap plans A, B, D, G, M, N, C, and F pay 100% of Original Medicare's Blood (First 3 pints) costs.

NOTE: Medigap plan K pay 50% of Original Medicare's Blood (First 3 pints) coverage costs; and

Medigap plan L pays 75% of Original Medicare's Blood (First 3 pints) coverage costs.

Medigap plans A, B, D, G, M, N, C, and F pay 100% of Original Medicare's Part A Hospice Care Coinsurance / Copayment coverage costs.

NOTE: Medigap plan K pays 50% of Original Medicare's Part A Hospice Care Coinsurance / Copayment coverage costs; and,

Medigap plan L pays 75% of Original Medicare's Part A Hospice Care Coinsurance/copay coverage costs.

Medigap plans D, G, M, N, C, and F pay 100% of Original Medicare's skilled Nursing Facility Care Coinsurance coverage costs.

NOTE: Medigap Plan K pays 50% of Original Medicare's Skilled Nursing Facility Care Coinsurance coverage costs; and

Medigap plan L pays 75% of Original Medicare's Skilled Nursing Facility Care Coinsurance coverage costs.

Note: Medigap Plans A and B pay 0% of Original Medicare's Skilled Nursing Facility Care Coinsurance coverage costs.

Medigap Plan K consistently pays 50%; and, Medigap Plan L consistently pays 75%.

Medigap Plans C and F are available only to beneficiaries eligible before 2020.

Plan F also has a high-deductible option. In 2022, a policyholder pays $2,490 before the Medigap policy pays anything. Once the plan deductible is met, the plan pays 100% of covered services for the rest of the calendar year. However, high deductible Plan F counts payment of the Medicare Part B deductible toward meeting the plan deductible.

NOTE: Plan F as well as Plan C are available only to beneficiaries eligible before 2020.

Plan F pays 100% of Medicare Part A deductible, 100% of Medicare Part B deductible, 100% of Medicare Part B Excess Charges, and 80% of Foreign Travel Emergency (up to plan limits).

Plan C, like Plan F, is available only to beneficiaries eligible before 2020.

Plan C pays %100 of the Medicare Part A deductible and 100% of Part B deductible, but is does not pay any portion of Medicare Part B Excess Charges.

Plan C pays 80% of Foreign Travel Emergency (up to plan limits)

There is a high deductible version of Plan G. The deductible for 2022 is $2,4090.

Medigap Plan G pays 100% of Medicare Part A Deductible. Plan G pays 0% of Medicare Part B Deductible, but does pay %100 of Medicare Part B Excess Charges. And, finally, Plan G pays 80% of the Foreign travel benefit after a $250 deductible, up to a $50,000 lifetime maximum.

The agent explains that Plans C and F, which cover %100 of the Part B deductible, are not available to her because she became eligible after January 1, 2020. However, Plans D, G, or N are most likely to fit the bill.