Overview of Medicare Supplemental Insurance

Background information on Medigap insurance plans that supplement Medicare and the benefits those plans cover.

Source: AARP.org | 2008-10-24

Medicare has several gaps and doesn't pay for all of the health care services you may need. If you are in the Original Medicare Plan, you may want to buy Medicare supplemental insurance, also called Medigap insurance. This is health insurance that helps pay for some of your costs in the Original Medicare program and for some care it doesn't cover.

Medigap insurance is sold by private insurance companies. By law, companies can offer only 12 standard Medigap insurance plans, plans, named A through L. Each plan has a different set of benefits. (Beginning in 2006, Medigap Plans H, I, and J, cannot be sold with prescription-drug benefits, although people who already had those policies can keep them.)

You are advised to study all the Medigap plans before deciding which is best for you. No matter which insurance company offers a particular plan, all plans with the same letter cover the same benefits. For instance, all Plan C policies have the same benefits no matter which company sells the plan. However, the premiums can vary.

All 12 Medigap policies cover basic benefits, but each has additional benefits that vary according to the plan. Briefly, Plan A is the most basic plan. Plans B-L offer everything in Plan A and provide even more coverage. Plans K-L offer similar services as Plans A-J, but the cost-sharing for the basic benefits is at different levels.

None of the standard Medigap plans cover:
• Long-term care to help you bathe, dress, eat, or use the bathroom
• Vision or dental care
• Hearing aids
• Private-duty nursing
• Prescription drugs

FYI: If you live in Massachusetts, Minnesota, or Wisconsin, you have different standard Medigap plans. Check with your state insurance department or the Guide to Health Insurance for People with Medicare: Choosing a Medigap Policy.

FYI: In addition to the standard A-L Medigap policies, Medicare SELECT is a type of Medigap policy that can cost less than standard Medigap plans. However, you can only go to certain doctors and hospitals for your care. Check with your state insurance department to find out whether or not Medicare SELECT policies are available in your state.

Medigap Basic Benefits
Medigap Plan A is the most basic plan. All plans A-J must offer the following basic benefits:

Medicare Part A
After you have paid your hospital deductible ($1,068 in 2009), the Original Medicare plan pays all your hospital costs for up to 60 days in a benefit period*. If you stay in the hospital more than 60 days, you pay $267 (in 2009) a day for days 61 through 90. If you stay longer than 90 days in a benefit period, the cost for each day is $534 (in 2009) for up to 60 days over your lifetime.

All 12 Medigap plans cover; that is, pay, your costs for days 61 through 150. In addition, once you use your 150 days of Medicare hospital benefits, all Medigap plans cover the cost of 365 more hospital days in your lifetime. If you have the high-deductible options, Plans F or J, you must first pay your annual Medigap deductible before your costs will be covered. If you have Plans K or L, you will have to pay a portion of the hospital deductible ($1,068 in 2009), before your costs will be covered—unless you have already met the annual out-of-pocket maximum for the year.

*A benefit period begins the day you go to the hospital and ends when you have been out of the hospital for 60 days in a row. If you go into the hospital again after 60 days have passed, you begin a new benefit period.

Medicare Part B
After you pay your yearly Part B deductible ($135 in 2009), Medicare generally pays 80 percent of doctor and other medical services. It pays 50 percent of mental health services and 100 percent of some preventive services.

Medigap plans cover all or part of your share of the services mentioned above—20 percent of the Medicare-approved amount for doctor services and 50 percent for mental health services. The "Medicare approved amount" is the amount that Medicare decides is a reasonable payment for a medical service.

Blood
The Original Medicare plan doesn't cover the first three pints of blood you need each year. Plans A-J pay for these first three pints.

Medigap Extra Benefits
Some people want to have the extra benefits offered by Plans B through J and are willing to pay for more them. Medigap Plans B through J also cover all the basic benefits of Plan A. Plans K and L offer similar services as Plans A-J, but the cost-sharing for the benefits is at different levels.

Plans F and J also have a high-deductible option. You will have a lower premium with the high-deductible option, but you will have to pay more out-of-pocket before the policy will begin to pay benefits.

Medicare Part A Hospital Deductible
Medigap Plans B through J cover the hospital deductible ($1,068 in 2009) for each benefit period. This benefit usually saves you money if you have to stay in the hospital.

Skilled Nursing Home Costs
The Original Medicare Plan pays all of your skilled nursing home costs for the first 20 days of each benefit period. If you are in a nursing home for more than 20 days, you pay part of each day’s bill.

Medigap Plans C through J pay your share of the bill ($133.50 a day in 2009) for days 21 through 100. Neither Medicare nor any Medigap plan pays for any skilled nursing home stay longer than 100 days in a benefit period.

Medicare Part B Deductible
You must pay a deductible each year for doctor and other medical services before Medicare pays.

Medigap Plans C, F, and J pay this deductible. In 2009, the deductible is $135.

Medicare Part B Excess Charges
When you see that a doctor doesn't "accept assignment," it means he or she does not accept Medicare's approved amount as payment in full. The doctor can charge you up to 15 percent more than Medicare's approved amount.

Medigap Plans F, I, and J pay 100 percent of these excess charges. Medigap Plan G pays 80 percent of the excess charges. You might want this benefit if you don’t know whether the doctors you see accept assignment, such as when you are in the hospital.

Foreign Travel Emergency
Medicare does not cover any health care you receive outside of the United States. Medigap Plans C through J cover some emergency care outside the United States. After you meet the yearly $250 deductible, this benefit pays 80 percent of the cost of your emergency care during the first 60 days of your trip. There is a $50,000 lifetime maximum.

At-Home Recovery
Medicare covers some skilled home care given by a nurse or a physical, occupational, or speech therapist. It does not pay for at-home help for the activities of daily living, such as bathing and dressing. You pay for this type of care.

Medigap Plans D, G, I, and J cover this type of at-home help if you already are receiving skilled home health care that is covered by Medicare. These plans cover at-home help for up to eight weeks after you no longer need skilled care. However, they will not pay more than $40 per visit, seven visits a week, or $1,600 each year.

Preventive Care
Medigap Plans E and J offer this benefit, which is limited to $120 each year. It helps pay for preventive care not covered by Medicare. Since Medicare now covers more preventive care, make sure this benefit is helpful to you.

Prescription Drugs
After Jan. 1, 2006, you can not purchase new Medigap policies covering prescription drugs because private companies approved by Medicare offer this coverage separately. In order to get prescription drug coverage you must enroll in a Medicare Prescription Drug Plan.

Plans K and L
Important: Plans K and L offer similar coverage as plans A-J, but the cost-sharing for the benefits are different levels and have annual limits on how much you pay for services. The out-of-pocket limits are different for Plans K and L and will increase each year for inflation. In 2009, the out-of-pocket limit was $4,620 for Plan K and $2,310 for Plan L.

Ongoing Coverage
Once you buy a Medigap plan, the insurance company must keep renewing it. The company can't change what the policy covers and can't cancel it unless you don’t pay the premium. The company can increase the premium and should notify you in advance of any increases.