1 CENTERS FOR MEDICARE & MEDICAID SERVICES 2 0 19 Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare This official government guide has important information about: • Medicare Supplement Insurance (Medigap) policies • What Medigap policies cover • Your rights to buy a Medigap policy • How to buy a Medigap policy Developed jointly by the Centers for Medicare & Medicaid Services (CMS) and the National Association of Insurance Commissioners (NAIC)
2 Who should read this guide? This guide can help if you’re thinking about buying a Medigap policy or already have one. It'll help you understand Medicare Supplement Insurance policies (also called Medigap policies). A Medigap policy is a type of private insurance that helps you pay for some of the costs that Original Medicare doesn’t cover. Important information about this guide The information in this booklet describes the Medicare Program at the time this booklet was printed. Changes may occur after printing. Visit Medicare.gov , or call 1‑800‑MEDICARE (1‑800‑633‑4227) to get the most current information. TTY users can call 1‑877‑486‑2048. The “2019 Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare” isn’t a legal document. Official Medicare Program legal guidance is contained in the relevant statutes, regulations, and rulings. Paid for by the Department of Health & Human Services.
3 3 Table of Contents Section 1: 5 Medicare Basics ... A brief look at Medicare 5 6 What’s Medicare? ... The different parts of Medicare 6 ... Your Medicare coverage choices at a glance ... 7 Medicare and the Health Insurance Marketplace ... 8 Section 2: 9 Medigap Basics ... 9 What’s a Medigap policy? ... What Medigap policies cover 10 12 What Medigap policies don’t cover ... Types of coverage that are NOT Medigap policies ... 12 What types of Medigap policies can insurance companies sell? 12 ... What do I need to know if I want to buy a Medigap policy? ... 13 14 When’s the best time to buy a Medigap policy? ... Why is it important to buy a Medigap policy when I’m first eligible? ... 16 17 How do insurance companies set prices for Medigap policies? ... 18 ... What this pricing may mean for you Comparing Medigap costs 19 ... ... What's Medicare SELECT? 20 20 ... How does Medigap help pay my Medicare Part B bills? Section 3: Your Right to Buy a Medigap Policy 21 ... 21 What are guaranteed issue rights? 21 ... When do I have guaranteed issue rights? ... 24 Can I buy a Medigap policy if I lose my health care coverage? Section 4: Steps to Buying a Medigap Policy 25 Step‑by‑step guide to buying a Medigap policy ... 25 Section 5: 31 If You Already Have a Medigap Policy Switching Medigap policies 32 ... 36 ... Losing Medigap coverage ... 36 Medigap policies and Medicare prescription drug coverage
4 4 Table of Contents Section 6: 39 Medigap Policies for People with a Disability or ESRD ... Information for people under 65 39 41 Medigap Coverage in Massachusetts, Minnesota, and Wisconsin Section 7: Massachusetts benefits 42 ... Minnesota benefits 43 ... ... 44 Wisconsin benefits Section 8: 45 For More Information Where to get more information ... 45 How to get help with Medicare and Medigap questions 46 ... State Health Insurance Assistance Program and State Insurance Department .. 47 Section 9: Definitions 49 49 ... Where words in BLUE are defined
5 5 SECTION Medicare Basics A brief look at Medicare 1 A Medicare Supplement Insurance (Medigap) policy is health insurance that can help pay some of the health care costs that Original , . , or deductibles coinsurance copayments Medicare doesn’t cover, like Private insurance companies sell Medigap policies. Some Medigap policies also cover certain benefits Original Medicare doesn’t cover, like emergency foreign travel expenses. Medigap policies don’t cover your share of the costs under other types of health coverage, ‑ , stand Medicare Advantage Plans (like HMOs or PPOs) including Medicare Prescription Drug Plans , employer/union group health alone Medicaid coverage, , or TRICARE. Insurance companies generally can’t sell you a Medigap policy if you have coverage through Medicaid or a Medicare Advantage Plan. The next few pages provide a brief look at Medicare. If you already know the basics about Medicare and only want to learn about Medigap, skip to page 9 . Words in blue are defined on pages 49–50.
6 6 Section 1: Medicare Basics What's Medicare? Medicare is health insurance for: People 65 or older • • People under 65 with certain disabilities People of any age with End‑Stage Renal Disease (ESRD) (permanent kidney failure • requiring dialysis or a kidney transplant) The different parts of Medicare The different parts of Medicare help cover specific services. Part A (Hospital Insurance) Helps cover: • Inpatient care in hospitals • Skilled nursing facility care • Hospice care • Home health care Part B (Medical Insurance) Helps cover: • Services from doctors and other health care providers • Outpatient care • Home health care • Durable medical equipment (like wheelchairs, walkers, hospital beds, and other equipment and supplies) • Many preventive services (like screenings, shots, and yearly “Wellness” visits) Part D (Prescription drug coverage) Helps cover: • Cost of prescription drugs Part D plans are run by private insurance companies that follow rules set by Medicare.
7 7 Medicare Basics Section 1: Your Medicare options When you first enroll in Medicare and during certain times of the year, you can choose how you get your Medicare coverage. There are 2 main ways to get Medicare. Original Medicare Medicare Advantage (also known as Part C) • Original Medicare includes Medicare Part A (Hospital Insurance) and Part B Medicare Advantage is an “all in one” • (Medical Insurance). alternative to Original Medicare. These “bundled” plans include Part A, Part B, • If you want drug coverage, you can join a and usually Part D. separate Part D plan. • Some plans may have lower out-of-pocket To help pay your out-of-pocket costs in • costs than Original Medicare. Original Medicare (like your deductible and 20% coinsurance), you can also shop • Some plans offer extra benefits that for and buy supplemental coverage. Original Medicare doesn’t cover — like vision, hearing, or dental. Part A Part A Part B Part B You can add: Most plans include: Part D Part D You can also add: Some plans also include: Supplemental Lower out-of-pocket-costs coverage (Some examples include Extra benefits coverage from a Medicare Supplement Insurance (Medigap) policy, or coverage from a former employer or union.)
8 8 Section 1: Medicare Basics Medicare and the Health Insurance Marketplace If you have coverage through an individual Marketplace plan (not through an employer), you may want to end your Marketplace coverage and enroll in Medicare during your Initial Enrollment Period to avoid the risk of a delay in future Medicare coverage and the possibility of a Medicare late enrollment penalty. It’s important to terminate your Marketplace coverage in a timely manner to avoid an overlap in coverage. Once you’re considered eligible for premium free Part A, you won’t qualify for help paying your Marketplace plan premiums or other medical costs. If you continue to get help paying your Marketplace plan premium after you have Medicare, you may have to pay back some or all of the help you got when you file your taxes. Visit HealthCare.gov to connect to the Marketplace in your state and learn more. You can also find out how to terminate your Marketplace plan or Marketplace financial help when your Medicare enrollment begins to avoid a gap in coverage. You can also call the Marketplace Call Center at 1‑800‑318‑2596. TTY users can call 1‑855‑889‑4325. Note: Medicare isn ’ t part of the Marketplace. The Marketplace doesn’t offer Medicare Supplement Insurance (Medigap) policies, Medicare Advantage Plans , or Medicare drug plans (Part D). For more information Remember, this guide is about Medigap policies. To learn more about Medicare, visit Medicare.gov, look at your “Medicare & You” handbook, or call 1‑800‑MEDICARE (1‑800‑633‑4227). TTY users can call 1‑877‑486‑2048.
9 9 SECTION Medigap Basics What's a Medigap policy? A Medigap policy is private health insurance that helps supplement Original Medicare . This means it helps pay some of the health 2 copayments care costs that Original Medicare doesn’t cover (like , coinsurance , and deductibles ). These are “gaps” in Medicare coverage. If you have Original Medicare and a Medigap policy, Medicare will pay its share of the Medicare‑approved amounts for covered health care costs. Then your Medigap policy pays its share. A Medigap policy Medicare Advantage Plan (like an HMO or PPO) is different from a because those plans are ways to get Medicare benefits, while a Medigap policy only supplements the costs of your Original Medicare benefits. Note: Medicare doesn’t pay any of your costs for a Medigap policy. All Medigap policies must follow federal and state laws designed to protect you, and policies must be clearly identified as “Medicare Supplement Insurance.” Medigap insurance companies in most states can only sell you a “standardized” Medigap policy identified by letters A through N. Each standardized Medigap policy must offer the same basic benefits, no matter which insurance company sells it. Cost is usually the only difference between Medigap policies with the same letter sold by different insurance companies.
10 10 Section 2: Medigap Basics What Medigap policies cover The chart on page 11 gives you a quick look at the standardized Medigap Plans available. You’ll need more details than this chart provides to compare and choose a policy. Call your State Health Insurance Assistance Program (SHIP) for See pages 47–48 for your state’s phone number. help. • Insurance companies selling Medigap policies are required to make Plan A available. If they offer any other Medigap policy, they must also offer either Plan C or Plan F to individuals who are not new to Medicare and either Plan D or Plan G to individuals who are new to Medicare. Not all types of Medigap policies may be available in your state. • after June 1, 2010, have different benefits than Plans D and G effective on or Plans D or G bought before June 1, 2010. • Plans E, H, I, and J are , but, if you already have one, you can no longer sold generally keep it. • Starting January 1, 2020, Medigap plans sold to people new to Medicare won’t be allowed to cover the Part B deductible. Because of this, Plans C and F will no longer be available to people who are new to Medicare on or after January 1, 2020. If you already have either of these two plans (or the high deductible version – of Plan F) or are covered by one of these plans prior to January 1, 2020, you will be able to keep your plan. If you were eligible for Medicare before January 1, 2020 but not yet enrolled, you may be able to buy one of these plans. People new to Medicare are those who turn 65 on or after January 1, 2020, – and those who first become eligible for Medicare benefits due to age, disability or ESRD on or after January 1, 2020. In Massachusetts, Minnesota, and Wisconsin, Medigap policies are standardized in a different way. See pages 42–44 . In some states, you may be able to buy another type of Medigap policy called Medicare SELECT . Medicare SELECT plans are standardized plans that may require you to see certain providers and may cost less than other plans. See page 20 .
11 11 Medigap Basics Section 2: This chart shows basic information about the different benefits that Medigap policies cover. If a percentage appears, the Medigap plan covers that percentage of the benefit, and you must pay the rest. Medicare Supplement Insurance (Medigap) Plans B C A G K L M N Benefits D * F 100% 100% 100% 100% 100% 100% 100% Medicare Part A 100% 100% 100% coinsurance and hospital costs (up to an additional 365 days after Medicare benefits are used) 100% 100% 100% 100% Medicare Part B 100% 50% 75% 100% 100% 100% copayment coinsurance or *** 100% 100% 100% 100% 75% 100% 100% Blood (first 3 pints) 100% 100% 50% 100% Part A hospice care 100% 100% 100% 50% 75% 100% 100% 100% 100% coinsurance or copayment 100% 100% 50% 100% 100% 100% 100% Skilled nursing facility care 75% coinsurance 100% 100% 100% 100% 50% 75% 50% 100% deductible Part A 100% 100% 100% Part B deductible 100% 100% Part B excess charges 80% 80% 80% 80% 80% Foreign travel emergency 80% (up to plan limits) Out‑of‑ pocket limit in 2019** $2,780 $5,560 * Plan F is also offered as a high‑deductible plan by some insurance companies in some states. If you choose this option, this means you must pay for Medicare‑covered costs (coinsurance, copayments, deductibles) up to the deductible amount of $2,300 in 2019 before your policy pays anything. **For Plans K and L, after you meet your out‑of‑pocket yearly limit and your yearly Part B deductible ($185 in 2019), the Medigap plan pays 100% of covered services for the rest of the calendar year. *** Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that don’t result in an inpatient admission.
12 12 Section 2: Medigap Basics What Medigap policies don’t cover Generally, Medigap policies don’t cover long ‑ term care (like care in a nursing home), vision or dental care, hearing aids, eyeglasses, or private‑duty nursing. Types of coverage that are NOT Medigap policies • , like an HMO or PPO Medicare Advantage Plans (Part C) Medicare Prescription Drug Plans (Part D) • • Medicaid Employer or union plans, including the Federal Employees Health • Benefits Program (FEHBP) • TRICARE • Veterans’ benefits Long ‑ term care insurance policies • Indian Health Service, Tribal, and Urban Indian Health plans • • Qualified Health Plans sold in the Health Insurance Marketplace What types of Medigap policies can insurance companies sell? In most cases, Medigap insurance companies can sell you only a “standardized” Medigap policy. All Medigap policies must have specific benefits, so you can compare them easily. If you live in Massachusetts, Minnesota, or Wisconsin, see pages 42– 44 . Insurance companies that sell Medigap policies don’t have to offer every Medigap plan. However, they must offer Plan A if they offer any Medigap policy. blue Words in If they offer any plan in addition to Plan A, they must also offer Plan C or Plan F. Each are defined on insurance company decides which Medigap plan it wants to sell, although state laws might affect which ones they offer. pages 49–50. In some cases, an insurance company must sell you a Medigap policy if you want one , even if you have health problems. Here are certain times that you’re guaranteed the right to buy a Medigap policy: . See pages 14 –15 . Medigap When you’re in your • Open Enrollment Period . See pages 21–23. guaranteed issue right • If you have a You may be able to buy a Medigap policy at other times, but the insurance company can deny you a Medigap policy based on your health. Also, in some cases it may be illegal for the insurance company to sell you a Medigap policy (like if you already have Medicaid or a Medicare Advantage Plan).
13 13 Section 2: Medigap Basics What do I need to know if I want to buy a Medigap policy? • You must have Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) to buy a Medigap policy. If you have a (like an HMO or PPO) but are planning Medicare Advantage Plan • to return to Original Medicare , you can apply for a Medigap policy before your coverage ends. The Medigap insurer can sell it to you as long as you’re leaving the Plan. Ask that the new Medigap policy start when your Medicare Advantage Plan enrollment ends, so you'll have continuous coverage. You pay the private insurance company a premium for your Medigap policy in • addition to the monthly Part B premium you pay to Medicare. • A Medigap policy only covers one person. If you and your spouse both want you each will have to buy separate Medigap policies Medigap coverage, . When you have your Medigap Open Enrollment Period , • you can buy a Medigap policy from any insurance company that’s licensed in your state. • If you want to buy a Medigap policy, see page 11 for an overview of the basic benefits covered by different Medigap policies. Then, follow the “ Steps to Buying a Medigap Policy ” –30 . on pages 25 If you want to drop your Medigap policy, write your insurance company to cancel • the policy and confirm it’s cancelled. Your agent can’t cancel the policy for you. Any standardized Medigap policy is guaranteed renewable • even if you have health problems. This means the insurance company can’t cancel your Medigap policy as long as you stay enrolled and pay the premium. • Different insurance companies may charge different premiums for the same exact policy. As you shop for a policy, be sure you’re comparing the same policy (for example, compare Plan A from one company with Plan A from another company). Some states may have laws that may give you additional protections. • • Although some Medigap policies sold in the past covered prescription drugs, Medigap policies sold after January 1, 2006, aren’t allowed to include prescription drug coverage. If you want prescription drug coverage, you can join a Medicare Prescription Drug Plan (Part D) offered by private companies approved by Medicare. See pages 6–7 . To learn about Medicare prescription drug coverage, visit Medicare.gov, or call 1‑800‑MEDICARE (1‑800‑633‑4227). TTY users can call 1‑877‑486‑2048.
14 14 Section 2: Medigap Basics When's the best time to buy a Medigap policy? The best time to buy a Medigap policy is during your Medigap Open Enrollment Period . This period lasts for 6 months and begins on the first day of the month in which you’re both 65 or older and enrolled in Medicare Part B. Some states have additional Open Enrollment Periods including those for people under 65. During this period, an insurance company can’t use . medical underwriting This means the insurance company can’t do any of these because of your health problems: Refuse to sell you any Medigap policy it offers • • Charge you more for a Medigap policy than they charge someone with no health problems • Make you wait for coverage to start (except as explained below) While the insurance company can’t make you wait for your coverage to start, it may be able to make you wait for coverage related to a pre ‑ existing condition . A pre ‑ existing condition is a health problem you have before the date a new insurance policy starts. In some cases, the Medigap insurance company can refuse to cover your out of ‑ pocket costs for these pre ‑ existing health problems ‑ ‑ existing condition waiting period.” for up to 6 months. This is called a “pre After 6 months, the Medigap policy will cover the pre ‑ existing condition. Coverage for a pre ‑ existing condition can only be excluded if the condition was treated or diagnosed within 6 months before the coverage starts under the Medigap ‑ back period.” Remember, for Medicare‑covered policy. This is called the “look services, Original Medicare will still cover the condition, even if the Medigap policy won’t, but you’re responsible for the Medicare coinsurance or copayment . Words in blue are defined on pages 49–50.
15 15 Section 2: Medigap Basics When's the best time to buy a Medigap policy? (continued) Creditable coverage It’s possible to avoid or shorten waiting periods for pre‑existing conditions, if you have a pre‑existing condition , you buy a Medigap policy during your Open Enrollment Period , Medigap and you’re replacing certain kinds of health coverage that count as “creditable coverage.” Prior creditable coverage is generally any other health coverage you recently had before applying for a Medigap policy. If you’ve had at least 6 months of continuous prior creditable coverage, the Medigap insurance company can’t make you wait before it covers your pre‑existing conditions. There are many types of health care coverage that may count as creditable coverage for Medigap policies, but they’ll only count if you didn’t have a break in coverage for more than 63 days. Your Medigap insurance company can tell you if your previous coverage will count as creditable coverage for this purpose. You can also call your State Health Insurance Assistance Program . 48 . See pages 47– guaranteed issue right If you buy a Medigap policy when you have a (also called “Medigap protection”), the insurance company can’t use a pre‑existing condition waiting period. See pages 21–23 for more information about guaranteed issue rights. Note: If you’re under 65 and have Medicare because of a disability or End‑Stage Renal Disease (ESRD), you might not be able to buy the Medigap policy you want, or any Medigap policy, until you turn 65. Federal law generally doesn’t require insurance companies to sell Medigap policies to people under 65. However, some states require Medigap insurance companies to sell you a Medigap policy, even if you’re under 65. See page 39 for more information.
16 16 Section 2: Medigap Basics Why is it important to buy a Medigap policy when I'm first eligible? When you’re first eligible, you have the right to buy any Medigap policy offered in your state. In addition, you generally will get better prices and more choices among policies. It’s very important to understand your Medigap Open Enrollment Period . Medigap insurance companies are generally allowed medical underwriting to decide whether to accept your application to use and how much to charge you for the Medigap policy. However, if you apply during your Medigap Open Enrollment Period, you can buy any Medigap policy the company sells, even if you have health problems, for the same price as people with good health. If you apply for Medigap coverage after your Open Enrollment Period, there’s no guarantee that an insurance company will sell you a Medigap policy if you don’t meet the medical underwriting requirements, unless you’re eligible for guaranteed issue rights (Medigap protections) because of one of the limited situations listed on pages 22–23. It’s also important to understand that your Medigap rights may depend on when you choose to enroll in Medicare Part B. If you’re 65 or older, your Medigap Open Enrollment Period begins when you enroll in Part B and can’t be changed or repeated. In most cases, it makes sense to enroll in Part B and purchase a Medigap policy when you’re first eligible for Medicare, because you might otherwise have to pay a Part B late enrollment penalty and might miss your Medigap Open Enrollment Period. However, there are exceptions if you have employer coverage. Employer coverage If you have group health coverage through an employer or union, because either you or your spouse is currently working, you may want to wait to enroll blue Words in in Part B. Benefits based on current employment often provide coverage are defined on similar to Part B, so you wouldn't want to pay for Part B before you need it, pages 49–50. and your Medigap Open Enrollment Period might expire before a Medigap policy would be useful. When the employer coverage ends, you’ll get a chance to enroll in Part B without a late enrollment penalty which means your Medigap Open Enrollment Period will start when you’re ready to take advantage of it. If you or your spouse is still working and you have coverage through an employer, contact your employer or union benefits administrator to find out how your insurance works with Medicare. See page 24 for more information.
17 17 Section 2: Medigap Basics How do insurance companies set prices for Medigap policies? premium , for its Each insurance company decides how it’ll set the price, or Medigap policies. The way they set the price affects how much you pay now and in the future. Medigap policies can be priced or “rated” in 3 ways: 1. Community‑rated (also called “no‑age‑rated”) 2. Issue‑age‑rated (also called “entry‑age‑rated”) 3. Attained‑age‑rated Each of these ways of pricing Medigap policies is described in the chart on the next page. The examples show how your age affects your premiums, and why it’s important to look at how much the Medigap policy will cost you now and in the future. The amounts in the examples aren’t actual costs. Other factors like where you live, medical underwriting , and discounts can also affect the amount of your premium.
18 18 Section 2: Medigap Basics How do insurance companies set prices for Medigap policies? (continued) Examples Type of What this pricing may How it’s pricing priced mean for you Mr. Smith is 65. He buys a Medigap Community- Generally the Your premium isn’t based on policy and pays a $165 monthly same premium your age. Premiums may go rated is charged to up because of inflation and premium. (also called everyone who other factors but not because “no-age- Mrs. Perez is 72. She buys the same has the Medigap of your age. rated”) Medigap policy as Mr. Smith. She also policy, regardless pays a $165 monthly premium. of age or gender. Issue-age- The premium is Premiums are lower for people Mr. Han is 65. He buys a Medigap based on the age policy and pays a $145 monthly who buy at a younger age and rated (also you are when won’t change as you get older. premium. called “entry you buy (are Premiums may go up because age-rated”) Mrs. Wright is 72. She buys the same “issued”) the of inflation and other factors Medigap policy as Mr. Han. Since she Medigap policy. but not because of your age. is older when she buys it, her monthly premium is $175. Attained-age- Premiums are low for Mrs. Anderson is 65. She buys a The premium is younger buyers but go up Medigap policy and pays a $120 based on your rated as you get older. They may monthly premium. Her premium will current age be the least expensive at go up each year: (the age you've first, but they can eventually “attained”), so At 66, her premium goes up to $126. • become the most expensive. your premium • At 67, her premium goes up to $132. Premiums may also go up goes up as you because of inflation and get older. other factors. Mr. Dodd is 72. He buys the same Medigap policy as Mrs. Anderson. He pays a $165 monthly premium. His premium is higher than Mrs. Anderson’s because it’s based on his current age. Mr. Dodd’s premium will go up each year: At 73, his premium goes up to $171. • • At 74, his premium goes up to $177.
19 19 Section 2: Medigap Basics Comparing Medigap costs As discussed on the previous pages, the cost of Medigap policies can vary premiums that different widely. There can be big differences in the . As you shop insurance companies charge for exactly the same coverage for a Medigap policy, be sure to compare the same type of Medigap policy, and consider the type of pricing used. See pages 17–18 . For example, compare a Plan C from one insurance company with a Plan C from another c a n’ t give actual costs of Medigap insurance company. Although this guide policies, you can get this information by calling insurance companies or your State Health Insurance Assistance Program See pages 47– 48 . . You can also find out which insurance companies sell Medigap policies in your area by visiting . Medicare.gov The cost of your Medigap policy may also depend on whether the insurance company: Offers discounts (like discounts for women, non‑smokers, or people • who are married; discounts for paying yearly; discounts for paying your premiums using electronic funds transfer; or discounts for multiple policies). • Uses medical underwriting , or applies a different premium when you don’t have a guaranteed issue right Medigap Open Enrollment or aren’t in a . Period • Sells policies that may require you to use certain Medicare SELECT providers. If you buy this type of Medigap policy, your premium may be less. See page 20 . • Offers a “high‑ deductible option” for Plan F. If you buy Plan F with a high‑ deductible option, you must pay the first $2,300 of , copayments , deductibles and coinsurance (in 2019) for covered services not paid by Medicare before the Medigap policy pays anything. You must also pay a separate deductible ($250 per year) for foreign travel emergency services. If you bought Medigap Plan J before January 1, 2006, and it still covers prescription drugs, you would also pay a separate deductible ($250 per year) for prescription drugs covered by the Medigap policy. And, if you have a Plan J with a high deductible option, you must also pay a $2,300 deductible (in 2019) before the policy pays anything for medical benefits.
20 20 Section 2: Medigap Basics What's Medicare SELECT? Medicare SELECT is a type of Medigap policy sold in some states that requires you to use hospitals and, in some cases, doctors within its network to be eligible for full insurance benefits (except in an emergency). Medicare see page 11 ). These SELECT can be any of the standardized Medigap plans ( policies generally cost less than other Medigap policies. However, if you don’t use a Medicare SELECT hospital or doctor for non‑emergency services, you’ll have to pay some or all of what Medicare doesn’t pay. Medicare will pay its share of approved charges no matter which hospital or doctor you choose. How does Medigap help pay my Medicare Part B bills? In most Medigap policies, when you sign the Medigap insurance contract you agree to have the Medigap insurance company get your Medicare Part B claim information directly from Medicare, and then they pay the doctor directly whatever amount is owed under your policy. Some Medigap insurance companies also provide this service for Medicare Part A claims. If your Medigap insurance company d o e s n’ t provide this service, ask your doctors if they participate in Medicare. Participating providers have signed an arrangement to accept assignment for all Medicare‑covered services. If your doctor participates, the Medigap insurance company is required to pay the doctor directly if you request. If your doctor doesn't participate but still accepts Medicare, you may be asked to pay the coinsurance amount at the time of service. In these cases, your Medigap insurance company will pay you directly according to policy limits. If you have any questions about Medigap claim filing, call 1‑800‑MEDICARE (1‑800‑633‑4227). TTY users can call 1‑877‑486‑2048.
21 21 SECTION Your Right to Buy a Medigap Policy What are guaranteed issue rights? Guaranteed issue rights are rights you have in certain situations when insurance companies must offer you certain Medigap policies when you 3 aren’t in your . In these situations, an Medigap Open Enrollment Period insurance company must: • Sell you a Medigap policy • Cover all your pre‑existing health conditions • Can’t charge you more for a Medigap policy regardless of past or present health problems If you live in Massachusetts, Minnesota, or Wisconsin, you have guaranteed issue rights to buy a Medigap policy, but the Medigap policies are different. See pages 42– 44 for your Medigap policy choices. When do I have guaranteed issue rights? In most cases, you have a guaranteed issue right when you have certain types of other health care coverage that changes in some way, like when you lose the other health care coverage. In other cases, you have a “trial right” to try a Medicare Advantage Plan and still buy a Medigap policy if you change your mind. For information on trial rights, see page 23 .
22 22 Your Right to Buy a Medigap Policy Section 3: This chart describes the most common situations, under federal law, that give you a right to buy a policy, the kind of policy you can buy, and when you can or must apply for it. States may provide additional Medigap guaranteed issue rights. You have the right You can/must apply for a You have a guaranteed issue right if... to buy... Medigap policy... Medicare Advantage Medigap Plan A, B, C, F, K, or As early as 60 calendar days You’re in a (like an HMO or PPO) , and before the date your health care Plan L that’s sold in your state by any insurance company. coverage will end, but no later your plan is leaving Medicare or than 63 calendar days after stops giving care in your area, or You only have this right if you your health care coverage ends. you move out of the plan’s service switch to Original Medicare area. Medigap coverage can’t start until rather than join another your Medicare Advantage Plan Medicare Advantage Plan. coverage ends. Medigap Plan A, B, C, F, K, or No later than 63 calendar days You have Original Medicare and L that’s sold in your state by any after the latest of these 3 dates: an employer group health plan insurance company. (including retiree or COBRA 1. Date the coverage ends. coverage) or union coverage that If you have COBRA coverage, pays after Medicare pays and that 2. Date on the notice you get you can either buy a Medigap plan is ending. telling you that coverage is policy right away or wait until ending (if you get one). the COBRA coverage ends. Note: In this situation, you may have additional rights under state 3. Date on a claim denial, if this l aw. is the only way you know that your coverage ended. As early as 60 calendar days before Medigap Plan A, B, C, F, K, or You have Original Medicare and the date your Medicare SELECT L that’s sold by any insurance policy. You a Medicare SELECT coverage will end, but no later company in your state or the move out of the Medicare SELECT than 63 calendar days after your state you’re moving to. policy’s service area. Medicare SELECT coverage ends. Call the Medicare SELECT insurer for more information about your options.
23 23 Your Right to Buy a Medigap Policy Section 3: This chart describes the most common situations, under federal law, that give you a right to buy a policy, the kind of policy you can buy, and when you can or must apply for it. (continued) States may provide additional Medigap guaranteed issue rights. You have the right You can/must apply for a You have a guaranteed to buy... Medigap policy... issue right if... Medicare Trial right ( ) You joined a As early as 60 calendar days before Any Medigap policy that s sold ’ (like an HMO or Advantage Plan the date your coverage will end, in your state by any insurance PPO) or Programs of All‑inclusive but no later than 63 calendar days company. Care for the Elderly (PACE) after your coverage ends. when you were first eligible for Your rights may last Note: Medicare Part A at 65, and within for an extra 12 months the first year of joining, you decide under certain circumstances. you want to switch to Original Medicare. As early as 60 calendar days before The Medigap policy you had (Trial right) You dropped a the date your coverage will end, before you joined the Medicare Medigap policy to join a Medicare but no later than 63 calendar days Advantage Plan or Medicare Advantage Plan (or to switch to a after your coverage ends. SELECT policy, if the same Medicare SELECT policy) for the insurance company you had first time, you ’ ve been in the plan Your rights may last Note: before still sells it. less than a year, and you want to for an extra 12 months switch back. under certain circumstances. If your former Medigap policy isn’t available, you can buy Medigap Plan A, B, C, F, K, or L that’s sold in your state by any insurance company. No later than 63 calendar days Medigap Plan A, B, C, F, K, or Your Medigap insurance company from the date your coverage ends. L that’s sold in your state by any goes bankrupt and you lose your insurance company. coverage, or your Medigap policy coverage otherwise ends through no fault of your own. No later than 63 calendar days Medigap Plan A, B, C, F, K, or You leave a Medicare Advantage from the date your coverage ends. L that’s sold in your state by any Plan or drop a Medigap policy insurance company. because the company hasn’t followed the rules, or it misled you.
24 24 Your Right to Buy a Medigap Policy Section 3: Can I buy a Medigap policy if I lose my health care coverage? guaranteed Yes, you may be able to buy a Medigap policy. Because you may have a to buy a Medigap policy, make sure you keep these: issue right A copy of any letters, notices, emails, and/or claim denials that have your name on • them as proof of your coverage being terminated. The postmarked envelope these papers come in as proof of when it was mailed. • You may need to send a copy of some or all of these papers with your Medigap application to prove you have a guaranteed issue right. but you’re planning (like an HMO or PPO) Medicare Advantage Plan If you have a to return to , you can apply for a Medigap policy before your plan Original Medicare coverage ends. The Medigap insurer can sell it to you as long as you’re leaving the Medicare Advantage Plan. Ask that the new policy take effect when your Medicare Advantage enrollment ends, so you’ll have continuous health coverage. For more information about Medigap rights If you have any questions or want to learn about any additional Medigap rights in your state, you can: • State Health Insurance Assistance Program Call your to make sure that you qualify . See pages 47– for these guaranteed issue rights. 48 if you’re denied Medigap coverage in any of • Call your State Insurance Department . these situations. See pages 47– 48 The guaranteed issue rights in this section are from federal law. Important: These rights are for both Medigap and Medicare SELECT policies. Many states provide additional Medigap rights. There may be times when more than one of the situations in the chart on applies to you. When this happens, you can choose the guaranteed pages 22–23 issue right that gives you the best choice. Some of the situations listed include loss of coverage under Programs of All‑inclusive Care for the Elderly (PACE). PACE combines medical, social, and long‑term care services, and prescription drug coverage for frail people. To be eligible for PACE, you must meet certain conditions. PACE may be available in states that have chosen it as Medicaid an optional benefit. If you have Medicaid, an insurance company can sell in certain situations. For more information about PACE, only you a Medigap policy visit , or call 1‑800‑MEDICARE (1‑800‑633‑4227). TTY users can call Medicare.gov 1‑877‑486‑2048.
25 25 SECTION Steps to Buying a Medigap Policy Step-by-step guide to buying a Medigap policy Buying a Medigap policy is an important decision. Only you can 4 Original decide if a Medigap policy is the way for you to supplement Medicare coverage and which Medigap policy to choose. Shop carefully. Compare available Medigap policies to see which one meets your needs. As you shop for a Medigap policy, keep in mind that different insurance companies may charge different amounts for exactly the same Medigap policy, and not all insurance companies offer all of the Medigap policies. Below is a step‑by‑step guide to help you buy a Medigap policy. If you live in Massachusetts, Minnesota, or Wisconsin, see pages 42– 44 . STEP 1: Decide which benefits you want, then decide which of the standardized Medigap policies meet your needs. STEP 2: Find out which insurance companies sell Medigap policies in your state. STEP 3: Call the insurance companies that sell the Medigap policies you’re interested in and compare costs. STEP 4: Buy the Medigap policy.
26 26 Section 4: Steps to Buying a Medigap Policy enefits you want, then STEP 1: Decide which b decide which M edigap policy meets your needs. Think about your current and future health care needs when deciding which benefits you want because you might not be able to switch Medigap policies later. Decide which benefits you need, and select the Medigap policy that will work best for you. The chart on page 11 provides an overview of Medigap benefits. ind out which insurance companies sell STEP 2: F edigap policies in your state. M To find out which insurance companies sell Medigap policies in your state: . . See pages 47– Call your 48 State Health Insurance Assistance Program • Ask if they have a “Medigap rate comparison shopping guide” for your state. This guide usually lists companies that sell Medigap policies in your state and their costs. Call your State Insurance Department . See pages 47– 48 . • Visit a ‑ plan : • Medicare.gov/find ‑ This website will help you find information on your health plan options, including the Medigap policies in your area. You can also get information on: 4 How to contact the insurance companies that sell Medigap policies in our state. y blue Words in What each Medigap policy covers. 4 are defined on 4 How insurance companies decide what to charge you for a Medigap pages 49–50. p olicy premium . If you don’t have a computer, your local library or senior center may be able to help you look at this information. You can also call 1‑800‑MEDICARE (1 4227). A customer service representative will help you get ‑ 633 ‑ 800 ‑ information on all your health plan options including the Medigap policies in your area. TTY users can call 1‑877‑486‑2048.
27 27 Section 4: Steps to Buying a Medigap Policy STEP 2: (continued) Since costs can vary between companies, plan to call more than one insurance company that sells Medigap policies in your state. Before you call, check the companies to be sure they’re honest and reliable by: Calling your • . Ask if they keep a record of State Insurance Department complaints against insurance companies that can be shared with you. When deciding which Medigap policy is right for you, consider these complaints, if any. • Calling your State Health Insurance Assistance Program . These programs can give you help at no cost to you with choosing a Medigap policy. Going to your local public library for help with: • – Getting information on an insurance company’s financial strength from independent rating services like weissratings.com, A.M. Best, and Standard & Poor’s. – Looking at information about the insurance company online. • Talking to someone you trust, like a family member, your insurance agent, or a friend who has a Medigap policy from the same Medigap insurance company.
28 28 Section 4: Steps to Buying a Medigap Policy Call the insurance companies that sell the Medigap STEP 3: policies you’re interested in and compare costs. Medigap Open Enrollment Period Before you call any insurance companies, figure out if you’re in your carefully. If you have questions, pages 14 –15 . Read guaranteed issue right or if you have a and 22–23 State Health Insurance Assistance Program . See pages 47– 48 . This chart can help you keep call your track of the information you get. Ask each insurance company... Company 2 Company 1 “Are you licensed in ___?” (Say the name of your state.) Note: If the answer is NO, STOP here, and try another company. “Do you sell Medigap Plan ___?” (Say the letter of the Medigap Plan you’re interested in.) Note: Insurance companies usually offer some, but not all, Medigap policies. Make sure the company sells the plan you want. Also, if you’re interested in a Medicare SELECT or high‑deductible Medigap policy, tell them. “Do you use medical underwriting for this Medigap policy?” Note: If the answer is NO, go to step 4 on page 30 . If the answer is YES, but you know you’re in your Medigap Open Enrollment Period or have a guaranteed issue right to buy that Medigap policy, go to step 4. Otherwise, you can ask, “Can you tell me if I'm likely to qualify for the Medigap policy?” ?” “Do you have a waiting period for pre‑existing conditions If the answer is YES, ask how long the waiting period is and write it Note: in the box. “Do you price this Medigap policy by using community‑rating, Community Community issue‑age‑rating, or attained‑age‑rating?” See page 18. Issue‑age Issue‑age Circle the one that applies for that insurance company. Note: Attained‑age Attained‑age “I’m ___ years old. What would my premium be under this Medigap policy?” Note: If it’s attained‑age, ask, “How frequently does the premium increase due to my age?” “Has the premium for this Medigap policy increased in the last 3 years due to inflation or other reasons?” Note: If the answer is YES, ask how much it has increased, and write it in the box. “Do you offer any discounts or additional benefits?” See page 19.
29 29 Section 4: Steps to Buying a Medigap Policy STEP 3: (continued) Watch out for illegal practices. It’s illegal for anyone to: • Pressure you into buying a Medigap policy, or lie to or mislead you to switch from one company or policy to another. • Sell you a second Medigap policy when they know that you already have one, unless you tell the insurance company in writing that you plan to cancel your existing Medigap policy. Sell you a Medigap policy if they know you have Medicaid , except in certain • situations. • Medicare Advantage Plan Sell you a Medigap policy if they know you’re in a (like an HMO or PPO) unless your coverage under the Medicare Advantage Plan will end before the effective date of the Medigap policy. Claim that a Medigap policy is a part of Medicare or any other federal program. • Medigap is private health insurance. • Claim that a Medicare Advantage Plan is a Medigap policy. • Sell you a Medigap policy that can’t legally be sold in your state. Check with your State Insurance Department see pages 47– 48 ) to make sure that the ( Medigap policy you’re interested in can be sold in your state. • Misuse the names, letters, or symbols of the U.S. Department of Health & Human Services (HHS), Social Security Administration (SSA), Centers for Medicare & Medicaid Services (CMS), or any of their various programs like Medicare. (For example, they can’t suggest the Medigap policy has been approved or recommended by the federal government.) • Claim to be a Medicare representative if they work for a Medigap insurance c omp any. • Original Sell you a Medicare Advantage Plan when you say you want to stay in Medicare and buy a Medigap policy. A Medicare Advantage Plan isn’t the same as Original Medicare. See page 5 . If you enroll in a Medicare Advantage Plan, you can’t use a Medigap policy. If you believe that a federal law has been broken, call the Inspector General’s hotline at 1‑800‑HHS‑TIPS (1‑800‑447‑8477). TTY users can call 1‑800‑377‑4950. Your State Insurance Department can help you with other insurance‑related problems.
30 30 Steps to Buying a Medigap Policy Section 4: STEP 4: Buy the Medigap policy. Once you decide on the insurance company and the Medigap policy you want, apply. The insurance company must give you a clearly worded summary of your Medigap policy. Read it carefully. If you don’t understand it, ask questions. Remember these when you buy your Medigap policy: Fill out the application carefully and completely, Filling out your application. • including medical questions. The answers you give will determine your guaranteed issue rights eligibility for an Open Enrollment Period or . If the insurance agent fills out the application, make sure it’s correct. If you buy a Medigap Open Enrollment Period Medigap policy during your or provide evidence that you’re entitled to a guaranteed issue right, the insurance company can’t use any medical answers you give to deny you a Medigap policy or change the price. The insurance company can’t ask you any questions about your family history or require you to take a genetic test. Paying for your Medigap policy. You can pay for your Medigap policy • by check, money order, or bank draft. Make it payable to the insurance company, not the agent. If buying from an agent, get a receipt with the insurance company’s name, address, and phone number for your records. Some companies may offer electronic funds transfer. Starting your Medigap policy. • Ask for your Medigap policy to become effective when you want coverage to start. Generally, Medigap policies begin the first of the month after you apply. If, for any reason, the insurance company won’t give you the effective date for the month you want, call your State Insurance Department See pages 47– 48 . . If you already have a Medigap policy, ask for your new Medigap policy Note: to become effective when your old Medigap policy coverage ends. If you don’t get your Medigap policy in 30 Getting your Medigap policy. • days, call your insurance company. If you don’t get your Medigap policy in 60 days, call your State Insurance Department.
31 31 SECTION If You Already Have a Medigap Policy Read this section if any of these situations apply to you: You’re thinking about switching to a different Medigap policy. • 5 See pages 32–35 . • You’re losing your Medigap coverage. See page 36 . • You have a Medigap policy with Medicare prescription drug coverage. See pages 36–38 . If you just want a refresher about Medigap insurance, turn to page 11 .
32 32 Section 5: If You Already Have a Medigap Policy Switching Medigap policies If you’re thinking about switching to a new Medigap policy, see below and pages 33–35 to answer some common questions. Can I switch to a different Medigap policy? In most cases, you won’t have a right under federal law to switch Medigap policies, unless you’re within your 6‑month Medigap Open Enrollment Period or are eligible under a specific circumstance for guaranteed issue . But, if your state has more generous requirements, or the insurance rights company is willing to sell you a Medigap policy, make sure you compare benefits and premiums before switching. If you bought your Medigap policy before 2010, it may offer coverage that isn’t available in a newer Medigap policy. On the other hand, Medigap policies bought before 1992 might not guaranteed renewable and might have bigger premium increases than be newer, standardized Medigap policies currently being sold. If you decide to switch, don’t cancel your first Medigap policy until you’ve decided to keep the second Medigap policy. On the application for the new Medigap policy, you’ll have to promise that you’ll cancel your first Medigap policy. You have 30 days to decide if you want to keep the new Medigap policy. This is called your “free look period.” The 30‑day free look period starts when you get your new Medigap policy. You’ll need to pay both premiums for one month. Words in blue are defined on pages 49–50.
33 33 Section 5: If You Already Have a Medigap Policy Switching Medigap policies (continued) Do I have to switch Medigap policies if I have a Medigap policy that's no longer sold? No. But you can’t have more than one Medigap policy, so if you buy a new Medigap policy, you have to give up your old policy (except for your 30‑day described on page 32 “free look period,” ). Once you cancel the old policy, you can’t get it back. Do I have to wait a certain length of time after I buy my first Medigap policy before I can switch to a different Medigap policy? No. If you’ve had your old Medigap policy for less than 6 months, the Medigap insurance company may be able to make you wait up to 6 months for coverage of a . However, if your old Medigap pre‑existing condition policy had the same benefits, and you had it for 6 months or more, the new insurance company can’t exclude your pre‑existing condition. If you’ve had your Medigap policy less than 6 months, the number of months you’ve had your current Medigap policy must be subtracted from the time you must wait before your new Medigap policy covers your pre‑existing condition. If the new Medigap policy has a benefit that isn’t in your current Medigap policy, you may still have to wait up to 6 months before that benefit will be covered, regardless of how long you’ve had your current Medigap policy. If you’ve had your current Medigap policy longer than 6 months and want to replace it with a new one with the same benefits and the insurance company agrees to issue the new policy, they can’t write pre‑existing conditions, waiting periods, elimination periods, or probationary periods into the replacement policy.
34 34 If You Already Have a Medigap Policy Section 5: Switching Medigap policies (continued) Why would I want to switch to a different Medigap policy? Some reasons for switching may include: You’re paying for benefits you don’t need. • • You need more benefits than you needed before. • Your current Medigap policy has the right benefits, but you want to change your insurance company. Your current Medigap policy has the right benefits, but you want to find a • policy that’s less expensive. It’s important to compare the benefits in your current Medigap policy to . If you live in Massachusetts, Minnesota, the benefits listed on page 11 . To help you compare benefits and decide or Wisconsin, see pages 42– 44 which Medigap policy you want, follow the “ Steps to Buying a Medigap ” in Section 4. If you decide to change insurance companies, you can Polic y call the new insurance company and apply for your new Medigap policy. If your application is accepted, call your current insurance company, and ask to have your coverage end. The insurance company can tell you how to submit a request to end your coverage. on page 32 , make sure your old Medigap policy coverage ends As explained you have the new Medigap policy for 30 days. Remember, this is your after for one month. premiums 30‑day free look period. You’ll need to pay both
35 35 Section 5: If You Already Have a Medigap Policy Switching Medigap policies (continued) Can I ep my current Medigap policy (or Medicare SELECT policy) or ke switch to a different Medigap policy if I move out-of-state? In general, you can keep your current Medigap policy regardless of where you live as long as you still have Original Medicare . If you want to switch to a different Medigap policy, you’ll have to check with your current or the new insurance company to see if they’ll offer you a different Medigap policy. You may have to pay more for your new Medigap policy and answer some medical questions if you’re buying a Medigap policy outside of your Medigap Open Enrollment Period . See pages 14–16. If you have a policy and you move out of the policy’s area, Medicare SELECT you can: • Buy a standardized Medigap policy from your current Medigap policy insurance company that offers the same or fewer benefits than your current Medicare SELECT policy. If you’ve had your Medicare SELECT policy for more than 6 months, you won’t have to answer any medical questions. Use your guaranteed issue right to buy any Plan A, B, C, F, K, or L that’s sold • in most states by any insurance company. Your state may provide additional Medigap rights. Call your State Health or State Department of Insurance for more Insurance Assistance Program information. See pages 47–78 for their phone numbers. What happens to my Medigap policy if I join a Medicare Advantage Plan? Medicare Advantage Plans . If you decide to Medigap policies can’t work with blue Words in premium , keep your Medigap policy, you’ll have to pay your Medigap policy are defined on , coinsurance , but the Medigap policy can’t pay any deductibles , copayments pages 49–50. or premiums under a Medicare Advantage Plan. So, if you join a Medicare Advantage Plan, you may want to drop your Medigap policy. Contact your Medigap insurance company to find out how to disenroll. However, if you leave the Medicare Advantage Plan you might not be able to get the same Medigap policy back, or in some cases, any Medigap policy unless you have a “trial right.” See page 23. Your rights to buy a Medigap policy may vary by state. You always have a legal right to keep the Medigap policy after you join a Medicare Advantage Plan. However, because you have a Medicare Advantage Plan, the Medigap policy would no longer provide benefits that supplement Medicare.
36 36 If You Already Have a Medigap Policy Section 5: Losing Medigap coverage Can my Medigap insurance company drop me? after 1992 , in most cases the Medigap If you bought your Medigap policy guaranteed insurance company can’t drop you because the Medigap policy is . This means your insurance company can’t drop you unless one of renewable these happens: You stop paying your • . premium • You weren’t truthful on the Medigap policy application. • The insurance company becomes bankrupt or insolvent. , it might not be guaranteed before 1992 If you bought your Medigap policy renewable. This means the Medigap insurance company can refuse to renew the Medigap policy, as long as it gets the state’s approval to cancel your Medigap policy. However, if this does happen, you have the right to buy another Medigap policy. See the . guaranteed issue right on page 23 Medigap policies and Medicare prescription drug coverage If you bought a Medigap policy before January 1, 2006, and it has coverage for prescription drugs, see below and page 37 . Medicare offers prescription drug coverage (Part D) for everyone with Medicare. If you have a Medigap policy with prescription drug coverage, that means you chose not to join a Medicare Prescription Drug Plan when you were first eligible. However, you can still join a Medicare drug plan. Your situation may have changed in ways that make a Medicare Prescription Drug Plan fit your needs better than the prescription drug coverage in your Medigap policy. It’s a good idea to review your coverage each fall, because you can join a Medicare Prescription Drug Plan between October 15–December 7. Your new coverage will begin on January 1.
37 37 Section 5: If You Already Have a Medigap Policy Medigap policies and Medicare prescription drug coverage (continued) What if I change my mind and join a Medicare Prescription Drug Plan? If your Medigap premium or your prescription drug needs were very low when you had your first chance to join a Medicare Prescription Drug Plan, your Medigap prescription drug coverage may have met your needs. However, if your Medigap premium or the amount of prescription drugs you use has increased recently, a Medicare Prescription Drug Plan might now be a better choice for you. In a , you may have to pay a monthly Medicare Prescription Drug Plan premium , but Medicare pays a large part of the cost. There’s no yearly maximum coverage amounts as with Medigap prescription drug benefits in old Plans H, I, and J (these plans are no longer sold). However, a Medicare Prescription Drug Plan might only cover certain prescription drugs (on its “formulary” or “drug list”). It’s important that you check whether your current prescription drugs are on the Medicare Prescription Drug Plan's list of covered prescription drugs before you join. Will I have to pay a late enrollment penalty if I join a Medicare Prescription Drug Plan now? If you qualify for Extra Help, you won’t pay a late enrollment penalty. If you don’t qualify for Extra Help, it will depend on whether your Medigap policy includes “creditable prescription drug coverage.” This means that the Medigap policy’s drug coverage pays, on average, at least as much as Medicare’s standard prescription drug coverage. If your Medigap policy's drug coverage i s n’ t creditable coverage, and you join a Medicare Prescription Drug Plan now, you’ll probably pay a higher premium (a penalty added to your monthly premium) than if you had joined when you were first eligible. Each month that you wait to join a Medicare Prescription Drug Plan will make your late enrollment penalty higher. Your Medigap carrier must send you a notice each year telling you if the prescription drug coverage in your Medigap policy is creditable. Keep these notices in case you decide later to join a Medicare Prescription Drug Plan. Also consider that your prescription drug needs could increase as you get older.
38 38 If You Already Have a Medigap Policy Section 5: Will I have to pay a late enrollment penalty if I join a Medicare Prescription Drug Plan now? (continued) If your Medigap policy includes creditable prescription drug coverage and you decide to join a Medicare Prescription Drug Plan , you won’t have to pay a late enrollment penalty as long as you don’t go 63 or more days in a row without creditable prescription drug coverage. So, don’t drop your Medigap policy before you join the Medicare Prescription Drug Plan and the coverage starts. In general, –December 7. However, you can only join a Medicare drug plan between October 15 guaranteed renewable , and if you lose your Medigap policy (for example, if it isn’t your company cancels it), you may be able to join a Medicare drug plan at the time you lose your Medigap policy. Can I join a Medicare Prescription Drug Plan and have a Medigap policy with prescription drug coverage? No. If your Medigap policy covers prescription drugs, you must tell your Medigap insurance company if you join a Medicare Prescription Drug Plan so it can remove the prescription drug coverage from your Medigap policy and . Once the drug coverage is removed, you can’t get that adjust your premium coverage back even though you didn’t change Medigap policies. What if I decide to drop my entire Medigap policy (not just the Medigap prescription drug coverage) and join a Medicare Advantage Plan that offers prescription drug coverage? Medicare In general, you can only join a Medicare Prescription Drug Plan or Advantage Plan (like an HMO or PPO) during the Medicare Open Enrollment Period between October 15 –December 7. If you join during Medicare Open Enrollment Period, your coverage will begin on January 1. In most cases, if you drop your Medigap policy to join a Medicare Advantage Plan, you won’t be able to get it back so pay careful attention to the timing.
39 39 SECTION Medigap Policies for People with a Disability or ESRD Information for people under 65 6 Medigap policies for people under 65 and eligible for Medicare because of a disability or End-Stage Renal Disease (ESRD) You may have Medicare before turning 65 due to a disability or ESRD (permanent kidney failure requiring dialysis or a kidney transplant). If you're under 65 and have Medicare because of a disability or ESRD, you might not be able to buy the Medigap policy you want, or any Medigap policy, until you turn 65. Federal law generally doesn’t require insurance companies to sell Medigap policies to people under 65. However, some states require Medigap insurance companies to sell you a Medigap policy, even if you’re under 65. These states are l isted on the next page . Important: This section provides information on the minimum federal standards. For your state requirements, call your State Health Insurance Assistance Program . See pages 47– 48 .
40 40 Medigap Policies for People with a Disability or ESRD Section 6: Medigap policies for people under 65 and eligible for Medicare because of a disability or End-Stage Renal Disease (ESRD) (continued) At the time of printing this guide, these states required insurance companies to offer at least one kind of Medigap policy to people with Medicare under 65: • Arkansas • Kentucky • New Jersey • California • Louisiana • New York • Colorado • Maine • North Carolina • Connecticut • Maryland • Oklahoma • Delaware • Massachusetts • Oregon • Florida • Michigan • Pennsylvania • Georgia • Minnesota • South Dakota • Hawaii • Mississippi • Tennessee • Illinois • Missouri • Texas • Idaho • Montana • Vermont • Kansas • New Hampshire • Wisconsin Note: Some states provide these rights to all people with Medicare under 65, while others only extend them to people eligible for Medicare because of disability or only to people with ESRD. Check with your State Insurance Department about what rights you might have under state law. Even if your state isn’t on the list above, some insurance companies may voluntarily sell Medigap policies to people under 65, although they’ll probably cost you more than Medigap policies sold to people over 65, and they can probably use medical underwriting . Also, some of the federal guaranteed rights are available to people with Medicare under 65, see pages 21–24. Check with your State Insurance Department about what additional rights you might have under blue Words in st ate l aw. are defined on Remember, if you’re already enrolled in Medicare Part B, you’ll get a Medigap pages 49–50. Open Enrollment Period when you turn 65. You'll probably have a wider choice at that time. During the of Medigap policies and be able to get a lower premium Medigap Open Enrollment Period, insurance companies can’t refuse to sell you any Medigap policy due to a disability or other health problem, or charge you a higher premium (based on health status) than they charge other people who are 65. Because Medicare (Part A and/or Part B) is creditable coverage, if you had Medicare for more than 6 months before you turned 65, you may not have a pre ‑ existing condition waiting period imposed for coverage bought during the Medigap Open Enrollment Period. For more information about the Medigap Open Enrollment Period and pre . If you have existing conditions, ‑ see pages 16 –17 See pages 47–48. . questions, call your State Health Insurance Assistance Program
41 41 SECTION Medigap Coverage in Massachusetts, Minnesota, and Wisconsin benefits ... 4 2 Massachusetts 7 Minnesota benefits ... 4 3 Wisconsin benefits ... 4 4
42 42 Section 7: Medigap Coverage Charts Massachusetts —Chart of standardized Medigap policies Massachusetts benefits plus coverage for 365 Inpatient hospital care: coinsurance covers the Medicare Part A • additional days after Medicare coverage ends covers the Medicare Part B coinsurance (generally 20% of the Medical costs: • Medicare‑approved amount ) • Blood: covers the first 3 pints of blood each year copayment • Part A hospice coinsurance or The check marks in this chart mean the benefit is covered. b enefits Medigap 1 Plan Supplement Core p lan Basic b enefits 3 3 Part A i npatient h ospital 3 d eductible killed Part A s ursing n 3 (SNF) c acility oinsurance f 3 eductible Part B d Foreign t ravel e mergency 3 d ays in m ental Inpatient 60 days per 120 days per h ealth h ospitals calendar year benefit year State‑ m andated b enefits 3 3 a nnual Pap tests and ( — mammograms heck your plan c ) for other state‑mandated benefits For more information on these Medigap policies, visit Medicare.gov/find‑a‑plan , or call your State Insurance Department . See pages 47– 48 .
43 43 Section 7: Medigap Coverage Charts Minnesota —Chart of standardized Medigap policies Minnesota benefits coinsurance • covers the Part A Inpatient hospital care: Medicare ‑ approved amount ) Medical costs: • covers the Part B coinsurance (generally 20% of the • Blood: covers the first 3 pints of blood each year Part A hospice and respite cost sharing • Parts A • and B home health services and supplies cost sharing The check marks in this chart mean the benefit is covered. Extended lan p Basic enefits b Medigap riders Mandatory plan basic 3 3 benefits Basic Insurance companies can offer 4 additional Part A inpatient 3 riders that can be added hospital deductible plan. You may to a basic 3 3 Part A skilled nursing facility (Provides 120 days of (Provides 100 days of choose any one or all of (SNF) coinsurance SNF care) SNF care) these riders to design 3 Part B deductible a Medigap policy that 80% 80%* travel emergency Foreign meets your needs : 20% 20% health mental Outpatient Part A 1. inpatient hospital deductible 80%* Usual and customary fees 2. deductible Part B 3 3 Medicare care ‑ preventive red cove 3. Usual and 20% 20% Physical therapy ees customary f Coverage while in a 80%* 4. Non ‑ Medicare country foreign preventive c are benefits State ‑ mandated 3 3 (diabetic equipment and supplies, routine cancer screening, reconstructive surgery, and immunizations) * Pays 100% after you spend $1,000 in out-of-pocket costs for a calendar year. Minnesota versions of Medigap Plans K, L, M, N, and high-deductible F are available. Important: The basic and extended basic benefits are available when you enroll in Part B, regardless of age or health problems. If you are under 65, return to work and drop Part B to elect your employer’s health plan, you ’ ll get a 6‑month Medigap Open Enrollment Period after you turn 65 and retire from that employer when you can join Part B again.
44 44 Section 7: Medigap Coverage Charts hart of standardized Medigap policies — C Wisconsin Wisconsin benefits Inpatient hospital care: covers the Part A coinsurance • covers the Part B coinsurance (generally 20% of the Medical costs: • ‑ approved amount ) Medicare • covers the first 3 pints of blood each year Blood: • Part A hospice coinsurance or copayment The check marks in this chart mean the benefit is covered. riders Optional enefits b Medigap Basic lan p Insurance companies are Basic benefits 3 allowed to offer these 7 additional Part A skilled nursing riders to a Medigap policy: 3 facility (SNF) coinsurance 1. Part A deductible 175 days per lifetime in Inpatient mental Additional home health 2. health coverage addition to Medicare’s care (365 visits including benefit those paid by Medicare) Part B deductible 3. Home health care in per year 40 visits addition to those paid 4. excess charges Part B by Medicare 5. Foreign travel emergency 50% Part A deductible 6. State ‑ mandated benefits 3 7. Part B copayment or coinsurance For more information on these Medigap policies, visit Medicare.gov/find ‑ a ‑ plan or call your State Insurance Department . 48 . See pages 47– sharing plans” are available. These plans are similar to Plans known as “50% and 25% cost ‑ high standardized Plans K (50%) and L (25%). A plan ($2,300 deductible for 2019) is ‑ deductible also available.
45 45 SECTION For More Information Where to get more information 8 On pages 47– 48 , you’ll find phone numbers for your State Health Insurance Assistance Program (SHIP) and State Insurance Department . • Call your SHIP for help with: – Buying a Medigap policy or long‑term care insurance. – Dealing with payment denials or appeals. – Medicare rights and protections. – Choosing a Medicare plan. – Deciding whether to suspend your Medigap policy. – Questions about Medicare bills. • Call your State Insurance Department if you have questions about the Medigap policies sold in your area or any insurance‑related problems.
46 46 For More Information Section 8: How to get help with Medicare and Medigap questions If you have questions about Medicare, Medigap, or need updated phone on pages 47– : 48 numbers for the contacts listed Visit Medicare.gov : . • For Medigap policies in your area, visit Medicare.gov/find‑a‑plan . Medicare.gov/contacts For updated phone numbers, visit • Call 1-800-MEDICARE (1-800-633-4227): Customer service representatives are available 24 hours a day, 7 days a week. TTY users can call 1‑877‑486‑2048. If you need help in a language other than English or Spanish, let the customer service representative know the language.
47 47 For More Information Section 8: State Health Insurance Assistance Program and State Insurance Department State State Health Insurance State Insurance Assistance Program Department 1‑800‑243‑5463 Alabama 1‑800‑433‑3966 1‑800‑478‑6065 Alaska 1‑800‑467‑8725 1‑6 3 3‑ 4116 ‑6 vailable American Samoa 84 Not a 1‑800‑432‑4040 1‑800‑325‑2548 Arizona 1‑800‑224‑6330 Arkansas 1‑800‑224‑6330 1‑800‑434‑0222 1‑800‑927‑4357 California Colorado 1‑888‑696‑7213 1‑800‑930‑3745 Connecticut 1‑ 800‑994‑9422 1‑800‑203‑3447 1‑800‑282‑8611 Delaware 1‑800‑336‑9500 1‑877‑693‑5236 Florida 1‑800‑963‑5337 552 ‑ 4464 66 1‑800‑656‑2298 Georgia 1‑8 ‑ 15 1‑671‑6 35 ‑1835 1‑671‑735‑7 Guam 4 1‑808‑586‑2790 1‑888‑875‑9229 Hawaii 1‑800‑721‑ Idaho 1‑800‑247‑4422 3272 1‑800‑252‑8966 1‑8 88 ‑4 73 ‑ 4858 Illinois 1‑800‑622‑4461 Indiana 1‑800‑452‑4800 877‑955‑1212 Iowa 1‑ 1‑800‑351‑4664 1‑800‑432‑2484 Kansas 1‑800‑860‑5260 Kentucky 1‑800‑595‑6053 1‑877‑293‑7447 0 1‑800‑259‑53 01 1‑800‑259‑530 Louisiana 1‑800‑300‑5000 Maine 1‑800‑262‑2232 1‑800‑ 1‑800‑243‑3425 Maryland 735‑2258 1‑877‑563‑4467 1‑800‑243‑4636 Massachusetts Michigan 1‑800‑803‑7174 1‑877‑999‑6442 Minnesota 1‑800‑333‑2433 1‑800‑657‑3602 601‑359‑4577 Mississippi 1‑ 1‑800‑562‑2957 1‑800‑390‑3330 1‑800‑726‑7390 Missouri Montana 1‑800‑551‑3191 1‑800‑332‑6148 Nebraska 1‑800‑234‑7119 1‑800‑234‑7119
48 48 For More Information Section 8: State State Health Insurance State Insurance Assistance Program Department 99 00 1‑8 1‑800‑307‑4444 Nevada 2‑ ‑ 0900 1‑800‑852‑3416 1‑866‑634‑9412 New Hampshire 800‑446‑7467 New Jersey 800‑792‑8820 1‑ 1‑ 1‑800‑432‑2080 72 7‑ 5772 ‑ New Mexico 88 1‑8 701‑0501 1‑800‑ 342‑3736 1‑800‑ New York 855‑408‑1212 1‑ 800‑546‑5664 North Carolina 1‑ 1‑800‑247‑0560 888‑575‑6611 1‑ North Dakota a vailable 1‑670‑664‑3064 Northern Mariana Not Islands Ohio 1‑800‑686‑1578 1‑800‑686‑1526 Oklahoma 1‑800‑763‑2828 1‑800‑522‑0071 1‑800‑722‑4134 Oregon 1‑888‑877‑4894 Pennsylvania 1‑800‑783‑7067 1‑877‑881‑6388 ‑8686 Puerto Rico 1‑877‑725‑4300 1‑888‑ 722 Rhode Island 888‑884‑8721 1‑401‑ 462 1‑ ‑ 9500 6160 ‑ 37 3 1‑80 1‑800‑868‑9095 South Carolina ‑7 ‑ 8197 1‑ 605 ‑ 773 ‑ 3563 1‑8 00 ‑ South Dakota 3 6 5 Tennessee 1‑877‑801‑0044 1‑800‑342‑4029 252‑3439 Texas 1‑800‑252‑9240 1‑800‑ ‑ ‑ 439 ‑ 3805 541 ‑ 00 1‑8 Utah 1‑8 7735 00 Vermont 1‑800‑642‑5119 1‑800‑ 964 ‑ 1784 1‑340‑772‑7368 1‑340‑774‑7166 Virgin Islands (St. 4 1‑340‑714‑435 Thomas) 1‑877‑310‑6560 1‑80 0 ‑ Virginia ‑ 3402 552 Washington 1‑800‑562‑6900 1‑800‑562‑6900 ‑ 1‑202‑727‑8000 Washington D.C. 1‑202‑ 994 6272 1‑888‑879‑9842 1‑877‑987‑4463 West Virginia 1‑800‑236‑8517 1‑800‑242‑1060 Wisconsin 1‑800‑856‑4398 1‑800‑438‑5768 Wyoming
49 49 SECTION Definitions BLUE Where words in are defined Assignment —An agreement by your doctor, provider, or supplier 9 to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance. Coinsurance —An amount you may be required to pay as your share of the costs for services after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%). Copayment —An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or a prescription drug. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor’s visit or prescription drug. —The amount you must pay for health care or Deductible prescriptions before Original Medicare, your prescription drug plan, or your other insurance begins to pay. —If you have Original Medicare, and the amount a Excess charge doctor or other health care provider is legally permitted to charge is higher than the Medicare‑approved amount, the difference is called the excess charge. Guaranteed issue rights —Rights you have in certain situations when insurance companies are required by law to sell or offer you a Medigap policy. In these situations, an insurance company can’t deny you a Medigap policy, or place conditions on a Medigap policy, such as exclusions for pre‑existing conditions, and can’t charge you more for a Medigap policy because of a past or present health problem.
50 50 Definitions Section 9: Guaranteed renewable policy —An insurance — (Part D) n la p rug d rescription p Medicare policy that can’t be terminated by the insurance Part D adds prescription drug coverage to company unless you make untrue statements to Original Medicare, some Medicare Cost Plans, the insurance company, commit fraud, or don’t pay some Medicare Private‑Fee‑for‑Service Plans, and your premiums. All Medigap policies issued since Medicare Medical Savings Account Plans. These 1992 are guaranteed renewable. plans are offered by insurance companies and other private companies approved by Medicare. Medicaid —A joint federal and state program that Medicare Advantage Plans may also offer helps with medical costs for some people with prescription drug coverage that follows the same limited income and resources. Medicaid programs escription Drug Plans. rules as Medicare Pr vary from state to state, but most health care costs are covered if you qualify for both Medicare and —A type of Medigap policy Medicare SELECT Medicaid. that may require you to use hospitals and, in some cases, doctors within its network to be —The process that an Medical underwriting eligible for full benefits. insurance company uses to decide, based on your medical history, whether or not to take Medigap Open Enrollment Period —A your application for insurance, whether or not to one‑time‑only, 6‑month period when federal law add a waiting period for pre‑existing conditions allows you to buy any Medigap policy you want (if your state law allows it), and how much to that’s sold in your state. It starts in the first month charge you for that insurance. that you’re covered under Medicare Part B, and you’re 65 or older. During this period, you can’t be Medicare Advantage Plan (Part C) —A type denied a Medigap policy or charged more due to of Medicare health plan offered by a private past or present health problems. Some states may company that contracts with Medicare to provide have additional Open Enrollment rights under you with all your Medicare Part A and Part B st ate l aw. benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred —The periodic payment to Medicare, an Premium Provider Organizations, Private Fee‑for ‑Service insurance company, or a health care plan for health Plans, Special Needs Plans, and Medicare Medical care or prescription drug coverage. Savings Account Plans. If you’re enrolled in a State Health Insurance Assistance Program Medicare Advantage Plan, Medicare services —A state program that gets money from (SHIP) are covered through the plan and aren’t paid the federal government to give free local health for under Original Medicare. Most Medicare insurance counseling to people with Medicare. Advantage Plans offer prescription drug coverage. State Insurance Department —A state agency —In Original Medicare-approved amount that regulates insurance and can provide Medicare, this is the amount a doctor or supplier information about Medigap policies and other that accepts assignment can be paid. It may be private health insurance. less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you're responsible for the difference.
51 Notice of Accessible Communications To help ensure people with disabilities have an equal opportunity to participate in our services, activities, programs, and other benefits, we provide communications in accessible formats. The Centers for Medicare & Medicaid Services (CMS) provides auxiliary aids and services, like publications, documents and communications, in Braille, large print, data/audio CD, relay services and TTY communications. CMS provides free auxiliary aids and services to help us better communicate with people with disabilities. Auxiliary aids include materials in Braille, audio/data CD or other accessible formats. Note: You can get the Choosing a Medigap Policy electronically in standard print, large print, or as an eBook. For Medicare publications, call us at 1‑800‑MEDICARE (1‑800‑633‑4227). TTY: 1‑877‑486‑2048. For all other CMS publications and documents, you can contact our Customer Accessibility Resource Staff: Call 1‑844‑ALT ‑FORM (1‑844‑258‑3676). TTY: 1‑844‑716‑3676. Send a fax to 1‑844‑530‑3676. Send an email to [email protected] Send a letter to: Centers for Medicare & Medicaid Services Offices of Hearings and Inquiries (OHI) 7500 Security Boulevard, Mail Stop S1‑13‑25 Baltimore, MD 21244‑1850 Attn: Customer Accessibility Resource Staff You can also contact the Customer Accessibility Resource staff: • To follow up on a previous accessibility request • If you have questions about the quality or timeliness of your previous request Note: Your request for a CMS publication or document should include: • Your name, phone number, and the mailing address where we should send the publications or documents. • The publication title and CMS Product No., if known. The format you need, like Braille, large print, or data/audio CD. • If you’re enrolled in a Medicare Advantage or Prescription Drug Plan, you can contact your plan to request Note: their documents in an accessible format. Nondiscrimination Notice CMS doesn’t exclude, deny benefits to, or otherwise discriminate against any person on the basis of race, color, national origin, disability, sex, or age in admission to, participation in, or receipt of the services and benefits under any of its programs and activities, whether carried out by CMS directly or through a contractor or any other entity with which CMS arranges to carry out its programs and activities. How to file a complaint If you believe you’ve been subjected to discrimination in a CMS program or activity, there are 3 ways to file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights: 1. Online at hhs.gov/civil‑rights/filing‑a‑complaint/complaint‑process/index.html. 2. By phone: Call 1‑800‑368‑1019. TDD user can call 1‑800‑537‑7697. 3. In writing: Send information about your complaint to: Office for Civil Rights U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201
52 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, Maryland 21244‑1850 Official Business Penalty for Private Use, $300 CMS Product No. 02110 Revised January 2019 To get this publication in Braille, Spanish, or large print (English), visit Medicare.gov, or call 1‑800‑MEDICARE (1‑800‑633‑4227). TTY users can call 1‑877‑486‑2048. ¿Necesita una copia en español? Visite Medicare.gov en el sitio Web. Para saber si esta publicación esta impresa y disponible (en español), llame GRATIS al 1‑800‑MEDICARE (1‑800‑633‑4227). Los usuarios de TTY deben llamar al 1‑877‑486‑2048.
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