medigap policy

What Is Covered – Part C “Medigap” (Supplemental Insurance)

What Is Covered – Part C “Medigap” (Supplemental Insurance)

A Medigap policy is private health insurance sold by private insurance companies specifically designed to supplement the Original Medicare Plan. It Offers:

· Added Coverage – Medigap policies cover certain things that Medicare doesn’t cover.

· Lowers Deductibles & Co-Pays – It helps pay some of the health care costs (”gaps”) that the Original Medicare Plan doesn’t cover.

· Standardized Plans – By law, insurance companies can offer only 12 standardized Medigap benefit packages, referred to as Plans A through L. That means that the only difference in any standardized plan, such as Plan J, from one insurance company to another is the price. The benefits are identical.

· Guaranteed Issue Rights – If you are in your Medigap open enrollment period, 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 or existing conditions, and can’t charge you more for a Medigap policy because of past or present health problems. You may also be able to buy a Medigap policy at other times, but the insurance company is allowed to 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 (such as if you already have Medicaid or a Medicare Advantage Plan).

· Guaranteed Renewable – Your insurance company must automatically renew or continue your Medigap policy, unless you make untrue statements to the insurance company, commit fraud, or don’t pay your premiums.

· Medigap policy only covers one person – If you and your spouse both want Medigap coverage, you each must buy separate Medigap policies.

· Every insurance company must make Medigap Plan A available if they offer any other Medigap policy.

· Not all types of Medigap policies may be available in your state. (e.g Massachussets, Minnesota, or Wisconsin).

· Medigap plans A – J must offer the following basic benefits:
Co-insurance for hospital days 61-90 – ($267/day in 2009) and
– Co-insurance for the 60 lifetime reserve days ($534/day in 2009).
– 100% of the cost of hospital care beyond 150 days covered by Medicare, up to a maximum of 365 lifetime days.
– 20% Co-insurance for Medicare approved charges after the $135 annual Part B Medicare deductible has been met.
– The first 3 pints of blood in each calendar year.
– Plan A has only the basic benefits.

The following Chart recaps Medigap coverage.

· If a check mark appears in the column, this means that the Medigap policy covers 100% of the described benefit.

· If the column lists a percentage, this means the Medigap policy covers that percentage of the described benefit.

· If no percentage appears or if the column is blank, this means the Medigap policy doesn’t cover that benefit.

· The Medigap policy covers coinsurance only after you have paid the deductible (unless the policy also covers the deductible).

Click Here for Medigap Plan A thru L Benefits info

*Medigap Plans F and J also offer a high-deductible option. You must pay the first $2,000 (high-deductible in 2009) in Medigap-covered costs before the Medigap policy pays anything.

** You must also pay a separate deductible for foreign travel emergency ($250 per year).

*** After you meet your out-of-pocket yearly limit and your yearly Part B deductible ($135 in 2008), the plan pays 100% of covered services for the rest of the calendar year.

Medicare Advantage Plans

These Plans provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) benefits and must cover at least all of the medically necessary services that the Original Medicare Plan provides. Medicare Advantage Plans, like HMOs and PPOs, are another way to get Medicare benefits. These plans are health plan options approved by Medicare and run by private companies.

Medicare Advantage Plans may offer extra benefits, such as vision, hearing, dental, and/or health and wellness programs, and most include Medicare prescription drug coverage (usually for an extra cost). Medicare Advantage Plans generally have provider networks. This means you probably have to see doctors who belong to the plan or go to certain hospitals to get covered services. You may need a referral to see specialists.

Medicare Advantage plans include:

· Medicare Preferred Provider Organization Plans (PPO)
A PPO is a specific group of doctors and/or hospitals that provides medical services. PPO members pay for services as they are rendered.

Are prescription drugs covered?
In most cases, yes. Ask the plan. If you want drug coverage, you must enroll in a PPO plan that offers prescription drug coverage.

Do I need to choose a primary care doctor?
No.

Can I get my health care from any doctor or hospital?
Yes. PPOs have network doctors and hospitals, but you can also use out-of-network providers for covered services, usually for a higher cost.

Do I have to see a primary care doctor to get a referral to see a specialist?
In most cases, no. What else do I need to know about this type of plan? You may be able to get extra benefits for an additional premium.

· Medicare Health Maintenance Organization Plans (HMO)

HMOs provide medical treatment on a prepaid basis regardless of how much medical care is needed. HMOs provide a wide variety of medical services, from office visits to hospitalization and surgery. With a few exceptions, HMO members must receive their medical treatment from physicians and facilities within the HMO network.

Are prescription drugs covered?
In most cases, yes. Ask the plan. If you want drug coverage, you must enroll in an HMO plan that offers prescription drug coverage.

Do I need to choose a primary care doctor?
Yes. You generally must see a primary care doctor to get a referral before you see any other health care provider.

Can I get my health care from any doctor or hospital?
No. You generally must get your care and services from doctors or hospitals in the plan’s network (except emergency or urgent care). If the plan has a point-of-service option, you can go out-of-network, but it will cost more.

Do I have to see a primary care doctor to get a referral to see a specialist?
In most cases, yes. Exceptions include yearly screening mammograms and in-network Pap tests and pelvic exams (at least every other year), which don’t require a referral.

What else do I need to know about this type of plan?
– If your doctor leaves, your plan will notify you, You can choose another doctor in the plan.
– If you get health care outside the plan’s network, you may have to pay the full cost.
– It’s important that you follow the plan’s rules, like getting prior authorization when needed.
– You may be able to get extra benefits for an extra premium.

· Medicare Private Fee-for-Service Plans (PFFS)

PFFS is a Medicare Advantage health plan offered by a state licensed risk bearing entity, which has a yearly contract with the Centers for Medicare & Medicaid Services to provide beneficiaries with all their Medicare benefits plus any additional benefits the company decides to provide. In most cases, people who join a PFFS are not required to use a network of providers. Beneficiaries can see any provider who is eligible to receive payment from Medicare and agrees to accept payment from the PFFS MAO.

Are prescription drugs covered?
Sometimes. If your PFFS Plan doesn’t offer drug coverage, you can join a Medicare Prescription Drug Plan to get coverage.

Do I need to choose a primary care doctor?
No.

Can I get my health care from any doctor or hospital?
In most cases, yes. You can go to any Medicare-approved doctor or hospital if they agree to the plan’s terms and conditions of payment before treating you. Not all providers will accept the plan’s payment terms or agree to treat you.

Do I have to see a primary care doctor to get a referral to see a specialist?
No.

What else do I need to know about this type of plan?
PFFS Plans aren’t the same as the Original Medicare Plan and they have different rules from other Medicare Advantage Plans.
– PFFS Plans are offered by private companies. The private company, not Medicare, decides how much the plan will pay and how much you pay for services.
– You may be able to get extra benefits for an extra premium.
– Before you join a PFFS Plan, make sure you find doctors, hospitals, and other types of providers willing to contact the plan for payment information and accept the plan’s payment terms.

· Medicare Special Needs Plans (SNP)

SNPs serve certain people with Medicare who are chronically ill with specific diseases or conditions (such as diabetes, congestive heart failure, mental illness, or HIV/AIDS), who live in institutions like nursing homes, or who have other special needs.

Are prescription drugs covered?
Yes. All SNPs must provide Medicare prescription drug coverage. Formularies may be designed to cover the drugs members need most.

Do I need to choose a primary care doctor?
In some cases, yes, or you may need to have a care coordinator help you develop personal care plans and coordinate your care.

Can I get my health care from any doctor or hospital?
You generally must get your care and services from doctors or hospitals in the plan’s network (except emergency or urgent care). Plans typically have specialists for the diseases or conditions that affect their members.

Do I have to see a primary care doctor to get a referral to see a specialist?
In most cases, yes. Yearly screening mammograms and an in-network Pap test and pelvic exam (at least every other year) don’t require a referral.

· Medicare Medical Savings Account Plans (MSA)

MSAs are two-part health insurance programs consisting of a high-deductible health insurance policy and a tax-free investment account set up to fund medical costs not covered by the policy.

Are prescription drugs covered?
No. You can join a Medicare Prescription Drug Plan to get drug coverage.

Do I need to choose a primary care doctor?
No.

Can I get my health care from any doctor or hospital?
Yes. Some plans may have network doctors and hospitals you could go to for a lower cost.

Do I have to see a primary care doctor to get a referral to see a specialist?
No.

What else do I need to know about this type of plan?
– if the year is added to your next deposit.
– Medicare MSA Plans have two parts: a high-deductible health plan and a bank account. Medicare gives the plan an amount each year for your health care, and the plan deposits a portion of this money into your account.
–You can use the money in your account to pay your health care costs. When you use account money for Medicare-covered Part A and Part B services, it counts toward your plan’s deductible. After you reach your deductible, your plan will cover your Medicare-covered services.

· If You Join a Medicare Advantage Plan:

You are still in the Medicare Program.You still have Medicare rights and protections, including the right to appeal.

You still get Part A and Part B coverage.

You generally still pay the monthly Part B premium. You also pay the Medicare Advantage Plan’s premium (if they charge one) that includes coverage for Part A and Part B benefits and prescription drug coverage (Part D, if offered), and any extra benefits (if offered).

You may have to use providers who belong to the plan. If you use providers who aren’t in the network, you may have to pay the entire cost of the covered service.

You must follow plan rules, like getting a referral to see a specialist or getting prior authorization for certain procedures. Check with the plan.

You usually will have to pay some other costs (such as copayments, deductibles, or coinsurance) for the services you get. Out-of-pocket costs in these plans cary by the services you get. Check with your plan before you get a service to find out what your costs may be.

You don’t need to (and can’t) buy a Medigap policy . It won’t cover your Medicare Advantage Plan deductibles, copayments, or coinsurance.

If you see a doctor who doesn’t belong to the plan, your services won’t be covered, or your costs could be higher.

The plan will send you an Evidence of Coverage each year. This document gives you details about what benefits the plan will cover, how much you pay, how to file an appeal, and more. Plan benefits may change each year. The plan will send you an Annual Notice of Change each fall. This notice has information about any changes in benefits, costs, or service area that will be effective in January. If the plan covers prescription drugs, the notice will include changes to the formulary. You should review this notice carefully to learn about changes for the upcoming year to decide if you want to look at other plans in your area.

Medicare offers prescription drug coverage for everyone with Medicare. This coverage is called “Part D”.

· To get Medicare drug coverage, you must either join a Medicare drug plan adding on to your Original Medicare Plan, or join a Medicare Advantage Plan that includes Part D.

· Medicare drug plans are run by insurance companies and other private companies approved by Medicare.

· Each plan can vary in cost and drugs covered.

· If you decide not to join a Medicare drug plan when you are first eligible, you may pay a late-enrollment penalty if you choose to join late.

· If you qualify for extra help and don’t choose a plan yourself, Medicare will enroll you in one.

All Medicare drug plans must generally cover at least two drugs in each category of drugs, but plans can choose which specific drugs are covered in each category. Plans are required to cover almost all drugs in six classes that include anti-psychotics, anti-depressants, anti-convulsants, immunosuppressants, cancer, and HIV/AIDS drugs.

There are certain drugs that Medicare drug plans aren’t required to cover, such as benzodiazepines, barbiturates, drugs for weight loss or gain, and drugs for erectile dysfunction. Some plans may choose to cover these drugs as an added benefit. In addition, drug plans generally aren’t allowed to cover over-the-counter drugs. Some states may cover these drugs if you have Medicaid.

Plans may also exclude certain drugs from coverage. Although your Medicare drug plan may not have a certain drug on its list of covered drugs (formulary), a different drug that is safe and effective for the same purpose will be covered. This may be a generic version of the drug, or it may be another brand-name drug that may provide the same benefit as the drug that isn’t on the plan’s formulary. All plans must have a process for you to ask them to pay for a drug you need that isn’t on their formulary. They may or may not agree to cover the drug.

What Is Not Covered

Items and services that Medicare doesn’t cover include, but are not limited to the following:

· Acupuncture,

· Chiropractic services (with some exceptions),

· Cosmetic surgery,

· Custodial care (such as help with bathing or using the bathroom), except when you also get skilled nursing care in a skilled nursing facility, at home, or in a hospice,

· Deductibles, co-insurance, or co-payments when you get certain health care services,

· Dental care and dentures (with only a few exceptions),

· Eye care (routine exam), eye refractions (exam that measures your ability to see at specific distances), and most eyeglasses (with some exceptions),

· Foot care (routine) like cutting corns or calluses (with few exceptions), Hearing aids and exams for the purpose of fitting a hearing aid, Hearing tests that haven’t been ordered by your doctor,

· Laboratory tests for screening purposes (with some exceptions), Long-term care, for example, if you only need custodial care in a nursing home,

· Orthopedic shoes (with few exceptions),

· Physical exams (routine or yearly). Medicare will cover a one-time physical exam within the first 6 months of enrolling in Part B (co-insurance and Part B deductible applies),

· Prescription drugs. Most precription drugs aren’t covered by Part A or Part B, Shots to prevent illness (with some exceptions),

· Syringes or insulin, unless the insulin is used with an insulin pump, but it may be covered by Medicare Prescription Drug Coverage (Part D), and

· Travel (health care while you’re traveling outside the United States… with some exceptions).

Medigap policies don’t cover long-term care (like care in a nursing home),

Jim Bigelow 918-640-4657

www.jimbigelow.com jim@jimbigelow.com

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