Medicare Choosing a Medigap Policy 2012.pdf

7/29/2019 Medicare Choosing a Medigap Policy 2012.pdf

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This ocial government guide has

important inormation about the ollowing:

WhatisaMedigap(MedicareSupplementInsurance)policy

WhatMedigappoliciescover

YourrightstobuyaMedigappolicy

HowtobuyaMedigappolicy

This guide can help if youre thinking about buying a Medigap policy or already have one.

DevelopedjointlybytheCentersforMedicare&MedicaidServices(CMS)andthe

NationalAssociationofInsuranceCommissioners(NAIC)


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How to use this guideTere are two ways to nd the inormation you need:

1. Te able o Contents can help you nd the sections you need.

2. Te List o opics lists topics in this guide and the page number o where tond them.

Note: Highlighted words are hyperlinked to denitions located at end o book.

Who should read this guide?

Tis guide helps people with Medicare understand Medigap (also called MedicareSupplement Insurance) policies. A Medigap policy is a type o private insurance thathelps you pay or some o the costs that Original Medicare doesnt cover.


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Section 1: Medicare Basics

A brie look at Medicare

What is Medicare?Te dierent parts o Medicare

Your Medicare coverage choices at a glance

Section 2: Medigap Basics

What is a Medigap policy?

What Medigap policies cover

What Medigap policies dont cover

ypes o coverage that are NO Medigap policies

What types o Medigap policies can insurance companies sell?

What do I need to know i I want to buy a Medigap policy?

When is the best time to buy a Medigap policy?

Why is it important to buy a Medigap policy when I'm rst eligible?

How do insurance companies set prices or Medigap policies?

What this pricing may mean or you

Comparing Medigap costs

What is Medicare SELEC?

How does Medigap help pay your Medicare Part B bills?

Section 3: Your Right to Buy a Medigap Policy

What are guaranteed issue rights?

When do I have guaranteed issue rights?

Can I buy a Medigap policy i I lose my health care coverage?

Section 4: Steps to Buying a Medigap Policy

Step-by-Step Guide to Buying a Medigap Policy
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Section 5: For People Who Already Have a Medigap Policy

Switching Medigap policies

Losing Medigap coverageMedigap policies and Medicare prescription drug coverage

Section 6: Medigap Policies or People with a Disability or ESRD

Inormation or people under 65

Section 7: Medigap Coverage in Massachusettes, Minnesota, and

Wisconsin

Massachusetts benets

Minnesota benetsWisconsin benets

Section 8: For More Inormation

Where to get more inormation

How to get help with Medicare and Medigap questions

State Health Insurance Assistance Program

State Insurance Department

Section 9: Defnitions

Where words in Blue are dened

Section 10: List o Topics

An alphabetical list o whats in this guide
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Section 1: Medicare Basics

A brie look at Medicare

Tis guide helps people with Medicare understand Medigap (also called MedicareSupplement Insurance) policies.

A Medigap policy is health insurance sold by private insurance companies to llgaps in Original Medicare coverage. Medigap policies can help pay your share(coinsurance, copayments, or deductibles) o the costs o Medicare-covered services.Some Medigap policies also cover certain benets Original Medicare doesnt cover.Medigap policies dont cover your share o the costs under other types o health

coverage, including Medicare Advantage Plans, stand-alone Medicare PrescriptionDrug Plans, employer/union group health coverage, Medicaid, Department oVeterans Aairs (VA) benets, or RICARE. Insurance companies generally cantsell you a Medigap policy i you have coverage through Medicaid or a MedicareAdvantage Plan.

Beore you learn more about Medigap policies, the next ew pages provide a brielook at Medicare. I you already know the basics about Medicare and only want tolearn about Medigap, skip to this section.


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6 Section 1Medicare Basics

What is Medicare?

Medicare is health insurance or the ollowing:

People 65 or older

People under 65 with certain disabilities

People o any age with End-Stage Renal Disease (ESRD) (permanent kidneyailure requiring dialysis or a kidney transplant)

The dierent parts o Medicare

Te dierent parts o Medicare help cover specic services:

Medicare Part A (Hospital Insurance)

Helps cover inpatient care in hospitals

Helps cover skilled nursing acility, hospice, and home health care

Medicare Part B (Medical Insurance)

Helps cover doctors and other health care providers services, outpatient care,durable medical equipment, and home health care

Helps cover some preventive services to help maintain your health and to keepcertain illnesses rom getting worse

Medicare Part C (also known as Medicare Advantage)

Oers health plan options run by Medicare-approved private insurance companies.

Medicare Advantage Plans are a way to get the benets and services covered underPart A and Part B. Most Medicare Advantage Plans cover Medicare prescription drugcoverage (Part D). Some Medicare Advantage Plans may include extra benets or anextra cost.


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Medicare Part D (Medicare Prescription Drug Coverage)

Helps cover the cost o prescription drugs

May help lower your prescription drug costs and help protect against higher costs

Run by Medicare-approved private insurance companies

Your Medicare coverage choices at a glance

Tere are two main ways to get your Medicare coverage: Original Medicare or aMedicare Advantage Plan. Use these steps to help you decide which way to get yourcoverage. See here or inormation about Medicare Advantage Plans and Medigappolicies.

Step 1: Decide how you want to get your coverage, Original Medicare or a

Medicare Advantage Plan (like an HMO or PPO).

Original Medicare includes Part A (Hospital Insurance) and/or Part B (MedicalInsurance).

Combines Part A, Part B, and usually Part D.

Step 2: Decide i you need to add drug coverage.

I you choose Original Medicare and you want drug coverage, you must join aMedicare Prescription Drug Plan (Part D).

I you choose a Medicare Advantage Plan, most will cover your prescriptiondrugs. You may be able to join a Medicare Prescription Drug Plan (Part D) insome plan types i not already included.

Step 3: Decide i you need to add supplemental coverage.

I you choose Original Medicare, you can choose to buy a Medicare SupplementInsurance (Medigap) policy.

I you join a Medicare Advantage Plan, you dont need and cant be sold aMedicare Supplement Insurance (Medigap) policy.


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For more inormation

Remember, this guide is about Medigap policies. o learn more about Medicare,visit www.medicare.gov/publications to view the Medicare & You handbook.You can also call 1-800-MEDICARE (1-800-633-4227). Y users should call1-877-486-2048.
http://www.medicare.gov/publicationshttp://www.medicare.gov/publications


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Section 2: Medigap Basics

What is a Medigap policy?

A Medigap policy (also called Medicare Supplement Insurance) is private healthinsurance thats designed to supplement Original Medicare. Tis means it helpspay some o the health care costs (gaps) that Original Medicare doesnt cover(like copayments, coinsurance, and deductibles). I you have Original Medicareand a Medigap policy, Medicare will pay its share o the Medicare-approvedamounts or covered health care costs. Ten your Medigap policy pays its share. AMedigap policy is dierent rom a Medicare Advantage Plan (like an HMO or PPO)because those plans are ways to get Medicare benets, while a Medigap policy onlysupplements your Original Medicare benets. Note: Medicare doesnt pay any o thecosts or you to get a Medigap policy.

Every Medigap policy must ollow Federal and state laws designed to protect you,and the policy must be clearly identied as Medicare Supplement Insurance.Medigap insurance companies in most states can only sell you a standardizedMedigap policy identied by letters A through N. Each standardized Medigap policymust oer the same basic benets, no matter which insurance company sells it. Costis usually the only dierence between Medigap policies with the same letter sold bydierent insurance companies.

In Massachusetts, Minnesota, and Wisconsin, Medigap policies arestandardized in a dierent way. See here or more inormation. In somestates, you may be able to buy another type o Medigap policy calledMedicare SELEC. SELEC plans are standardized plans that mayrequire you to see certain providers and may cost less than other plans.(More ino.)


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10 Section 2Medigap Basics

What Medigap policies cover

Te ollowing inormation gives you a quick look at the standardized Medigap Plans

available. Note:

Insurance companies selling Medigap policies are required to make Plan Aavailable. I they oer any other Medigap plan, they must also oer either MedigapPlan C or Plan F. Not all types o Medigap policies may be available in your state.See more ino i you live in Massachusetts, Minnesota, or Wisconsin. I you needmore inormation, call your State Insurance Department or State Health InsuranceAssistance Program. (More ino.)

Plans D and G Plans D and G eective on or aer June 1, 2010, have dierentbenets than D or G Plans bought beore June 1, 2010.

Plans No Longer or Sale Plans E, H, I, and J are no longer sold, but, i youalready have one, you can keep it.

Medigap Plans and Benefts

Note: Te Medigap policy covers coinsurance only aer you have paid the deductible(unless the Medigap policy also covers the deductible).

Benet: Medicare Part A Coinsurance and hospital costs up to an additional 365days aer Medicare benets are used up

Plan A: Covered Plan F*: Covered Plan M: Covered Plan B: Covered Plan G: Covered Plan N: Covered Plan C: Covered Plan K: Covered Plan D: Covered Plan L: Covered

Benet: Medicare Part B Coinsurance or Copayment Plan A: Covered Plan F*: Covered Plan M: Covered Plan B: Covered Plan G: Covered Plan N: Covered*** Plan C: Covered Plan K**: 50% Plan D: Covered Plan L**: 75%

Benet: Blood (First 3 Pints) Plan A: Covered Plan F*: Covered Plan M: Covered Plan B: Covered Plan G: Covered Plan N: Covered Plan C: Covered Plan K**: 50% Plan D: Covered Plan L**: 75%

Benet: Part A Hospice Care Coinsurance or Copayment Plan A: Covered Plan F*: Covered Plan M: Covered Plan B: Covered Plan G: Covered Plan N: Covered Plan C: Covered Plan K**: 50%

Plan D: Covered Plan L**: 75%


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Benet: Skilled Nursing Facility Care Coinsurance Plan A: not covered Plan B: not covered

Plan C: Covered Plan D: Covered

Plan F*: Covered Plan G: Covered

Plan K**: 50% Plan L**: 75%

Plan M: Covered Plan N: Covered

Benet: Medicare Part A Deductible Plan A: not covered Plan B: Covered Plan C: Covered Plan D: Covered

Plan F*: Covered Plan G: Covered Plan K**: 50% Plan L**: 75%

Plan M: 50% Plan N: Covered

Benet: Medicare Part B Deductible Plan A: not covered Plan B: not covered Plan C: Covered Plan D: not covered

Plan F*: Covered Plan G: not covered Plan K: not covered Plan L: not covered

Plan M: not covered Plan N: not covered

Benet: Medicare Part B Excess Charges Plan A: not covered Plan B: not covered Plan C: not covered Plan D: not covered

Plan F*: Covered Plan G: Covered Plan K: not covered Plan L: not covered

Plan M: not covered Plan N: not covered

Benet: Foreign ravel Emergency (Up to Plan Limits) Plan A: not covered Plan B: not covered Plan C: Covered Plan D: Covered

Plan F*: Covered Plan G: Covered Plan K: not covered Plan L: not covered

Plan M: Covered Plan N: Covered

*Plan F also oers a high-deductible plan. I you choose this option, this means you mustpay or Medicare-covered costs up to the deductible amount o $2,070 in 2012 beore yourMedigap plan pays anything.

**Out-o-Pocket Limit Plan or K=$4,660. Out-o-Pocket Limit or Plan L=$2,330. Aer

you meet your out-o-pocket yearly limit and your yearly Part B deductible ($140 in 2012),the Medigap plan pays 100% o covered services or the rest o the calendar year.

***Plan N pays 100% o the Part B coinsurance, except or a copayment o up to $20 orsome oce visits and up to a $50 copayment or emergency room visits that dont result inan inpatient admission.


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What Medigap policies dont cover

Generally, Medigap policies dont cover long-term care (like care in a nursing home),

vision or dental care, hearing aids, eyeglasses, or private-duty nursing.

Types o coverage that are NOT Medigap policies

Medicare Advantage Plans (Part C), like an HMO, PPO, or Private Fee-or-ServicePlan

Medicare Prescription Drug Plans (Part D)

Medicaid

Employer or union plans, including the Federal Employees Health Benets

Program (FEHBP) RICARE

Veterans benets

Long-term care insurance policies

Indian Health Service, ribal, and Urban Indian Health plans

What types o Medigap policies can insurance companies sell?

In most cases, Medigap insurance companies can sell you only a standardizedMedigap policy. All Medigap policies must have specic benets so you can comparethem easily. I you live in Massachusetts, Minnesota, or Wisconsin, see here or moreinormation.

Insurance companies that sell Medigap policies dont have to oer every Medigapplan. However, they must oer Medigap Plan A i they oer any Medigap policy. Ithey oer any plan in addition to Plan A, they must also oer Plan C or Plan F. Eachinsurance company decides which Medigap policies it wants to sell, although statelaws might aect which ones they oer.

In some cases, an insurance company must sell you a Medigap policy, even i youhave health problems. Listed below are certain times that youre guaranteed the rightto buy a Medigap policy:

When youre in your Medigap open enrollment period. (More ino.)

I you have a guaranteed issue right. (More ino.)

You may also buy a Medigap policy at other times, but the insurance company candeny you a Medigap policy based on your health. Also, in some cases it may beillegal or the insurance company to sell you a Medigap policy (such as i you alreadyhave Medicaid or a Medicare Advantage Plan).
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What do I need to know i I want to buy a Medigap policy?

You must have Medicare Part A and Part B to buy a Medigap policy.

I you have a Medicare Advantage Plan but are planning to return to OriginalMedicare, you can apply or a Medigap policy beore your coverage ends. TeMedigap insurer can sell it to you as long as youre leaving the plan. Ask that thenew policy start no later than when your Medicare Advantage Plan enrollmentends, so you will have continuous coverage.

Plans E, H, I, and J are no longer or sale, but you can keep these plans i youalready have one.

You pay the private insurance company a monthlypremium or your Medigappolicy in addition to the monthly Part B premium that you pay to Medicare.

A Medigap policy only covers one person. I you and your spouse both wantMedigap coverage,you each will have to buy separate Medigap policies.

You can buy a Medigap policy rom any insurance company thats licensed in yourstate to sell one.

I you want to buy a Medigap policy, see here to review the benet choices. Ten,ollow the Steps to Buying a Medigap Policy listed here.

I you want to drop your Medigap policy, write your insurance company to cancelthe policy and conrm its cancelled. Your agent cant cancel the policy or you.

Any standardized Medigap policy is guaranteed renewableeven i you have healthproblems. Tis means the insurance company cant cancel your Medigap policy aslong as you pay the premium.

Cost is usually the only dierence between Medigap policies with the same lettersold by dierent insurance companies.


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Although some Medigap policies sold in the past covered prescription drugs,Medigap policies sold aer January 1, 2006, arent allowed to include prescriptiondrug coverage.

I you want prescription drug coverage, you can join a Medicare PrescriptionDrug Plan (Part D) oered by private companies approved by Medicare. See hereor more inormation.

o learn about Medicare prescription drug coverage, visit www.medicare.gov/publications to view the booklet Your Guide to Medicare Prescription DrugCoverage, or call 1-800-MEDICARE (1-800-633-4227). Y users should call1-877-486-2048.

When is the best time to buy a Medigap policy?

Te best time to buy a Medigap policy is during your Medigap open enrollmentperiod. Tis period lasts or 6 months and begins on the rst day o the month inwhich youre both 65 or older and enrolled in Medicare Part B. Some states haveadditional open enrollment periods including those or people under 65. Duringthis period, an insurance company cant use medical underwriting. Tis means theinsurance company cant do any o the ollowing because o your health problems:

Reuse to sell you any Medigap policy it oers

Charge you more or a Medigap policy than they charge someone with no healthproblems

Make you wait or coverage to start (except as explained below)

While the insurance company cant make you wait or your coverage to start, it maybe able to make you wait or coverage related to a pre-existing condition. A pre-existing condition is a health problem you have beore the date a new insurancepolicy starts. In some cases, the Medigap insurance company can reuse to coveryour out-o-pocket costs or these pre-existing health problems or up to 6 months.Tis is called a pre-existing condition waiting period. Aer 6 months, the Medigappolicy will cover the pre-existing condition. Coverage or a pre-existing conditioncan only be excluded in a Medigap policy i the condition was treated or diagnosedwithin 6 months beore the date the coverage starts under the Medigap policy. Tisis called the look-back period. Aer the 6-month pre-existing waiting period,the Medigap policy will cover the condition that was excluded. Remember, orMedicare-covered services, Original Medicare will still cover the condition, even ithe Medigap policy wont cover your out-o-pocket costs, but youre responsible orthe coinsurance or copayment.
http://www.medicare.gov/publicationshttp://www.medicare.gov/publicationshttp://www.medicare.gov/publicationshttp://www.medicare.gov/publications


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I you have a pre-existing condition and you buy a Medigap policy during yourMedigap open enrollment periodand youre replacing certain kinds o healthcoverage that count as creditable coverage, its possible to avoid or shorten waiting

periods or pre-existing conditions. Prior creditable coverage is generally any otherhealth coverage you recently had beore applying or a Medigap policy. I you havehad at least 6 months o continuous prior creditable coverage, the Medigap insurancecompany cant make you wait beore it covers your pre-existing conditions.

Tere are many types o health care coverage that may count as creditable coverageor Medigap policies, but they will only count i you didnt have a break in coverageor more than 63 days.

alk to your Medigap insurance company. It will be able to tell you i your previous

coverage will count as creditable coverage or this purpose. You can also call yourState Health Insurance Assistance Program. (More ino.)

I you buy a Medigap policy when you have a guaranteed issue right (also calledMedigap protection), the insurance company cant use a pre-existing conditionwaiting period. (More ino.)

Note: I youre under 65 and have Medicare, generally because o a disability orESRD, you might not be able to buy the Medigap policy you want, or any Medigappolicy, until you turn 65. Federal law doesnt require insurance companies tosell Medigap policies to people under 65. However, some states require Medigap

insurance companies to sell you a Medigap policy, even i youre under 65. (Moreino.)
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Why is it important to buy a Medigap policy when I'm frst

eligible?

Its very important to understand your Medigap open enrollment period. Medigapinsurance companies are generally allowed to use medical underwriting to decidewhether to accept your application and how much to charge you or the Medigappolicy. However, i you apply during your Medigap open enrollment period, you canbuy any Medigap policy the company sells, even i you have health problems, orthe same price as people with good health. I you apply or Medigap coverage aeryour open enrollment period, there is no guarantee that an insurance company willsell you a Medigap policy i you dont meet the medical underwriting requirements,unless youre eligible because o one o the limited situations listed here.

Its also important to understand that your Medigap rights may depend on whenyou choose to enroll in Medicare Part B. I youre 65 or older, your Medigap openenrollment period begins when you enroll in Part B and cant be changed orrepeated. In most cases, it makes sense to enroll in Part B when youre rst eligible,because you might otherwise have to pay a Part B late enrollment penalty.

However, i you have group health coverage through an employer or union, becauseeither you or your spouse is currently working, you may want to wait to enroll inPart B. Tis is because employer plans oen provide coverage similar to Medigap,so you dont need a Medigap policy. When your employer coverage ends, you will

get a chance to enroll in Part B without a late enrollment penalty which means yourMedigap open enrollment period will start when youre ready to take advantage oit. I you enrolled in Part B while you still had the employer coverage, your Medigapopen enrollment period would start, and unless you bought a Medigap policy beoreyou needed it, you would miss your open enrollment period entirely. I you or yourspouse is still working and you have coverage through an employer, contact youremployer or union benets administrator to nd out how your insurance works withMedicare. (More ino.)
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How do insurance companies set prices or Medigap policies?

Each insurance company decides how it will set the price, or premium, or its

Medigap policies. Its important to ask how an insurance company prices its policies.Te way they set the price aects how much you pay now and in the uture. Medigappolicies can be priced or rated in three ways:

1. Community-rated (also called no-age-rated)

2. Issue-age-rated (also called entry-age-rated)

3. Attained-age-rated

Each o these ways o pricing Medigap policies is described in the chart on thenext page. Te examples show how your age aects your premiums, and why its

important to look at how much the Medigap policy will cost you now and in theuture. Te amounts in the examples arent actual costs. Other actors such asgeographical rating, medical underwriting, and discounts can also aect the amounto your premiums.

Type o pricing: Community-rated (also called no-age-rated)

How its priced: Generally the same monthly premium is charged to everyone whohas the Medigap policy, regardless o age.

What this pricing may mean or you: Your premium isnt based on your age.

Premiums may go up because o infation and other actors but not because o yourage.

Examples:

Mr. Smith is 65. He buys a Medigap policy and pays a $165 monthly premium.

Mrs. Perez is 72. She buys the same Medigap policy as Mr. Smith. She also pays a$165 monthly premium because, with this type o Medigap policy, everyone paysthe same price regardless o age.


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Type o pricing: Issue-age-rated (also called entry age-rated)

How its priced: Te premium is based on the age you are when you buy (areissued) the Medigap policy.

What this pricing may mean or you: Premiums are lower or people who buy ata younger age and wont change as you get older. Premiums may go up because oinfation and other actors but not because o your age.

Examples:

Mr. Han is 65. He buys a Medigap policy and pays a $145 monthly premium.

Mrs. Wright is 72. She buys the same Medigap policy as Mr. Han. Since she isolder when she buys it, her monthly premium is $175.

Type o pricing: Attained-age-rated

How its priced: Te premium is based on your current age (the age you haveattained), so your premium goes up as you get older.

What this pricing may mean or you: Premiums are low or younger buyers but goup as you get older. Tey may be the least expensive at rst, but they can eventuallybecome the most expensive. Premiums may also go up because o infation andother actors.

Examples:

Mrs. Anderson is 65. She buys a Medigap policy and pays a $120 monthlypremium.

At 66, her premium goes up to $126.



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. Andersons because itsbased on his current age. Mr. Dodds premium will go up each year.

At 73, his premium goes up to $171.

At 74, his premium goes up to $177.


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Comparing Medigap costs

As discussed on the previous pages, the cost o Medigap policies can vary widely.

Tere can be big diferences in the premiums that diferent insurance companiescharge or exactly the same coverage. As you shop or a Medigap policy, be sureto compare the same type o Medigap policy, and consider the type o pricing used.(More ino). For example, compare a Medigap Plan C rom one insurance companywith a Medigap Plan C rom another insurance company. Although this guidecant give actual costs o Medigap policies, you can get this inormation by callinginsurance companies or your State Health Insurance Assistance Program. (Moreino.)

You can also nd out which insurance companies sell Medigap policies in your area

by visiting www.medicare.gov/medigap.

Te cost o your Medigap policy may also depend on whether the insurancecompany does any o the ollowing:

Oers discounts (such as discounts or women, non-smokers, or people who aremarried; discounts or paying yearly; discounts or paying your premiums usingelectronic unds transer; or discounts or multiple policies).

Uses medical underwriting, or applies a dierent premium when you dont have aguaranteed issue right, or arent in a Medigap open enrollment period.

Sells Medicare SELEC policies that may require you to use certain providers. Iyou buy this type o Medigap policy, your premium may be less. See page 20.

Oers a high-deductible option or Medigap Plan F. I you buy MedigapPlan F with a high-deductible option, you must pay the rst $2,070 (in 2012)odeductibles, copayments, and coinsurance not paid by Medicare beore theMedigap policy pays anything. You must also pay a separate deductible ($250 peryear) or oreign travel emergency services.

I you bought your Medigap Plan J beore January 1, 2006, and it still coversprescription drugs, you would also pay a separate deductible ($250 per year) or

prescription drugs covered by the Medigap policy. And, i you have a Plan J witha high deductible option, you must pay a $2,070 deductible beore the policy paysanything.
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What is Medicare SELECT?

Medicare SELEC is a type o Medigap policy sold in some states that requires you

to use hospitals and, in some cases, doctors within its network to be eligible or ullinsurance benets (except in an emergency). Medicare SELEC can be any o thestandardized Medigap Plans. (More ino). Tese policies generally cost less thanother Medigap policies. However, i you dont use a Medicare SELEC hospitalor doctor or non-emergency services, you will have to pay some or all o whatMedicare doesnt pay. Medicare will pay its share o approved charges no matterwhich hospital or doctor you choose.

How does Medigap help pay your Medicare Part B bills?

In most Medigap policies, when you sign the Medigap insurance contract you agreeto have the Medigap insurance company get your Medicare Part B claim inormationdirectly rom Medicare, and then they pay the doctor directly. Some Medigapinsurance companies also provide this service or Medicare Part A claims.

I your Medigap insurance companydoesnt provide this service, ask your doctorsi they participate in Medicare. Tis means that they accept assignment or allMedicare patients. I your doctor participates, the Medigap insurance company isrequired to pay the doctor directly i you request.

I you have any questions about Medigap claim ling, call 1-800-MEDICARE (1-800-633-4227). Y users should call 1-877-486-2048.


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Section 3: Your Right to Buy a

Medigap PolicyWhat are guaranteed issue rights?

As explained on pages 1416, the best time to buy a Medigap policy is during yourMedigap open enrollment period, when you have the right to buy any Medigappolicy oered in your state. However, even i you arent in your Medigap openenrollment period, there are several situations in which you may still have aguaranteed right to buy a Medigap policy i youre 65 or older. (More Ino.)

Guaranteed issue rights(also called Medigap protections) are rights you havein certain situations when insurance companies must oer you certain Medigappolicies. In these situations, an insurance company must do the ollowing:

Sell you a Medigap policy

Cover all your pre-existing health conditions

Cant charge you more or a Medigap policy regardless o past or present healthproblems

I you live in Massachusetts, Minnesota, or Wisconsin, you have guaranteed issue

rights to buy a Medigap policy, but the Medigap policies are dierent. See hereoryour Medigap policy choices.

When do I have guaranteed issue rights?

In most cases, you have a guaranteed issue right when you have other health carecoverage that changes in some way, such as when you lose the other health carecoverage. In other cases, you have a trial right to try a Medicare AdvantagePlan and still buy a Medigap policy i you change your mind. See here or moreinormation about trail rights..
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22 Section 3Your Right to Buy a Medigap Policy

An insurance company cant reuse to sell you a Medigap policy in

the ollowing situations:

1. You have a guaranteed issue right iyoure in a Medicare Advantage Plan, and yourplan is leaving Medicare or stops giving care in your area, or you move out o the plansservice area.

You have the right to buy Medigap Plan A, B, C, F, K, or L thats sold in your state by anyinsurance company. You only have this right i you switch to Original Medicare ratherthan join another Medicare Advantage Plan.

You can/must apply or a Medigap policy as early as 60 calendar days beore the date yourhealth care coverage will end, but no later than 63 calendar days aer your health care

coverage ends. Medigap coverage cant start until your Medicare Advantage Plan coverageends.

2. You have a guaranteed issue right iyou have Original Medicare and an employer grouphealth plan (including retiree or COBRA coverage) or union coverage that pays aer Medicare

pays and that plan is ending. Note: In this situation, you may have additional rights under state law

You have the right to buyMedigap Plan A, B, C, F, K, or L thats sold in your state by anyinsurance company. I you have COBRA coverage, you can either buy a Medigap policy right

away or wait until the COBRA coverage ends.

You can/must apply or a Medigap policyno later than 63 calendar days aer the latest othese 3 dates:

1. Date the coverage ends

2. Date on the notice you get telling you that coverage is ending (i you get one)

3. Date on a claim denial, i this is the only way you know that your coverage ended

3. You have a guaranteed issue right iYou have Original Medicare and a Medicare SELECpolicy. You move out o the Medicare SELEC policys service area. Call the Medicare SELEC

insurer or more inormation about your options.

You have the right to buyMedigap Plan A, B, C, F, K, or L thats sold by any insurancecompany in your state or the state youre moving to.

You can/must apply or a Medigap policyas early as 60 calendar days beore the date yourMedicare SELEC coverage will end, but no later than 63 calendar days aer your Medicare

SELEC coverage ends.


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4. You have a guaranteed issue right i(rial Right) you joined a Medicare AdvantagePlan or Programs o All-inclusive Care or the Elderly (PACE) when you were rsteligible or Medicare Part A at 65, and within the rst year o joining, you decide you

want to switch to Original Medicare.

You have the right to buy any Medigap policy thats sold in your state by any insurancecompany.

You can/must apply or a Medigap policy as early as 60 calendar days beore the date yourcoverage will end, but no later than 63 calendar days aer your coverage ends.

Note: Your rights may last or an extra 12 months under certain circumstances.

5. You have a guaranteed issue right i(rial Right) you dropped a Medigap policy to

join a Medicare Advantage Plan (or to switch to a Medicare SELEC policy) or the rsttime, you have been in the plan less than a year, and you want to switch back.

You have the right to buy the Medigap policy you had beore you joined the MedicareAdvantage Plan or Medicare SELEC policy, i the same insurance company you hadbeore still sells it. I your ormer Medigap policyisnt available, you can buy MedigapPlan A, B, C, F, K, orL thats sold in your state by any insurance company.

You can/must apply or a Medigap policy As early as 60 calendar days beore the dateyour coverage will end, but no later than 63 calendar days aer your coverage ends.

Note: Your rights may last or an extra 12 months under certain circumstances.

6. You have a guaranteed issue right iyour Medigap insurance company goes bankruptand you lose your coverage, or your Medigap policy coverage otherwise ends through noault o your own.

You have the right to buyMedigap Plan A, B, C, F, K, or thats sold in your state by anyinsurance company.

You can/must apply or a Medigap policyno later than 63 calendar days rom the date yourcoverage ends.

7. You have a guaranteed issue right iyou leave a Medicare Advantage Plan or drop aMedigap policy because the company hasnt ollowed the rules, or it misled you.

You have the right to buyMedigap Plan A, B, C, F, K, or L thats sold in your state by anyinsurance company.

You can/must apply or a Medigap policyno later than 63 calendar days rom the date yourcoverage ends.


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Can I buy a Medigap policy i I lose my health care coverage?

Because you may have a guaranteed issue right to buy a Medigap policy, make sure

you keep the ollowing: A copy o any letters, notices, emails, and/or claim denials that have your name on

them as proo o your coverage being terminated

Te postmarked envelope these papers come in as proo o when it was mailed

You may need to send a copy o some or all o these papers with your Medigapapplication to prove you have a guaranteed issue right.

I you have a Medicare Advantage Plan but youre planning to return to OriginalMedicare, you can apply or a Medigap policy beore your coverage ends. TeMedigap insurer can sell it to you as long as youre leaving the plan. Ask that the newpolicy take eect no later than when your Medicare Advantage enrollment ends, soyou will have continuous coverage.

For more inormation

I you have any questions or want to learn about any additional Medigap rights inyour state, you can do the ollowing:

Call your State Health Insurance Assistance Program to make sure that you

qualiy or these guaranteed issue rights. (More ino.) Call your State Insurance Department i youre denied Medigap coverage in any o

these situations. (More ino.)

Important: Te guaranteed issue rights in this section are rom Federallaw. Tese rights are or both Medigap and Medicare SELEC policies.Many states provide additional Medigap rights.

Tere may be times when more than one o the situations in the chart listed hereapplies to you. When this happens, you can choose the guaranteed issue right that

gives you the best choice.

Some o the situations listed here include loss o coverage under Programs o All-inclusive Care or the Elderly (PACE). PACE combines medical, social, and long-term care services, and prescription drug coverage or rail people. o be eligibleor PACE, you must meet certain conditions. PACE may be available in states thathave chosen it as an optional Medicaid benet. I you have Medicaid, an insurancecompany can sell you a Medigap policyonlyin certain situations. For moreinormation about PACE, call 1-800-MEDICARE (1-800-633-4227). Y usersshould call 1-877-486-2048.
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Section 4: Steps to Buying a

Medigap PolicyStep-by-Step Guide to Buying a Medigap Policy

Buying a Medigap policyis an important decision. Only you can decide i aMedigap policy is the way or you to supplement Original Medicare coverage andwhich Medigap policy to choose. Shop careully. Compare available Medigap policiesto see which one meets your needs. As you shop or a Medigap policy, keep inmind that dierent insurance companies may charge dierent amounts or exactlythe same Medigap policy, and not all insurance companies oer all o the Medigap

policies.

Below is a step-by-step guide to help you buy a Medigap policy. I you live inMassachusetts, Minnesota, or Wisconsin, see here.

SEP 1: Decide which benets you want, then decide which o the Medigap PlansA through N meet your needs.

SEP 2: Find out which insurance companies sell Medigap policies in your state.

SEP 3: Call the insurance companies that sell the Medigap policies youre

interested in and compare costs.SEP 4: Buy the Medigap policy.


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26 Section 4Steps to Buying a Medigap Policy

STEP 1: Decide which benefts you want, then decide which

o the Medigap Plans meets your needs.

You should think about your current and uture health care needs when decidingwhich benets you want because you might not be able to switch Medigap policieslater. Decide which benets you need, and select the Medigap policy that willwork best or you. Te chart on page 11 provides an overview o Medigap benets.

STEP 2: Find out which insurance companies sell Medigap

policies in your state.

o nd out which insurance companies sell Medigap policies in your state, you

can do any o the ollowing: Call your State Health Insurance Assistance Program. (More ino.) Ask i they

have a Medigap rate comparison shopping guide or your state. Tis guideusually lists companies that sell Medigap policies in your state and their costs.

Call your State Insurance Department. (More ino.)

Visit www.medicare.gov/medigap.

Tis Web site will help you nd inormation on all your health plan options,including the Medigap policies in your area. You can also get inormation onthe ollowing:

How to contact the insurance companies that sell Medigap policies in yourstate

What each Medigap policy covers

How insurance companies decide what to charge you or a Medigap policypremium

I you dont have a computer, your local library or senior center may be able tohelp you look at this inormation. You can also call 1-800-MEDICARE (1-800-633-4227). A customer service representative will help you get inormation on

all your health plan options including the Medigap policies in your area. Yusers should call 1-877-486-2048.
http://www.medicare.gov/medigaphttp://www.medicare.gov/medigap


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Since costs can vary between companies, you should plan to call more than oneinsurance company that sells Medigap policies in your state. Beore you call, checkthe companies to be sure theyre honest and reliable by using one o the resources

listed below.

Call your State Insurance Department. Ask i they keep a record o complaintsagainst insurance companies that can be shared with you. When deciding whichMedigap policy is right or you, consider any complaints against the insurancecompany.

Call your State Health Insurance Assistance Program. Tese programs can giveyou ree help with choosing a Medigap policy.

Go to your local public library or help with the ollowing:

Getting inormation on an insurance companys nancial strength romindependent rating services such as Te Street.com Ratings, A.M. Best, andStandard & Poors.

Looking at inormation about the insurance company online.

alk to someone you trust, like a amily member, your insurance agent, or a riendwho has a Medigap policy rom the same Medigap insurance company.
http://www.thestreet.com/http://www.thestreet.com/


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STEP 3: Call the insurance companies that sell the Medigap

policies youre interested in and compare costs.

Beore you call any insurance companies, gure out i youre in your Medigapopen enrollment period or i you have a guaranteed issue right. Read here andhere careully. I you have questions, call your State Health Insurance AssistanceProgram. (More ino.) Use the ollowing questions as a guideline when interviewinginsur and take notes or each company contacted:

Ask each insurance company

Are you licensed in ___? (Say the name o your state.)

Note: I the answer is NO, stop right here, and try another company.Do you sell Medigap Plan ___? (Say the letter o the Medigap Plan youreinterested in.)Note: Insurance companies usually oer some, but not all, Medigap policies. Makesure the company sells the plan you want. Also, i youre interested in a MedicareSELEC or high-deductible Medigap policy, say so.

Do you use medical underwriting or this Medigap policy?Note: I the answer is NO, go to step 4. I the answer is YES, but you know youre inyour 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 whether I amlikely to qualiy or the Medigap policy?

Do you have a waiting period or pre-existing conditions?Note: I the answer is YES, ask how long the waiting period is and write it in thebox.

Do you price this Medigap policy by using community-rating, issue-age-rating, orattained-age-rating? (More ino.)

I am ___ years old. What would my premium be under this Medigap policy?

Note: I its attained-age, ask, How requently does the premium increase due to myage?

Has the premium or this Medigap policy increased in the last 3 years due toinfation or other reasons?Note: I the answer is YES, ask how much it has increased, and write it in the box.Do you oer any discounts or additional (innovative) benets? (More ino.)

Is there any extra charge to process my claims automatically?


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Watch out or illegal insurance practices.

Its illegal or anyone to do the ollowing:

Pressure you into buying a Medigap policy, or lie to or mislead you to switch romone 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 yourexisting Medigap policy.

Sell you a Medigap policy i they know you have Medicaid, except in certainsituations.

Sell you a Medigap policy i they know youre in a Medicare Advantage Plan (like

an HMO, PPO, or Private Fee-or-Service Plan) unless your coverage under theMedicare Advantage Plan will end beore the eective date o the Medigap policy.

Claim that a Medigap policy is part o the Medicare Program or any other Federalprogram. Medigap is private health insurance.

Claim that a Medicare Advantage Plan is a Medigap policy.

Sell you a Medigap policy that cant legally be sold in your state. Check with yourState Insurance Department(more ino) to make sure that the Medigap policyyoure interested in can be sold in your state.

Misuse the names, letters, or symbols o the U.S. Department o Health & Human

Services (HHS), Social Security Administration (SSA), Centers or Medicare& Medicaid Services (CMS), or any o their various programs like Medicare.(For example, they cant suggest the Medigap policy has been approved orrecommended by the Federal government.)

Claim to be a Medicare representative i they work or a Medigap insurancecompany.

Sell you a Medicare Advantage Plan when you say you want to stay in OriginalMedicare and buy a Medigap policy. A Medicare Advantage Plan isnt the same asOriginal Medicare. (More ino.) I you enroll in a Medicare Advantage Plan, you

cant use a Medigap policy.

I you believe that a Federal law has been broken, call the Inspector Generals hotlineat 1-800-HHS-IPS (1-800-447-8477). Y users should call 1-800-377-4950. YourState Insurance Department can help you with other insurance-related problems.


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STEP 4: Buy the Medigap policy.

Once you decide on the insurance company and the Medigap policy you want, you

should apply. Te insurance company must give you a clearly worded summary oyour Medigap policy. Read it careully. I you dont understand it, ask questions.Remember the ollowing when you buy your Medigap policy:

Filling out your application. Fill out the application careully and completely,including medical questions. Te answers you give will determine your eligibilityor open enrollment or guaranteed issue rights. I the insurance agent lls outthe application, make sure its correct. I you buy a Medigap policy during yourMedigap open enrollment period or provide evidence that youre entitled to aguaranteed issue right, the insurance company cant use any medical answers you

give to deny you a Medigap policy or change the price. Te insurance companycant ask you any questions about your amily history or require you to take agenetic test.

Paying or your Medigap policy. Its best to pay or your Medigap policy bycheck, money order, or bank dra. Make it payable to the insurance company,not the agent. I buying rom an agent, get a receipt with the insurance companysname, address, and phone number or your records. Some companies may oerelectronic unds transer.

Starting your Medigap policy. Ask or your Medigap policy to become eective

when you want coverage to start. Generally, Medigap policies begin the rst o themonth aer you apply. I, or any reason, the insurance company wont give youthe eective date or the month you want, call your State Insurance Department.(More ino.)

Note: I you already have a Medigap policy, ask or your new Medigap policy tobecome eective when your old Medigap policy coverage ends.

Getting your Medigap policy. I you dont get your Medigap policy in 30 days,call your insurance company. I you dont get your Medigap policy in 60 days, callyour State Insurance Department.

I you already have a Medigap policy, its illegal or an insurance company to sell youa second policy unless you tell them in writing that you will cancel the rst Medigappolicy. However, dont cancel your old Medigap policy until the new one is in place,and you decide to keep it. (More ino.) Once you get the new Medigap policy, youhave 30 days to decide i you want to keep the new policy. Tis is called your reelook period. Te 30-day ree look period begins on the day you get your Medigappolicy. You will need to pay both premiums or one month.
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Section 5: For People WhoAlready Have a Medigap PolicyYou should read this section i any o these situations apply to you:

Youre thinking about switching to a dierent Medigap policy. (More ino.)

Youre losing your Medigap coverage. (More ino.)

You have a Medigap policy with Medicare prescription drug coverage. (Moreino.)

I you just want a reresher about Medigap insurance, see here.


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Switching Medigap policies

I youre satised with your current Medigap policys cost, coverage, and customer

service, you dont need to do anything. I youre thinking about switching to a newMedigap policy, see below to answer some common questions about switchingMedigap policies.

Can I switch to a diferent Medigap policy?

In most cases, you wont have a right under Federal law to switch Medigap policies,unless youre within your 6-month Medigap open enrollment period or are eligibleunder a specic circumstance or guaranteed issue rights. But, i your state has moregenerous requirements, or the insurance company is willing to sell you a Medigappolicy, make sure you compare benets and premiumsbeore switching. I youbought your Medigap policy beore 2010, it may oer coverage that isnt available ina newer Medigap policy. On the other hand, Medigap policies bought beore 1992might not be guaranteed renewable and might have bigger premium increases thannewer, standardized Medigap policies currently being sold.

I you decide to switch, dont cancel your rst Medigap policy until you have decidedto keep the second Medigap policy. On the application or the new Medigap policy,you will have to promise that you will cancel your rst Medigap policy. You have 30days to decide i you want to keep the new Medigap policy. Tis is called your reelook period. Te 30-day ree look period starts when you get your new Medigappolicy. You will need to pay both premiums or one month.
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Do I have to switch Medigap policies i I have an older Medigap policy?

No. But i you buy a new Medigap policy, you have to give up your old policy (except

or your 30-day ree look period, described here). Once you cancel the policy, youcant get it back, and it can no longer be sold because it isnt a standardized policy.

Do I have to wait a certain length o time aer I buy my rst Medigap policybeore I can switch to a diferent Medigap policy?

No. You should be aware that i youve had your old Medigap policy or less than6 months, the Medigap insurance company may be able to make you wait up to6 months or coverage o a pre-existing condition. However, i your old Medigappolicy had the same benets, and you had it or 6 months or more, the newinsurance company cant exclude your pre-existing condition. I youve had your

Medigap policy less than 6 months, the number o months youve had your currentMedigap policy must be subtracted rom the time you must wait beore your newMedigap policy covers your pre-existing condition.

I the new Medigap policy has a benet that isnt in your current Medigap policy, youmay still have to wait up to 6 months beore that benet will be covered, regardlesso how long youve had your current Medigap policy.

I youve had your current Medigap policy longer than 6 months and want to replaceit with a new one with the same benets and the insurance company agrees to issue

the new policy, they cant write pre-existing conditions, waiting periods, eliminationperiods, or probationary periods into the replacement policy.


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34 Section 5For People Who Already Have a Medigap Policy

Why would I want to switch to a diferent Medigap policy?

Some reasons or switching may include the ollowing:

Youre paying or benets you dont need.

You need more benets than you needed beore.

Your current Medigap policy has the right benets, but you want to change yourinsurance company.

Your current Medigap policy has the right benets, but you want to nd a policythats less expensive.

Its important to compare the benets in your current Medigap policy to the benetslisted here. I you live in Massachusetts, Minnesota, or Wisconsin, see here. o

help you compare benets and decide which Medigap policy you want, ollow theSteps to Buying a Medigap Policy in Section 4. I you decide to change insurancecompanies, you can call the new insurance company and arrange to apply or yournew Medigap policy. I your application is accepted, call your current insurancecompany, and ask to have your coverage end. Te insurance company can tell youhow to submit a request to end your coverage.

As discussed here, you should have your old Medigap policy coverage end aer youhave the new Medigap policy or 30 days. Remember, this is your 30-day ree lookperiod. You will need to pay both premiums or one month.


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Can I keep my current Medigap policy (or Medicare SELEC policy) or switch toa diferent Medigap policy i I move out-o-state?

You can keep your current Medigap policy regardless o where you live as long asyou still have Original Medicare. I you want to switch to a dierent Medigap policy,you will have to check with your current or the new insurance company to see ithey will oer you a dierent Medigap policy.

You may have to pay more or your new Medigap policy and answer some medicalquestions i youre buying a Medigap policy outside o your Medigap openenrollment period. (More ino.)

I you have a Medicare SELEC policy and you move out o thepolicys area, you have the ollowing choices:

Buy a standardized Medigap policy rom your current Medigap policy insurancecompany that oers the same or ewer benets than your current MedicareSELEC policy. I youve had your Medicare SELEC policy or more than 6months, you wont have to answer any medical questions.

You have a guaranteed issue right to buy any Medigap Plan A, B, C, F, K, or Lthats sold in most states by any insurance company.

What happens to my Medigap policy i I join a Medicare Advantage Plan?

Medigap policies cant work with Medicare Advantage Plans. I you decide to keepyour Medigap policy, you will have to pay your Medigap policypremium, but theMedigap policy cant pay anydeductibles, copayments, coinsurance, or premiumsunder a Medicare Advantage Plan. So, i you want to join a Medicare AdvantagePlan, you may want to drop your Medigap policy. Contact your Medigap insurancecompany to nd out how to disenroll. However, i you leave the Medicare AdvantagePlan 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. (More ino.) Your rights to buy aMedigap policy may vary by state. You always have a legal right to keep the Medigappolicy aer you join a Medicare Advantage Plan. However, because you have a

Medicare Advantage Plan, the Medigap policy would no longer provide benets thatsupplement Medicare.
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Losing Medigap coverage

Can my Medigap insurance company drop me?

I you bought your Medigap policyaer 1992, in most cases the Medigap insurancecompany cant drop you because the Medigap policy is guaranteed renewable. Tismeans your insurance company cant drop you unless one o the ollowing happens:

You stop paying your premium.

You werent truthul on the Medigap policy application.

Te insurance company becomes bankrupt or insolvent.

However, i you bought your Medigap policybeore 1992, it might not be guaranteedrenewable. Tis means the Medigap insurance company can reuse to renew the

Medigap policy, as long as it gets the states approval to cancel your Medigap policy.However, i this does happen, you have the right to buy another Medigap policy. Seethe guaranteed issue righthere.

Medigap policies and Medicare prescription drug coverage

I you bought a Medigap policybeore January 1, 2006, and it has coverageor prescription drugs, see below.

Medicare oers prescription drug coverage (Part D) or everyone with Medicare.I you have a Medigap policy with prescription drug coverage, that means youchose not to join a Medicare Prescription Drug Plan when you were rst eligible.However, you can still join a Medicare Prescription Drug Plan. Your situation mayhave changed in ways that make a Medicare Prescription Drug Plan t your needsbetter than the prescription drug coverage in your Medigap policy. Its a good idea toreview your coverage each all, because you can join a Medicare Prescription DrugPlan between October 15December 7. Your new coverage will begin on January 1.
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Why would I change my mind and join a Medicare Prescription Drug

Plan?

In a Medicare Prescription Drug Plan, you may have to pay a monthlypremium,but Medicare pays a large part o the cost. Teres no maximum yearly amount aswith Medigap prescription drug benets in old Plans H, I, and J (these plans are nolonger sold). However, a Medicare Prescription Drug Plan might only cover certainprescription drugs (on its ormulary or drug list). Its important that you checkwhether your current prescription drugs are on the Medicare Prescription Drug Planslist o covered prescription drugs beore you join.

I your Medigap premium or your prescription drug needs were very low whenyou had your rst chance to join a Medicare Prescription Drug Plan, your Medigapprescription drug coverage may have met your needs. However, i your Medigappremium or the amount o prescription drugs you use has increased recently, aMedicare Prescription Drug Plan might now be a better choice or you.

Will I have to pay a late enrollment penalty i I join a Medicare Prescription DrugPlan now?

Tis will depend on whether your Medigap policy includes creditable prescriptiondrug coverage. Tis means that the Medigap policys drug coverage pays, on average,

at least as much as Medicares standard prescription drug coverage.

I it isnt creditable coverage, and you join a Medicare Prescription Drug Plan now,you will probably pay a higher premium (a penalty added to your monthly premium)than i you had joined when you were rst eligible. You should also consider that yourprescription drug needs could increase as you get older. Each month that you wait tojoin a Medicare Prescription Drug Plan will make your late enrollment penalty higher.Your Medigap carrier must send you a notice each year telling you i the prescriptiondrug coverage in your Medigap policy is creditable. You should keep these notices incase you decide later to join a Medicare Prescription Drug Plan.


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I your Medigap policy includes creditable coverage and you decide to join aMedicare Prescription Drug Plan, you wont have to pay a late enrollment penaltyas long as you dont drop your Medigap policybeore you join the Medicare

Prescription Drug Plan. You can only join a Medicare Prescription Drug Planbetween October 15December 7 unless you lose your Medigap policy (or example,i it isnt guaranteed renewable, and your company cancels it). In that case, you maybe able to join a Medicare Prescription Drug Plan at the time you lose your Medigappolicy.

Can I join a Medicare Prescription Drug Plan and have a Medigap policy withprescription drug coverage?

No. I your Medigap policy covers prescription drugs, you must tell your Medigap

insurance company i you join a Medicare Prescription Drug Plan so it can removethe prescription drug coverage rom your Medigap policy and adjust your premium.Once the drug coverage is removed, you cant get that coverage back even thoughyou didnt change Medigap policies.

What i I decide to drop my entire Medigap policy (not just the Medigapprescription drug coverage) and join a Medicare Advantage Plan that ofersprescription drug coverage?

You need to be careul about the timing because you can only join a MedicarePrescription Drug Plan or Medicare Advantage Plan during the open enrollment

period between October 15December 7. Your coverage will begin on January 1 aslong as the plan gets your enrollment request by December 7.


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Section 6: Medigap Policies or

People with a Disability or ESRDInormation or people under 65

Medigap policies or people under 65 and eligible or Medicare because o adisability or End-Stage Renal Disease (ESRD)

You may have Medicare beore 65 due to a disability or ESRD (permanent kidneyailure requiring dialysis or a kidney transplant).

I youre a person with Medicare under 65 and have a disability or ESRD, you mightnot be able to buy the Medigap policy you want, or any Medigap policy, until youturn 65. Federal law doesnt require insurance companies to sell Medigap policiesto people under 65. However, some states require Medigap insurance companies tosell you a Medigap policy, even i youre under 65. Tese states are listed on the nextpage.

Important: Tese are the minimum Federal standards. For your staterequirements, call your State Health Insurance Assistance Program.(More ino.)


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40 Section 6Medigap Policies or People with a Disability or ESRD

Medigap policies or people under 65 and eligible or Medicare because o adisability or End-Stage Renal Disease (ESRD) (continued)

At the time o printing this guide, the ollowing states required insurance companiesto oer at least one kind o Medigap policy to people with Medicare under 65:

Caliornia*

Colorado

Connecticut

Delaware**

Florida

Georgia Hawaii

Illinois

Kansas

Louisiana

Maine

Maryland

Massachusetts*

Michigan

Minnesota

Mississippi Missouri

New Hampshire

New Jersey

New York

North Carolina

Oklahoma

Oregon

Pennsylvania

South Dakota

ennessee exas

Vermont*

Wisconsin

* A Medigap policy isnt available to people with ESRD under 65.

** A Medigap policy is only available to people with ESRD.

Even i your state isnt on the list above, some insurance companies may voluntarilysell Medigap policies to people under 65, although they will probably cost youmore than Medigap policies sold to people over 65, and they can use medicalunderwriting. Check with your state about what rights you might have under statelaw.

Remember, i youre already enrolled in Medicare Part B, you will get a Medigapopen enrollment period when you turn 65. You will probably have a wider choiceo Medigap policies and be able to get a lower premium at that time. During theMedigap open enrollment period, insurance companies cant reuse to sell you anyMedigap policy due to a disability or other health problem, or charge you a higherpremium (based on health status) than they charge other people who are 65.

Because Medicare (Part A and/or Part B) is creditable coverage, i you had Medicareor more than 6 months beore you turned 65, you may not have a pre-existingcondition waiting period. For more inormation about the Medigap open enrollmentperiod and pre-existing conditions, see here. I you have questions, call your StateHealth Insurance Assistance Program. (More ino.)


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Section 7: Medigap Coveragein Massachusetts, Minnesota,and Wisconsin

Massachusetts beneits

Minnesota beneits

Wisconsin beneits


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42 Section 7Medigap Coverage in Massachusetts, Minnesota, and Wisconsin

MassachusettsStandardized Medigap policies

Inpatient Hospital Care: Covers the Medicare Part A coinsurance plus coverage

or 365 additional days aer Medicare coverage ends Medical Costs: Covers the Medicare Part B coinsurance (generally 20% o the

Medicare-approved amount)

Blood: Covers the rst 3 pints o blood each year

Part A hospice coinsurance or copayment

Te ollowing list indicates i the the benet is covered or not.

Basic Benets

Core Plan: Covered Supplement 1 Plan: Covered

Medicare Part A: Inpatient Hospital Deductible

Core Plan: not covered Supplement 1 Plan: Covered

Medicare Part A: Skilled Nursing Facility Coinsurance


Medicare Part B: Deductible Core Plan: not covered Supplement 1 Plan: Covered

Foreign ravel Emergency


Inpatient Days in Mental Health Hospitals

Core Plan: 60 days per calendar year Supplement 1 Plan: 120 days per benet year

State-Mandated Beneits (Annual Pap tests and mammograms. Check yourplan or other state-mandated beneits.

Core Plan: Covered Supplement 1 Plan: Covered

For more inormation on these Medigap policies, visit www.medicare.gov/medigap,or call your State Insurance Department. (More ino.)
http://www.medicare.gov/medigaphttp://www.medicare.gov/medigap


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MinnesotaStandardized Medigap policies

Inpatient Hospital Care: Covers the Medicare Part A coinsurance

Medical Costs: Covers the Medicare Part B coinsurance (generally 20% o theMedicare-approved amount)

Blood: Covers the rst 3 pints o blood each year

Part A hospice and respite cost sharing

Parts Aand B home health services and supplies cost sharing

Te ollowing list indicates i the the benet is covered or not.

Basic Benets

Core Plan: Covered Extended Basic Plan: Covered


Core Plan: not covered Extended Basic Plan: Covered

Medicare Part A: Skilled Nursing Facility Coinsurance

Core Plan: Covered (Provides 100 days o SNF care) Extended Basic Plan: Covered (Provides 100 days o SNF care)

Medicare Part B: Deductible Core Plan: not covered Extended Basic Plan: Covered

Foreign ravel Emergency

Core Plan: 80% Extended Basic Plan: 80%*

Outpatient Mental Health

Core Plan: 50% Extended Basic Plan: 50%

Usual and Customary Fees

Core Plan: not covered Extended Basic Plan: 80%*


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Medicare Covered Preventive Care


Physical Terapy

Core Plan: 20% Extended Basic Plan: 20%

Coverage while in a Foreign Country

Core Plan: not covered Extended Basic Plan: 80%*

State-Mandated Beneits (Diabetic equipment and supplies, routine cancerscreening, reconstructive surgery, and immunizations.)


* Pays 100% aer you spend $1,000 in out-o-pocket costs or a calendar year.

Mandatory Riders

Insurance companies can oer our additional riders that can be added to a BasicPlan. You may choose any one or all o the ollowing riders to design a Medigappolicy that meets your needs:


Medicare Part B: Deductible

Usual and Customary Fees

Non-Medicare Preventive Care

Minnesota versions o Medigap Plans K, L, M, N, and high deductible F areavailable.

Important: Te Basic and Extended Basic benets are available whenyou enroll in Part B, regardless o age or health problems. I you return

to work and drop Part B to elect your employers health plan, you willget another 6-month Medigap open enrollment periodaer you retirerom that employer when you can elect Part B again.


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Section 8: For More Inormation

Where to get more inormation

Here you will nd phone numbers or your State Health Insurance AssistanceProgramand State Insurance Department.

Call your State Health Insurance Assistance Program or help with any o theollowing:

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 i you have questions about the Medigappolicies sold in your area or any insurance-related problems.

How to get help with Medicare and Medigap questions

I you have questions about Medicare, Medigap, or need updated phone numbersor the contacts listed below, you can do the ollowing:

Visit www.medicare.gov:

For Medigap policies in your area, visit www.medicare.gov/medigap

For updated phone numbers, visit ww.medicare.gov/contacts.

Call 1-800-MEDICARE (1-800-633-4227):

Customer service representatives are available 24 hours a day, 7 days a week.

Y users should call 1-877-486-2048. I you need help in a language otherthan English or Spanish, let the customer service representative know thelanguage.
http://www.medicare.gov/http://www.medicare.gov/medigaphttp://ww.medicare.gov/contactshttp://ww.medicare.gov/contactshttp://www.medicare.gov/medigaphttp://www.medicare.gov/


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47 Section 8For More Inormation

State Health Insurance Assistance Program (SHIP)

Alabama (800) 243-5463

Alaska (800) 478-6065

American Samoa Number not available

Arizona (800) 432-4040

Arkansas (800) 224-6330

Caliornia (800) 434-0222

Colorado (888) 696-7213

Connecticut (800) 994-9422

Delaware (800) 336-9500

Florida (800) 963-5337

Georgia (800) 669-8387

Guam (671) 735-7388

or (671) 735-7390

Hawaii (888) 875-9229

Idaho (800) 247-4422

Illinois (800) 548-9034

Indiana (800) 452-4800

Iowa (800) 351-4664

Kansas (800) 860-5260

Kentucky (877) 293-7447

Louisiana (800) 259-5301

Maine (877) 353-3771

Maryland (800) 243-3425

Massachusetts (800) 243-4636

Michigan (800) 803-7174

Minnesota (800) 333-2433

Mississippi (800) 948-3090

Missouri (800) 390-3330

Montana (800) 551-3191

Nebraska (800) 234-7119

Nevada (800) 307-4444

New Hampshire (866) 634-9412

New Jersey (800) 792-8820

New Mexico (800) 432-2080

New York (800) 701-0501

North Carolina (800) 443-9354

North Dakota (888) 575-6611

Northern Mariana Islands

Number not available

Ohio (800) 686-1578

Oklahoma (800) 763-2828

Oregon (800) 722-4134

Pennsylvania (800) 783-7067

Puerto Rico (877) 725-4300

Rhode Island (401) 462-4444

South Carolina (800) 868-9095

South Dakota (800) 536-8197

ennessee (877) 801-0044

exas (800) 252-9240

Utah (800) 541-7735

Vermont (800) 642-5119

Virgin Island (340) 772-7368

(St. Tomas) (340) 714-4354

Virginia (800) 552-3402

Washington (800) 562-6900

Washington, DC (202) 739-0668

West Virginia (877) 987-4463

Wisconsin (800) 242-1060

Wyoming (800) 856-4398


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Section 9: Defnitions

Where words are defned

AssignmentAn agreement by your doctor or other supplier to be paid directly byMedicare, to accept the payment amount Medicare approves or the service, and notto bill you or any more than the Medicare deductible and coinsurance.

CoinsuranceAn amount you may be required to pay as your share o the costsor services aer you pay any deductibles. Coinsurance is usually a percentage (orexample, 20%).

CopaymentAn amount you may be required to pay as your share o the costor a medical service or supply, like a doctors visit, hospital outpatient visit, or aprescription. A copayment is usually a set amount, rather than a percentage. Forexample, you might pay $10 or $20 or a doctors visit or prescription.

DeductibleTe amount you must pay or health care or prescriptions, beoreOriginal Medicare, your prescription drug plan, or your other insurance begins topay.

Excess ChargeI you have Original Medicare, and the amount a doctor or otherhealth care provider is legally permitted to charge is higher than the Medicare-

approved amount, the dierence is called the excess charge.

Guaranteed Issue Rights (also called Medigap Protections)Rights you havein certain situations when insurance companies are required by law to sell or oeryou a Medigap policy. In these situations, an insurance company cant deny you aMedigap policy, or place conditions on a Medigap policy, such as exclusions or pre-existing conditions, and cant charge you more or a Medigap policy because o a pastor present health problem.

Guaranteed Renewable PolicyAn insurance policy cant be terminated by the

insurance company unless you make untrue statements to the insurance company,commit raud, or dont pay your premiums. All Medigap policies issued since 1992are guaranteed renewable.


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51 Section 9Defnitions

Open Enrollment Period (Medigap)A one-time-only, 6-month period whenFederal law allows you to buy any Medigap policy you want that is sold in your state.It starts in the rst month that youre covered under Medicare Part B, and youre

65 or older. During this period, you cant be denied a Medigap policy or chargedmore due to past or present health problems. Some states may have additional openenrollment rights under state law.

Original MedicareOriginal Medicare is ee-or-service coverage under which thegovernment pays your health care providers directly or your Part A and/or Part Bbenets.

Pre-existing ConditionA health problem you had beore the date that a newinsurance policy starts.

PremiumTe periodic payment to Medicare, an insurance company, or a healthcare plan or health care or prescription drug coverage.

State Health Insurance Assistance Program (SHIP)A state program that getsmoney rom the Federal government to give ree local health insurance counselingto people with Medicare.

State Insurance DepartmentA state agency that regulates insurance and canprovide inormation about Medigap policies and other private health insurance.


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53

I

Illegal Insurance Practices #1Inspector Generals Oce #1Issue-age-rated Policies #1, #2, #3

L

Long-term Care Insurance #1, #2, #3

M

Medicaid #1, #2, #3, #4, #5Medical Savings Account Plan #1

Medical Underwriting #1, #2, #3, #4, #5, #6, #7Medicare Advantage Plan #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12Medicare-approved Amount #1, #2, #3Medicare Cost Plan #1Medicare Part A (Hospital Insurance) #1, #2, #3, #4, #5, #6Medicare Part B (Medical Insurance) #1, #2, #3, #4, #5, #6, #7, #8Medicare Prescription Drug Plan #1, #2, #3, #4, #5, #6, #7Medicare SELEC #1, #2, #3, #4, #5, #6, #7, #8, #9Medicare Supplement Insurance (see Medigap)Medigap

Best ime to Buy#1Claim Filing #1Steps to Buying #1Under 65#1What it is #1Whats Covered and Whats Not Covered #1

Medigap Benets ChartPlans A through N #1Massachusetts #1Minnesota #1Wisconsin #1

Medigap Policies and Medicare Prescription Drug Coverage #1Medigap Protections (Guaranteed Issue Rights) #1, #2, #3,#4Moving #1
http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-


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54

N

No-age-rated Policies #1O

Open Enrollment Period(Medigap) #1, #2, #3,#4,#5,#6,#7,#8, #9,#10, #11

Original Medicare #1, #2, #3,#4,#5,#6,#7,#8

P

PACE (Programs o All-Inclusive Care or the Elderly) #1, #2Pre-existing Condition #1, #2, #3,#4,#5,#6

Premium#1, #2, #3,#4,#5,#6,#7,#8,#9,#10, #11, #12, #13, #14

Prescription Drug Coverage (Medicare) #1, #2, #3,#4,#5,#6Preventive Care #1, #2Pricing Policies #1

R

Right to Buy a Medigap Policy#1

S

Skilled Nursing Facility (Care) #1, #2, #3,#4,#5State Health Insurance Assistance Program #1, #2, #3,#4,#5,#6State Insurance Department #1, #2, #3,#4,#5,#6,#7Switching Medigap Policies #1

T

RICARE #1, #2

U

Union Coverage #1

V

Veterans Benets #1W

Waiting Period #1, #2, #3,#4,#5www.medicare.gov#1, #2, #3,#4,#5
http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-http://-/?-


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55

Important Inormation about this guide

Te inormation, phone numbers, and web addresses in this guide were correctat the time o printing. Changes may occur aer printing. o get the most up-to-date inormation and Medicare phone numbers, visit www.medicare.gov, or call1-800-MEDICARE (1-800-633-4227). Y users should call 1-877-486-2048.

Te 2012 Choosing a Medigap Policy: A Guide to Health Insurance or Peoplewith Medicare isnt a legal document. Ocial Medicare Program legal guidanceis contained in the relevant statutes, regulations, and rulings.
http://www.medicare.gov/http://www.medicare.gov/


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U.S. DEPARMEN OFHEALH AND HUMAN SERVICES

Centers or Medicare & Medicaid Services

7500 Security BoulevardBaltimore, Maryland 21244-1850

Ocial BusinessPenalty or Private Use, $300

CMS Product No. 02110Revised December 2011

o get this publication on audiotape, in Braille, Spanish,or large print (English), visit www.medicare.gov, or call1-800-MEDICARE (1-800-633-4227). Y users should call

1-877-486-2048.Necesita una copia en espaol? Visite www.medicare.goven el sitio Web. Para saber si esta publicacin esta impresa ydisponible (en espaol), llame GRAIS al 1-800-MEDICARE(1 800 633 4227) Los usuarios de Y deben llamar al
http://www.medicare.gov/http://www.medicare.gov/http://www.medicare.gov/http://www.medicare.gov/

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