Your Guide to Choosing a
MEDIGAP
POLICY
Medigap is private health insurance designed to help pay healthcare costs that aren’t
covered by Medicare. Each Medigap plan covers dierent costs and services.
This guide will provide a brief overview of Medicare, what Medigap coverage is, what
the dierent Medigap plans cover and how to buy a Medigap policy. It will also answer
questions people often have about Medigap coverage.
Medicare eligible employees/retirees may be able to get group coverage that will
supplement their Medicare from their current or former employer. This coverage
may oer more comprehensive benets at a cheaper rate and is dierent from the
standardized individual plans discussed here. Check with your employer for details.
Learn more at insurance.pa.gov
Understanding Medigap
WHAT IS MEDICARE?
• Medicare is a federal health insurance program
for people age 65 or older, younger than age 65
with certain disabilities and any age with
permanent kidney failure, also called End-
Stage Renal Disease (ESRD).
• To qualify for Medicare, you must be a legal
citizen and have been in the United States for
at least ve years.
• Like other insurance plans, there are maximum
benets, exclusions and other requirements.
You pay monthly premiums and are sometimes
responsible for out-of-pocket deductibles and
co-payments.
THERE ARE TWO TYPES OF MEDICARE
COVERAGE.
1. ORIGINAL MEDICARE: is coverage under
which the government pays your healthcare
providers directly. Original Medicare has two
parts:
• MEDICARE PART A IS HOSPITAL
INSURANCE. It helps cover costs if you
are in the hospital, a skilled nursing facility,
hospice or home healthcare.
• MEDICARE PART B IS MEDICAL
INSURANCE. It helps cover services from
doctors and other healthcare providers,
as well as the cost of hospital outpatient
care, durable medical equipment, home
healthcare and preventive services.
Enrollment in Medicare Part A and Part B
You may be automatically enrolled in Medicare
Part A, but if you are not, sign up as soon as you are
eligible. Be sure to also sign up for Part B as soon
as you are eligible. Otherwise, you may face late
enrollment penalties. Parts A and B work together,
so you need to be enrolled in both.
You will need to sign up for Part A and Part B
on your own if:
• Are not receiving Social Security or
Railroad Retirement Board (RRB) benets.
• Qualify for Medicare because you have ESRD.
You should apply three months before your 65th
birthday. You can apply:
• Online at www.socialsecurity.gov/
medicareonly
• In person at your local Social Security
oce.
• By phone at 1-800-772-1213 ( if you worked
for a railroad, call the RRB at 1-877-772-5772.
2. MEDICARE ADVANTAGE: plans are
Medicare-approved health plans run by
private insurance companies. They combine
both the hospital (Part A) and medical
(Part B) components of coverage into one
plan. Medicare Advantage Plans are called
Medicare Part C.
Medicare Part D is prescription drug coverage.
Some Medicare Advantage Plans include Medicare
Part D. If you are covered by Original Medicare,
you may purchase Part D coverage through a
Medicare-approved prescription drug plan (PDP).
Medicare Part A is hospital insurance. Medicare Part B is medical insurance.
Medicare Part C is a Medicare Advantage Plan. Medicare Part D is prescription drug coverage.
For more information on Medicare, please visit www.Medicare.gov.
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THREE IMPORTANT THINGS TO KNOW ABOUT MEDIGAP POLICIES.
• Medigap is private health insurance you have the option to purchase yourself.
It wraps around your Medicare coverage and lls in the gaps.
• If you are covered under a Medicare Advantage Plan (Medicare Part C),
you cannot purchase Medigap coverage.
• One policy will not cover both you and your spouse. You would need
to purchase individual policies.
OVERVIEW OF MEDIGAP.
Medicare Supplement Insurance – often called “Medigap” – is private health insurance
designed to help pay some healthcare costs that aren’t covered by Medicare, such as
co-payments, coinsurance and deductibles. You must have Medicare Parts A and B
to purchase a Medigap policy. If you have a Medicare Advantage Plan, also known as
Medicare Part C, you cannot purchase a Medigap policy.
When you have a healthcare expense, Medicare (Parts A and B) will pay Medicare-
approved amounts rst, then the Medigap policy will pay its part.
Each Medigap plan covers dierent costs and services. Medicare and Medigap plans
are named by letter. The following table show what each plan covers. Medigap policies
generally don’t cover Long-Term Care, vision or dental care, hearing aids, eyeglasses or
private-duty nursing. As with any insurance policy, review the policy language closely
so you understand what is or is not covered.
NOTE: Plans E, H, I and J are no longer sold, but if you already have one, you may
keep it.
WHAT IS MEDIGAP?
(Medicare Supplement Insurance)
Overview of Medigap Who sells Medigap policies?
What do Medigap policies cost?
Learn more at insurance.pa.gov
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MEDIGAP
HOW TO READ THE CHART:
If a check mark appears in a column of this chart, the Medigap policy covers 100
percent of the described benet. If a row lists a percentage, the policy covers that
percentage of the described benet. If a row is blank, the policy doesn’t cover that
benet. Note: The Medigap policy covers coinsurance only after you have paid the
* Plan F also oers a high-
deductible plan. If you choose
this option, this means you
must pay for Medicare-covered
costs up to the deductible
amount before your Medigap
plan pays anything.
** Plans K and L have out-of-
pocket annual limits. After you
meet your out-of-pocket yearly
limit and your yearly Part B
deductible, the Medigap plan
pays 100 percent of covered
services for the rest of the
calendar year.
*** Coinsurance is covered
except copayments are
required for certain oce
or emergency room visits.
Review the plan carefully to
understand the details.
SOURCE: Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare,
Developed jointly by the Centers for Medicare & Medicaid Services (CMS) and the National
Association of Insurance Commissioners (NAIC), 2012.
MEDIGAP BENEFITS
MEDIGAP PLANS
A B C D F
*
G K
**
L
**
M N
Medicare Part A
Coinsurance and hospital costs
up to an additional 365 days after
Medicare benets are used up
√ √ √ √ √ √ √ √ √ √
Medicare Part B
Coinsurance or Copayment
√ √ √ √ √ √
50% 75%
√ √
***
Blood (First 3 Pints) √ √ √ √ √ √
50% 75%
√ √
Part A Hospice Care
Coinsurance or Copayment
√ √ √ √ √ √
50% 75%
√ √
Skilled Nursing Facility Care
Coinsurance
√ √ √ √
50% 75%
√ √
Medicare Part A Deductible √ √ √ √ √
50% 75% 50%
√
Medicare Part B Deductible √ √
Medicare Part B Excess Charges √ √
Foreign Travel Emergency
(Up to Plan Limits)
√ √ √ √ √ √
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Learn more at insurance.pa.gov
WHO SELLS MEDIGAP PLANS?
Medigap policies are sold by private insurance companies. Companies may charge
dierent amounts for a policy, but the benets are identical. That means, for example,
every Plan A will oer the exact same benets regardless of which company sells it.
WHAT DOES A MEDIGAP POLICY COST?
You will pay a monthly premium for your Medigap policy. Each insurance company
sets its own prices for Medigap policies, subject to PA Insurance Department approval.
Prices for Medigap policies can be set in one of three ways:
1. COMMUNITYRATED PRICING
• The premium is not based on your age.
• The same premium is charged to everyone.
2. ISSUEAGERATED ENTRYAGERATED PRICING
• The premium is based on your age when you buy the policy.
• People who buy the policy when they are younger will pay a lower premium
than those who purchase at higher ages.
3. ATTAINEDAGERATED PRICING
• The premium is based on your current age and goes up as you get older.
• The premium may be the least expensive at rst, but can become the most
expensive as you get older.
In all three cases, premiums may increase each year due to ination and
other factors.
MEDIGAP
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There are several other factors that could impact the price of your Medigap policy, including:
• MEDICAL UNDERWRITING: This means a company considers your medical
history when deciding how much to charge you for insurance. Companies may not
use medical underwriting during your open enrollment period.
• DISCOUNTS: Some companies oer discounts. These could be for things like being
a non-smoker, paying your premium yearly (instead of monthly), purchasing coverage
for both you and your spouse or having multiple policies with the same company,
such as a Medigap policy and a long-term care policy.
• MEDICARE SELECT POLICIES: These policies require you to use certain
hospitals and sometimes certain doctors (except for emergencies) and are available
for all Medigap plan types. Medicare SELECT plans usually charge a lower premium,
but if you don’t use a Medicare SELECT provider, you will have to pay all or some of
what Medicare doesn’t pay. Medicare SELECT plans may not be available from all
insurance companies.
• HIGHDEDUCTIBLE OPTION MEDIGAP PLAN F: If you buy Medigap
Plan F with the high-deductible option, each year you will be responsible for
all deductibles, co-payments and coinsurance until you have satised the high
deductible, at which point your policy will begin to pay benets. The deductible is
adjusted annually based on the Consumer Price Index. Because you are responsible
for paying the high deductible, the premium for this policy is generally much lower
than the premium for other plans that do not include the high deductible option.
Your premium may also be aected by your Medigap open enrollment period and
guaranteed issue rights which are explained in the following section.
Learn more at insurance.pa.gov
6 7
BUYING A
MEDIGAP POLICY
Open Enrollment Guaranteed Issue Rights How to Buy a Medigap Policy
OPEN ENROLLMENT
Each individual has a specic Medigap open enrollment period. Open enrollment
starts on the rst day of the month in which you rst enrolled in Medicare Part B.
The open enrollment period lasts for six months. During your open enrollment,
an insurance company must oer every plan it sells and may not use medical
underwriting or consider your medical history to:
• Refuse to sell you a Medigap policy.
• Charge you more for a Medigap policy.
• Make you wait for coverage to start (however, they may be able to make you
wait for coverage related to a pre-existing condition).
If you do have a medical condition that existed within the six-month period before
you purchased your Medigap policy, this condition may not be covered during the
rst six months of your coverage unless you had prior creditable coverage such as
group health insurance, individual health insurance, Medicare or Medical Assistance.
You will most likely get the best price for a Medigap policy during your Medigap
open enrollment period. Remember, your Medigap open enrollment period is
dierent than open enrollment for Medicare Advantage plans.
Learn more at insurance.pa.gov
6 7
You have a guaranteed
issue right if...
You have the right to buy...
You can/must apply for a
Medigap policy...
•You’re in a Medicare
Advantage Plan.
• Your plan is leaving Medicare
or stops giving care in your
area.
• You move out of the plan’s
service area.
Medigap Plan A, B, C, F, K, or
L that’s sold in your state by
any insurance company.
You only have this right if you
switch to Original Medicare
rather than join another
Medicare Advantage Plan.
* As early as 60 calendar
days before the date your
healthcare coverage will end,
but no later than 63 calendar
days after your healthcare
coverage ends. Medigap
coverage can’t start until your
Medicare Advantage Plan
coverage ends.
• You have Original Medicare.
• An employer group health
plan (including retiree or
COBRA coverage).
• Union coverage that pays after
Medicare pays and that plan
is ending.
NOTE: In this situation, you
may have additional rights
under state law.
Medigap Plan A, B, C, F, K, or
L that’s sold in your state by
any insurance company.
If you have COBRA coverage,
you can either buy a Medigap
policy right away or wait until
the COBRA coverage ends.
No later than 63 calendar days
after the latest of these dates:
1. Date the coverage ends
2. Date on the notice you get
telling you that coverage is
ending (if you get one)
3. Date on a claim denial, if
this is the only way you know
that your coverage ended
• You have Original Medicare
and a Medicare SELECT
policy. You move out of the
Medicare
•SELECT policy’s service area.
Call the Medicare SELECT
insurer for more information
about your options.
Medigap Plan A, B, C, F, K, or
L that’s sold by any insurance
company in your state or the
state you’re moving to.
• As early as 60 calendar days
before the date your Medicare
SELECT coverage will end,
but no later than 63 calendar
days after your Medicare
SELECT coverage ends.
GUARANTEED ISSUE RIGHTS
There are certain periods of time when you have the right to purchase a Medigap policy. During
these times, Medigap insurance companies must sell or oer you a Medigap policy without placing
conditions on the policy (such as not covering pre-existing conditions) or charging you a higher
premium because of a past or present health problem.
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You have a guaranteed
issue right if...
You have the right to buy...
You can/must apply for a
Medigap policy...
(Trial Right)* You joined a
Medicare Advantage Plan
or Programs of All-inclusive
Care for the Elderly (PACE)
when you were rst eligible
for Medicare Part A at 65, and
within the rst year of joining,
you decide you want to switch
to Original Medicare.
Any Medigap policy that’s sold
in your state by any insurance
company.
As early as 60 calendar days
before the date your coverage
will end, but no later than
63 calendar days after your
coverage ends.
NOTE: Your rights may last for
an extra 12 months under certain
circumstances.
(Trial Right)* You dropped
a Medigap policy to join a
Medicare Advantage Plan (or to
switch to a Medicare SELECT
policy) for the rst time, you
have been in the plan less than
a year, and you want to switch
back.
The Medigap policy you had
before you joined the Medicare
Advantage Plan or Medicare
SELECT policy, if the same
insurance company you had
before still sells it.
If your former Medigap policy
isn’t available, you can buy
Medigap Plan A, B, C, F, K or L
that’s sold in your state by any
insurance company.
As early as 60 calendar days
before the date your coverage
will end, but no later than
63 calendar days after your
coverage ends.
NOTE: Your rights may last for
an extra 12 months under certain
circumstances.
Your Medigap insurance
company goes bankrupt and
you lose your coverage, or
your Medigap policy coverage
otherwise ends through no
fault of your own.
Medigap Plan A, B, C, F, K or
L that’s sold in your state by
any insurance company.
No later than 63 calendar
days from the date your
coverage ends.
You leave a Medicare
Advantage Plan or drop a
Medigap policy because the
company hasn’t followed the
rules, or it misled you.
Medigap Plan A, B, C, F, K or
L that’s sold in your state by
any insurance company.
No later than 63 calendar
days from the date your
coverage ends.
* In some cases, you have the right to try a Medicare Advantage Plan and still buy a Medigap policy if
you change your mind.
SOURCE: Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare, Developed
jointly by the Centers for Medicare & Medicaid Services (CMS) and the National Association of Insurance
Commissioners (NAIC), 2012.
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HOW TO BUY A MEDIGAP POLICY.
1. Review the benets of each plan and decide which plan best ts
your needs (Page 4).
2. Check the listing of companies licensed to sell Medigap policies in Pennsylvania
at insurance.pa.gov.
3. Call the companies that sell the type of Medigap policy you want.
4. Compare the cost of the policies.
5. Decide on a Medigap policy that's right for you.
When buying a Medigap policy, remember:
• Not all companies sell all the dierent Medigap plans.
• Insurance companies may charge dierent premiums for the
same Medigap policy.
Learn more at insurance.pa.gov
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WATCH OUT FOR ILLEGAL INSURANCE PRACTICES.
It’s illegal for anyone to:
• Pressure you into buying a Medigap policy, or lie to or mislead you to
switch from one company or policy to another.
• Sell you a second Medigap policy when they know that you already have
one, unless you tell the insurance company in writing that you plan to
cancel your existing Medigap policy.
• Sell you a Medigap policy if they know you have Medical Assistance
(also called Medicaid in Pennsylvania). There are exceptions in certain
situations.
• Sell you a Medigap policy if they know you’re in a Medicare Advantage
Plan (like an HMO, PPO or Private Fee for Service Plan) unless your
coverage under the Medicare Advantage Plan will end before the eective
date of the Medigap policy.
• Claim that a Medigap policy is part of the Medicare Program or any other
federal program. Medigap is private health insurance.
• Claim that a Medicare Advantage Plan is a Medigap policy.
• Sell you a Medigap policy that has not been approved in Pennsylvania.
Check with the Pennsylvania Insurance Department to make sure that the
Medigap policy you’re interested in is sold in your state.
• Misuse the names, letters, or symbols of the U.S. Department of Health &
Human Services (HHS), Social Security Administration (SSA), Centers for
Medicare & Medicaid Services (CMS) or any of their various programs like
Medicare. (For example, they can’t suggest the Medigap policy has been
approved or recommended by the Federal government.)
• Claim to be a Medicare representative if they work for an insurance
company that sells Medigap plans.
• Sell you a Medicare Advantage Plan when you say you want to stay in
Original Medicare and buy a Medigap policy. A Medicare Advantage Plan
isn’t the same as Original Medicare. If you enroll in a Medicare Advantage
Plan, you may not use a Medigap policy.
If you believe the law has been broken, please call the Pennsylvania Insurance
Department at 1-877-881-6388.
SOURCE: Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare, Developed
jointly by the Centers for Medicare & Medicaid Services (CMS) and the National Association of Insurance
Commissioners (NAIC), 2012.
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FREQUENTLY ASKED
QUESTIONS
I AM UNDER AGE 65 BUT HAVE A DISABILITY OR ENDSTAGE RENAL
DISEASE ESRD. CAN I BUY A MEDIGAP POLICY?
Yes. In Pennsylvania, Medigap insurance companies are required to sell you a
Medigap policy if you are in your open enrollment period.
WHAT IF I HAVE A MEDICARE ADVANTAGE PLAN BUT WILL
BE RETURNING TO ORIGINAL MEDICARE. CAN I BUY A
MEDIGAP POLICY?
Yes. You can apply for a Medigap policy before your Medicare Advantage Plan
coverage ends. Make sure you have continuous coverage – the new policy should start
no later than when your Medicare Advantage Plan coverage ends.
I JUST RECEIVED MY POLICY AND HAVE CHANGED MY MIND.
WHAT CAN I DO?
You have 30 days from the date you received the policy to review it. If you return the
policy within this timeframe, the insurance company must refund in full the premium
you paid.
WHAT IF I WANT TO CANCEL MY MEDIGAP POLICY?
You may cancel your Medigap policy by writing to your insurance company. You must
contact the insurance company directly; your insurance agent may not cancel the
policy for you.
CAN MY INSURANCE COMPANY CANCEL MY POLICY IF
I HAVE HEALTH PROBLEMS?
No. Standardized Medigap policies are guaranteed renewable. The insurance
company may not cancel your Medigap policy as long as you pay the premium.
DO MEDIGAP POLICIES COVER PRESCRIPTION DRUGS?
No. Medigap policies sold after January 1, 2006, do not include prescription
drug coverage. If you want prescription drug coverage, you must join a Medicare
Prescription Drug Plan (Part D).
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