Protect Yourself Against Medicare “Gaps”

Protect Yourself Against Medicare “Gaps”

David Sayen
Courtesy: Medicare

Medicare helps to pay for a wide variety of health services, from flu shots to hospital stays to hospice care. But it doesn’t cover everything, including all of your out-of-pocket costs.

Many services covered by Medicare require co-payments, co-insurance and deductibles. You can purchase supplemental insurance — called Medicare Supplement Insurance, or Medigap — to cover these “gaps” in Medicare. Some Medigap policies also cover certain benefits that Medicare does not, such as emergency care in a foreign country.

If you have Medicare and purchase a Medigap policy, Medicare will pay its share of the Medicare-approved amount for covered health services. Your Medigap policy will then pay its share.

You must pay for Medigap yourself. It is sold through private insurance companies, but you can only buy it if you have traditional Medicare, not Medicare Advantage, which is managed care provided by private insurers.

Every Medigap policy must follow federal and state laws designed to protect you. Medigap insurance companies can only sell you a “standardized” Medigap policy identified in most states by the letters A through D, F through G and K through N. Each standardized policy must offer the same basic benefits, no matter which company sells it.

So, beware when shopping for a Medigap policy: Cost is usually the only difference between Medigap policies with the same letter sold by different companies. And there can be significant differences in how much various insurers charge for exactly the same coverage.

Here are some of the costs that Medigap policies often cover:

  • Medicare Part A (hospital) co-insurance and hospital costs for up to 365 days after Medicare benefits run out;
  • Medicare Part B (medical) co-insurance or co-pays;
  • Blood (first three pints);
  • Part A hospice care co-insurance or co-pays;
  • Skilled nursing facility co-insurance;
  • Part A and Part B deductibles.

Medigap policies generally do not cover long-term care (like care in a nursing home), vision or dental, hearing aids, eyeglasses and private-duty nursing.

The best time to buy a Medigap policy is during your six-month Medigap open enrollment period, because you can buy any Medigap policy sold in your state, even if you have health problems. This period starts automatically the month you turn 65 and are enrolled in Medicare Part B. Once it’s over, you cannot get it again.

Medigap insurance companies are generally allowed to use medical underwriting to decide whether to accept your application and how much to charge you for the Medigap policy. However, if you apply during your Medigap open enrollment period, you can buy any Medigap policy the company sells for the same price as people with good health, even if you have health problems. Some other points to keep in mind:

  • You must have Medicare Part A and Part B in order to buy a Medigap policy;
  • A Medigap policy covers only one person. If you and your spouse both want Medigap coverage, you must each buy a separate policy;
  • You pay the private insurer a monthly premium for your Medigap policy, in addition to the monthly Part B premium that you pay to Medicare;
  • Any standardized Medigap policy is guaranteed renewable even if you have health problems. This means the insurance company cannot cancel your Medigap policy as long as you pay the premium.

David Sayen is Medicare’s regional administrator for Hawai‘i, California, Nevada, Arizona and the Pacific Territories. You can get answers to your Medicare questions by calling 1-800-MEDICARE (1-800-633-4227).

David Sayen is Medicare’s regional administrator for Hawai‘i, California, Nevada, Arizona and the Pacific Territories.

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