Medicare pays only a portion of your hospital and doctor bills so most people purchase additional insurance to help pay for the portion Medicare doesn’t pay for. There are two types of Medicare Insurance: Medicare Advantage (Part C) and Medigap Insurance which is sometimes called Medicare Supplement Insurance. Each type of insurance has advantages and disadvantages.
What is Medigap Insurance (also called Medicare Supplement)
These insurance plans are sold by private insurance companies and help cover the “gaps” not covered by Medicare. Medigap insurance plans are “standardized” and identified by a letter designating what and how much coverage is provided. The plans are labeled with the letters A – N with plan F being the most popular because it covers 100% of what Medicare A & B doesn’t cover. Medigap plans have both advantages and disadvantages as follows:
- Flexibility – Medigap plans allow access to any doctor or hospital who accepts Medicare and will accept new Medicare patients. This is helpful if you don’t want to be limited to providers in a specific network.
- Nationwide Coverage – because there are no networks you can keep your plan where ever you live so if you move you don’t have to change plans.
- Travel – Many people who travel throughout the US prefer Medigap insurance because they can see a doctor where ever they are and don’t need a referral from a Primary Care Physician.
- Coverage – Medigap insurance plan F covers 100% of what Medicare A & B doesn’t which means you can see a doctor or hospital without co-pays, co-insurance or deductibles.
- Year-round enrollment – Unlike Medicare Advantage plans which only allow you to enroll once a year with Medigap plans you can change coverage anytime providing you can pass the health questions.
- Free from paperwork with virtually no claim forms to file
- Foreign travel coverage - Some plans provide for emergency services in foreign countries
- Provide guaranteed renewable coverage, meaning the plan automatically renews or is guaranteed to continue from year to year as long as premiums are paid when due
- Provide a 30-day “free look” evaluation period. Full refund of premiums if policy is returned within 30 days of policy issuance.
- Extras – Some plans also offer extra benefits such as pharmacy savings, vision discounts, and a 24-hour Nurse Hotline, depending on the plan.
- Cost – Medigap insurance cost can range between $100-$300 depending on the insurance company and plan you choose.
- Underwriting – Medigap insurance plans are medically underwritten which means you may not qualify for a plan if you have a pre-existing illness.
- Prescription Drug Coverage – Prescriptions drug coverage is not included in Medigap Insurance an must be purchased separately adding additional cost.
Eligibility and Enrollment
In order to enroll in a Medigap Insurance plan you must be enrolled in Medicare A & B and you will continue to pay your monthly Medicare Part B premium. You will have an initial Medigap Open Enrollment when you first become eligible for Medicare Part B which begins the first day of the month you turn 65 and continues for 6 months.
Medicare Advantage also known as Medicare Part C
Medicare Part C which is also called "Medicare Advantage" is Medicare insurance that is offered through private insurance companies.
- HMO – Health Maintenance Organization
- PPO – Preferred Provider Organization
- POS – Point of Service Organization
- PFFS – Private Fee for Service Organization
- Feature single card convenience
- Include plans starting at $0 monthly plan premiums
- Provide additional benefits and services not covered by Original Medicare
- Include Medicare prescription drug coverage (Part D), depending on the plan
- Provide access to a local contracted network of doctors
- Do not require a referral to see a specialist, in some plans
- Coverage for many preventive services annually for a $0 copayment, including an annual routine physical
- Worldwide coverage for emergency care
PPO plans offer the benefits of an HMO plan as well as these additional key features:
- Freedom to receive care from provider of choice, inside or outside the network
- No provider referrals are ever needed
- Allows your client to maximize their benefit when they receive care inside the plan's network of providers. Going outside the network for covered services generally costs more money.
Point of Service plans are like HMO plans, but they also offer members the ability to:
- Visit doctors outside their network, typically for higher co-payment/coinsurance
- Access providers without referrals, in many plans
Eligibility and Enrollment Periods
Who is Eligible? In order to join a Medicare Advantage Plan, you must qualify for Medicare Part A and Part B before you can apply for Part C.
Medicare Advantage Calendar: Three Periods to Understand
When the government set up the MA plan they divided the year into three parts to help increase the efficiency
Annual Enrollment Period or AEP- begins October 15th and continues to December 7th. During this time Medicare wants to know if you are making changes for the following year. You don’t have to do anything if you like your current plan and if they are still offering coverage in your area. Remember that MA plans are renewed every year and each plan can elect to stay or leave your area or change the plan and premiums. If you are not happy you may want to change to another MA plan and what’s important to know is this is the only time when you can change your coverage. Once a year you should take some time to review your current plan and see if it is working the way you want and also review what other choices are available to see if something might work out better for you.
Annual Disenrollment Period – If you want to leave a Medicare Advantage plan and return to Original Medicare and enroll in a Medigap plan you can do this during the Annual Disenrollment Period which runs from January 1st through February 14th each year.
Lock-Out Period – this is where you stay with your final choice until the November 15.
Special Enrollment Period – SEP – there is one way to change plans during the lock-out period and that is through the SEP. If you move, if your marital status changes, there are several reasons that would allow you to make a change during the year. But this requires a SEP approval.
Initial Enrollment Period – ICEP – this is also known as “aging in” when you first turn 65 and become eligible for Medicare you have three months prior to your birth month and three months following your birth month for a total of seven months to enroll. Your coverage begins on the first of your birth month unless you enroll later.
Special Needs Plans
Some people are eligible to enroll in a Medicare Advantage Special Needs Plan if they have a chronic health condition.
Medicare Part D
Medicare Part D Plans help cover the cost of your prescription drugs. Here are some of the main features of a Part D plan:
- Provide help with the cost of prescription medications
- Are only offered through private insurance companies
- Are usually offered two ways:
- As a standalone plan to add coverage to Original Medicare Parts A and B and to complement a Medicare Supplement plan
- As part of a Medicare Advantage (Part C) Plan
- Have a specific list of approved drugs they cover (called a formulary or drug list)