Medigap plans are the most effective way to cover the financial gaps left in Medicare. In most states there are 10 plans available. This page helps you learn about each plan and why you need to seriously consider Medigap coverage.
Medigap plans are plans, sold by private insurance companies, which are designed to work with “original” Medicare (Medicare Part A and Part B). These plans are Federally-standardized, so although rates can vary considerably from one company to the next, coverage must adhere to the Medigap coverage chart.
Medigap plans can be an important part of a sound financial plan for an individual on Medicare because Medicare itself has some exposure to potentially high out-of-pocket costs. For example, both Medicare Part A and Medicare Part B have deductibles that must be met before coverage starts. Additionally, after the deductibles, Medicare pays 80% of most services/procedures, leaving an unlimited 20%.
These Medicare deductibles and this uncapped 20% is where the Medigap plans come in. Medigap plans pay some or all of the Medicare deductibles and 20% coinsurance. How much of these deductibles and coinsurance your Medigap plan pays depends on which Medigap plan you have (see below for plan synopsis or view Medigap coverage chart).
STANDARDIZED MEDIGAP PLANS
There are ten standardized Medigap plans, which are named for letters, A-N. In 2010, the plans were “re-standardized”, eliminating plans H, I and J. The following is a list of the current standardized Medigap plans and a synopsis of what each plan covers:
- Plan A: Plan A is a lower-tier Medigap plan. It pays the Medicare Part A (hospital) coinsurance and hospital costs, the Medicare Part B coinsurance/copayment, covers the first 3 pints of blood and pays the Medicare Part A hospice care coinsurance/copayment. It does not provide any coverage for the Medicare deductibles, skilled nursing facilities or Part B excess charges.
- Plan B: Plan B is very similar to Medigap Plan A. The only difference is that Plan B also adds in coverage of the Medicare Part A hospital deductible. The Part A deductible is not an annual deductible; instead, it operates on a “benefit period” model. A “benefit period” starts the day you are admitted to a hospital or skilled nursing facility and ends when you haven’t had inpatient hospital care for 60 days in a row.
- Plan C: Plan C is one of the two most comprehensive Medigap plans (along with Plan F). Plan C pays everything that Medicare itself does not cover with the exception of the Medicare Part B Excess charges. The benefits provided under this plan include: Medicare Part A coinsurance/hospital charges, Medicare Part B coinsurance/copayment, blood, Part A hospice care coinsurance/copayment, skilled nursing facility coinsurance, Medicare Part A deductible, Medicare Part B deductible, Medicare Part B excess charges, and foreign travel emergency.
- Plan D: Plan D is also a comprehensive Medigap plan. On this plan, all charges are covered with two exceptions – the Medicare Part B deductible and the Medicare Part B Excess charges.
- Plan F: Plan F is the most common and comprehensive Medigap plan. Sometimes, called the “Cadillac” of Medigap plans, this plan fills in the “gaps” in Medicare, pays the deductibles and coinsurance/copayments under Part A and Part B, as well as covering the Medicare Part B excess charges and offering the foreign travel emergency benefit. Although Plan F is the most common Medigap plan, it is also the most expensive in most cases and not always the best “deal”. There are also concerns about the long-term viability of this plan, based on recent legislation that looks to eliminate or reduce “first-dollar coverage”.
- Plan G: Plan G is one of the most popular Medigap plans. It has been increasing in market share and popularity in the last five years as an alternative to the more costly Plan F. The only difference in Medigap Plan F and Medigap Plan G is that Plan G does not cover the Medicare Part B deductible. Often, the premium savings on ‘G’ (as compared to ‘F’) are greater than the deductible amount, making ‘G’ a viable and prudent alternative.
- Plan K: Plan K is not a very common Medigap plan, but it is still offered by some companies. Plan K, as well as Plan L, works on a percentage model for most benefits. It does cover the Medicare Part A coinsurance and hospital charges at 100%. But, for the following benefits, it pays them at 50%: Medicare Part B coinsurance/copayment, blood, Part A hospice care coinsurance/copayment, skilled nursing facility coinsurance, and Part A deductible. Plan K does not provide any benefits for the Medicare Part B deductible, Medicare Part B Excess charges, or foreign travel emergencies.
- Plan L: Plan L, similarly to Plan K, operates on a percentage-based model. Plan L pays the Part A hospital coinsurance at 100%. Then, for the following benefits, it covers them at 75%: Medicare Part B coinsurance/copayment, blood, Part A hospice care, skilled nursing facility, and Part A deductible. Plan L does not provide any benefits for the Medicare Part B deductible or foreign travel emergencies.
- Plan M: Plan M is a new plan that was added when the plans were “re-standardized” in 2010. Plan M provides the following benefits at 100%: Medicare Part A coinsurance and hospital costs, Medicare Part B coinsurance/copayment, blood, Part A hospice care, and skilled nursing facility coinsurance. The Medicare Part A deductible is covered at 50%. There is no coverage provided on this plan for the Medicare Part B deductible, Part B excess charges or foreign travel emergency.
- Plan N: Plan N is also a new plan, which was added with the 2010 plan changes and has gained some traction as a popular offering. This plan pays the Medicare Part A hospital care coinsurance at 100%. Under Part B coinsurance, however, it operates on a co-pay model. For Part B (doctor visits/outpatient), the insured is responsible for an up to $20 doctor’s office co-pay and an up to $50 emergency room co-pay. The plan pays the remainder of charges under Part B coinsurance. It also covers at 100%: Blood, Part A hospice care, skilled nursing facility coinsurance, the Part A deductible and foreign travel emergency. It does not provide any coverage for the Part B deductible or Part B excess charges.
You probably noticed there are skips in the letters. When congress added Medicare Part D it made some of the plans have redundant coverage. For example, Medicare supplement plan J was just like Plan F, but contained prescription drug coverage. Once prescription drug coverage was available through Medicare Part D, plan J was no long necessary. Instead, they created several new plans that were designed to keep costs low for some people.
THE FUTURE OF MEDIGAP
Medigap plans have been often-discussed a possibility for changes within the health care system. It seems to “come up” every few years. However, over the years, changes to this type of coverage have been limited.
Because the plans are supplemental in nature, not primary coverage (Medicare is primary), the plans are not/were not affected by the passage of the Affordable Care Act.
It is, however, likely that the plans will be restructured in the future. This means that there will likely be “new” plan offerings that have slight differences from the plans that are available now.
Also, recent legislation has proposed eliminating “first-dollar coverage” (i.e. Plans F and C) in 2020. Assuming this does occur, the plans would likely be restructured at that time. In the past, when changes like this have occurred, existing policyholders in eliminated plans have been “grandfathered” into their current plan if they want to keep it. All signs would point to that being the case again. However, any time a plan is eliminated from new sales, the rates would likely not be as stable moving forward since all policyholders in that plan would be aging with no new 65-year-olds being added.
HOW MEDIGAP PLANS WORK
In addition to providing Federally-standardized coverage, Medigap plans also work in a way that is standardized and equivalent across companies. With satisfaction rates for this type of coverage in the 95% range, according to recent customer satisfaction studies, most people are pleased with the simplistic way these plans work as compared to individual/group insurance they may have had before going on Medicare. So, how do they work?
There are three big components of how Medigap plans work that you need to know:
- First and foremost, Medigap plans “follow” Medicare. That is, they pay claims on charges that are Medicare-approved or Medicare-covered. So, if Medicare covers a service/procedure, the Medigap plan will cover it as well. Medicare will pay its portion, and the Medigap plan will pay its portion.
- Second, Medigap claim payments are automated. There are no claims filing needed (except in rare instances) by the insured person. Medigap companies pay claims through the Medicare “crossover” system, which is Medicare’s automated claims payment system. The provider will bill Medicare, which enacts the “crossover” from the private Medigap insurance company. The insured person receives two “explanation of benefits” – one from Medicare showing what they paid and one from their Medigap Company showing what they paid. If your Medigap plan is one of the plans that doesn’t cover some of the Medicare deductibles or coinsurance, you’ll typically get billed from the provider after Medicare and your Medigap have paid their portions.
- Lastly, there are no networks on Medigap plans. Contrary to the other type of Medicare plan – Medicare Advantage Plans – Medigap plans can be used at any doctor or hospital that accepts Medicare (your primary coverage if you have a Medigap plan). There are no in-network or out-of-network differences in coverage and no need to get pre-approved or check a provider directory with this type of coverage. As long as your provider accepts Medicare, they are required to accept any of the standardized Medigap plans.
Overall, Medigap plans are among the most seamless, easy to use types of insurance available. Because you can use the plans anywhere, claims are processed automatically, and coverage is pre-established and unchanging, this type of coverage is a stable, secure way of protecting your financial security.
WHAT DO MEDIGAP PLANS COVER
Medigap plan coverage depends on which plan you choose. If you choose the top level of coverage, Plan F, your Medigap plan will pay what Medicare doesn’t cover, so you have no out-of-pocket costs. If you choose one of the other plans, you’ll be responsible for a set amount of out-of-pocket amounts, dependent on which Medicare “gap” your plan does not cover. You can learn more about that in the standardized Medigap plans section of this page or on the Medigap coverage chart.
Overall, Medigap plans cover “gaps” in Medicare. Their payment is triggered when Medicare pays its portion of Medicare-covered charges. If Medicare covers a service/procedure, the Medigap plan will also pay a portion, which is dependent on which Medigap plan you have chosen.
Some of the “gaps” in Medicare that are covered under the various Medigap plans are: Part A deductible, Part B deductible, Part A coinsurance (20%), Part B coinsurance (20%), skilled nursing facility coinsurance, hospice coinsurance, Part B excess charges, blood, durable medical equipment coinsurance, and foreign travel emergencies.
WHEN TO SIGN UP FOR MEDIGAP
Signing up for a Medigap plan is very easy to do. However, it is essential that you do it at the right time. Many people mistakenly believe that there is an annual enrollment period for Medigap plans. This is not the case. The end-of-year enrollment penalty only applies to Medicare Advantage plans and Medicare Part D.
For Medigap plans, there are essentially four times that you can/should sign up for a plan:
- The first time you can/should sign up for a Medigap plan is when you turn 65 or go on Medicare Part B for the first time. Enrollment in Part B, whether at age 65 or when you sign up for it after age 65, triggers a one-time 6-month open enrollment period during which you can sign up for a Medigap plan with no medical underwriting (i.e. health questions). It is important to sign up for a Medigap plan during this time in order to avoid the possibility of being denied coverage or made to pay more based on your health. If you are turning 65 or just enrolling in Part B, you can actually apply at least 3 (sometimes up to 6) months in advance of your Part B effective date and have the coverage start on the same day that your Medicare Part B begins.
- The second time you can and should sign up for a Medigap plan is when your rate changes. Just like any other type of insurance, Medigap plan rates increase over time. Some plans go up annually as you get older. However, you can “shop” plans and, often, when your rate increases, you can reduce your rates for the same plan (i.e. if you have Plan F, and it goes up, you can get a Plan F from a different company for a lower premium). So, if you have a Medigap plan currently and your rate increases, it is crucial to explore other options to avoid paying a higher premium for the same benefits. In most cases, when you change like this, you do have to answer some general health questions, but you can typically find a company that will work for you and save you money when your Medigap rate increases.
- The third time to sign up for a Medigap plan is when your group/employer coverage ends. When your group coverage ends, Medicare gives you a one-time “guaranteed issue” period to enroll in a Medigap plan. This “guaranteed issue” period lasts for 63 days and starts on the latest of a) when your group coverage ends b) date on the notice you get telling you coverage is ending or c) the date on a claim denial if this is how you find out your coverage ended. If you are going off of group coverage, whether voluntarily or involuntarily, it is important to use that opportunity to enroll in a Medigap plan on this “guaranteed issue” basis.
- There are also other, more unique situations that will enable you to sign up for a Medigap plan. These situations also fall into the “guaranteed issue” criteria, during which you can sign up for a Medigap plan without having to qualify medically to do so. Some of these such situations are:
- Losing a Medicare Advantage plan through the plan ending or you moving out of the service area
- Moving out of a Medicare SELECT plan service area
- If you joined a Medicare Advantage plan at age 65 and want to return to “original” Medicare and purchase a Medigap plan within the first 12 months
- If you dropped a Medigap plan to join a Medicare Advantage plan for the first time and have been in the plan for less than a year, you can switch back to the Medigap with “guaranteed issue.”
- If your Medigap company goes bankrupt, or you lose your Medigap coverage through no fault of your own
Medigap rates can vary considerably although the coverage and the way the plans work are completely standardized. It is essential that you compare plans on the basis of price to avoid paying “extra” for the same coverage. The best way to compare rates is via an independent broker. This allows you to compare all plan options in a centralized place so you can make an unbiased, educated choice.
Medigap companies set their rates, which are approved by the respective state department of insurance and offered for sale to the Medigap-buying public.
There are three different ways in which Medigap rates can be “rated”:
- Attained-age-rated – Premiums are based on your current age and changes based on your current (or “attained”) age.
- Community-rated – Generally, the same monthly premium is charged to everyone who has a Medigap policy with the company, regardless of their age.
- Issue-age-rated – The premium is based on your age when you buy the plan.
Some states have specific guidelines requiring companies to price their plans in a certain one of these “rating” methodologies. However, in states that have no such guidelines, the vast majority of options are attained-age rated.
Regardless of how a specific company’s prices are “rated”, it is important to understand that rates do go up over time (just for different reasons). And, it is crucial to make sure you have the best possible deal, which means that you can “shop” and reduce your costs in many instances if/when you rate increases.
Medigap plans can be confusing if you are new to the plans or not accustomed to purchasing your insurance. There is terminology that you may not be familiar with, as well as many variables to consider. All that said, there is a lot of information in the marketplace, and there are many misunderstandings, or myths when it comes to Medigap plans. Below, you can see the five most common myths about Medigap plans:
- MYTH: There is an annual enrollment for Medigap plans.
FACT: Actually, there is no annual enrollment period when it comes to Medigap plans. The end-of-year enrollment period only applies to Medicare Advantage and Part D plans. You can enroll in, or change, your Medigap policy at any time of the year.
- MYTH: Medicare Advantage plans are a type of Medicare Supplement.
FACT: Medicare Advantage plans take the place of Medicare, rather than “supplementing” it. Medigap plans (also called Medicare supplements) pay AFTER Medicare; Medicare Advantage plans pay INSTEAD of Medicare.
- MYTH: You must go to a doctor that “takes” your Medigap or is in the plan network.
FACT: There are no networks when it comes to Medigap plans. All plans can be used at any doctor/hospital that takes Medicare nationwide. There is no provider directory or source to check to see if you can use your Medigap plan at a certain doctor. Medigap plans “follow” Medicare.
- MYTH: Medigap Plan F is the always the best plan.
FACT: Although Plan F is the most comprehensive plan, it is not always the best “deal”. On the contrary, other plans, like Plan G and Plan N, are often better deals in cases where the premiums savings are greater than the differences in coverage between those plans and Plan F. In other words, if you can save $300/year by buying Plan G and only lose the coverage of the Medicare Part B deductible (which is lower than that), you would come out better on ‘G’ than ‘F’.
- MYTH: Bigger name companies are better for Medigap or pay claims better/faster.
FACT: Premiums should be the determining factor in choosing a Medigap plan. Often, the bigger name companies do not have to be as competitive on price (because of this myth). But in reality, all Medigap companies pay claims the same way, can be used at any doctor nationwide and work the same way.