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Medigap Plans


By: CalMedicare.org

Overview

There are 10 standardized Medigap plans — identified as A through J — sold by private insurance companies. No matter which company sells you one of these Medigap policies, each of the 10 plans must, by law, cover the basic benefits that are in Plan A. Most of the plans also offer some additional benefits.

No matter where you are in California, if insurance companies offer any of the 10 policies (A-J), they cannot change the benefits of those plans. The premium cost, however, can vary widely among insurance companies.

Some insurance companies can receive your claims directly from Medicare. This electronic claims service means you will not have to bill the company for your benefits.

Basic benefits

All A-J Medigap policies must offer the following basic benefits:

  • Co-insurance for hospital days 61-90 and co-insurance for the 60 lifetime reserve days
  • 100% of the cost for hospital care beyond the 150 days covered by Medicare, up to a maximum of 365 lifetime days
  • 20% co-insurance for Medicare-approved charges after the $110 Part B Medicare deductible (for 2005) has been paid
  • The first three pints of blood

The 10 Medigap policies

  A B C D E F* G H I J*
Basic Benefits:
All Part A hospital co-insurance, plus 100% of costs for a lifetime maximum of 365 additional hospital days; Part B co-insurance (20% of the Medicare-approved amount); three pints of blood (Parts A & B)
Part A Hospital Deductible
First day deductible, $912 in 2005 (per benefit period)
 
SNF Co-payment
$114 per day in 2005 for days 21-100 of skilled care in a skilled nursing facility (per benefit period)
   
Part B Deductible
First $110 of Part B services each year (for 2005)
             
Part B Excess Charges
80% or 100% of physician charges up to 15% above the Medicare-approved amount
          100% 80%   100% 100%
Foreign Travel Emergencies
80% of emergency care during the first two months of travel, after a $250 deductible, for a lifetime maximum of $50,000
   
At-Home Recovery
Maximum of $40/visit up to $1600 a year, while receiving Medicare-covered home health care, or for 8 weeks afterwards
           
Preventive Care
$120 per year for physician-ordered health screenings
               

Outpatient Prescription Drugs**

1. Basic coverage: 50% of outpatient prescription drug costs, after a calendar year deductible of $250, up to a maximum benefit of $1250                
2. Extended coverage: 50% of outpatient prescription drug costs, after a calendar year deductible of $250, up to a maximum benefit of $3000                  
  A B C D E F* G H I J*


*Policies F and J may be sold with a high deductible option of $1,730 in 2005. The benefits remain the same, but the deductible must be met each year before any claims will be paid.

**When the new Medicare Part D drug benefit takes effect in 2006, no Medigap policies sold after January 1, 2006 can include  drug coverage. People who have purchased a Medigap policy with drug benefits before this date, have a couple of options. They can 1) choose to keep their Medigap policy with drug coverage and not sign up for Part D; or 2) buy a new Medigap without drug benefits and sign up for a Medicare Part D prescription drug plan with one of the private companies offering one of those plans in 2006. Medigap companies will begin notifying people of their options in September 2005 if they have a Medigap with a drug benefit.

Medicare Select

Some insurance companies offer Medigap policies called Medicare Select plans. These plans are like managed care plans.

Medicare Select plans must cover the benefits listed in Medigap policies A-J, but they rely on a network (group) of selected providers to give you care. This is different from standard Medigap policies, where you can see any doctor you want.

If you want to use a doctor or hospital outside of a Medicare Select network, Original Medicare will still pay its share of the approved amount, but you may have to pay more than you would inside the network. In addition, some Medicare Select plans have prescription drug benefits that are different from those shown on the chart above. Medicare Select plans are sometimes less expensive than standard Medigap policies because some benefits are not paid outside the network.