No Gaps To understand: Here’s Your Primer On Medigap Coverage

Every year, seniors can opt from a Medicare Advantage plan and subscriber to original Medicare during open enrollment season, which begins on Oct. 15. But unexpected problems can arise with this particular change. Notably, seniors who wish to return to original Medicare might not be in a position to purchase Medigap, also referred to as Medigap coverage.

Medigap covers some or all the out-of-pocket costs associated with Medicare (deductibles, copayments and coinsurance), minimizing the financial risk to seniors. Under original Medicare, the world's your oyster to an individual's out-of-pocket liability. (By contrast, Medicare Advantage plans limit out-of-pocket costs to a maximum $6,700 annually.)

Yet private insurers have to offer Medigap policies only if people first enroll in Medicare and under a few special circumstances. Otherwise, insurers can refuse to cover people with preexisting conditions, for example diabetes and heart disease.

“People think they are able to choose Medicare Advantage one year and traditional Medicare another year, and shuttle quite easily,” said Tricia Neuman, senior v . p . in the Kaiser Family Foundation along with a co-author of a new report on consumer protections in Medigap. “But in states that don't guarantee supplemental coverage, this might 't be an authentic option.” (Kaiser Health News is definitely an editorially independent program from the foundation.)

Only four states require insurers to issue Medicare supplemental policies to adults age 65 and older, no matter their own health status: Connecticut, Massachusetts, Maine and New York. A large number of other states have more limited protections.

Craig Boyle, 69, learned about uncertainties surrounding Medigap the hard way 3 years ago, after he ran over a fire hose while biking to operate in Denver and landed on his head.

Rushed to the emergency room, Boyle was told that he'd broken a few vertebrae but were built with a much bigger problem: Scans revealed two tumors towards the top of his spine, compressing his spinal-cord.

Surgery was at order, and doctor friends recommended two local surgeons with significant experience in this rare procedure. But neither worked with Kaiser Permanente of Colorado, the Medicare Advantage plan Boyle had chosen when he turned 65.

Boyle thought he could switch to original Medicare and be treated with a specialist in the University of Colorado's Anschutz Medical Campus. But two large Medigap insurers declined to cover him because the spinal surgery was a disqualifying preexisting condition.

“I are saying, I'm fairly knowledgeable about insurance, however i was clueless that this was a possibility,” Boyle said.

He ended up getting lucky: A Medicare Advantage plan offered by Aetna in Colorado been on its network the University of Colorado surgeon he wanted to see. Boyle joined that plan (Medicare Advantage plans have to accept all applicants), had the procedure and experienced no significant complications afterward.

Because your health needs can alter after you first subscribe to Medicare, you need to understand the particulars of supplemental coverage, said Fred Riccardi, vice president of client services at the Medicare Rights Center. Your local chapter of SHIP (which often means Senior Medical health insurance Assistance Program) is a great place to start.

Here's some essential information about Medigap coverage:

Medigap basics. Medicare supplemental policies help fill gaps in traditional Medicare coverage. You will find 10 kinds of plans, each with standard benefits.

All plans cover coinsurance and copayments for Medicare Medicare part a (hospital services), Medicare Part B (physician services and outpatient care), and hospice care, in both full or in part. Basically one plan pays in full or in part for Medicare's hospital deductible – this season, $1,350 per stay in hospital. Some plans get coinsurance costs for skilled assisted living facilities ($167.50 each day following the first 20 days); some do not. Drug costs are not included among other benefits.

About 13 million people – over 95 percent of these older adults – had Medigap coverage in 2021, the most recent year for which data can be found.

Premiums vary based on someone's age, gender, geographic location and, in some states, smoking status. Monthly costs range from under $100 on the low end to in excess of $250 around the top end, said Katie Haug, an insurance coverage broker at Caravus in St. Louis.

Medigap open enrollment. Once you have enrolled in Medicare Medicare part b, insurers have to provide you with a Medigap policy, regardless of your health status, over the next six months.

If you've chosen original Medicare, your automatic to buy Medigap ends after this six-month period. Insurers can then exclude you from coverage or ask you for more for any policy if you have been recommended for surgery or if you have a pre-existing condition, for example chronic bronchitis, asthma or rheumatoid arthritis symptoms.

If you've selected a Medicare Advantage plan, you've 12 months to modify your mind, select original Medicare and be eligible for a a Medigap policy no matter your health status. This ends after you've been signed up for Medicare Advantage for any year. From this point on, Medigap insurers may take your medical status into account in deciding whether to provide you with coverage.

Special considerations. Under federal law, you get back your to buy a Medigap policy no matter your health status under the following conditions: in case your Medicare Advantage plan withdraws from the area where you live or perhaps is found guilty of fraud; should you leave your plan's service area; or maybe your retiree health coverage is canceled from your former employer.

Twenty-eight states go further by requiring insurers to issue Medigap policies to seniors when a company alters retiree coverage of health. (More than 13 million people on Medicare have out-of-pocket expenses covered through retiree health plans.) Nine states have a similar requirement for people who become ineligible for Medicaid. (A lot more than 7 million individuals on Medicare are also enrolled in Medicaid, which provides coverage for Medicare's out-of-pocket expenses.)

Last September, Boyle experienced another alternation in his insurance status when Aetna notified him it had been discontinuing his Medicare Advantage plan in Colorado. As this triggers an automatic to purchase Medigap coverage, he was able to transfer to original Medicare – this time, with supplemental coverage from UnitedHealthcare.

Now, he and the wife pay $360 a month for his or her supplemental coverage. This arrangement works better because the couple divides their time between Colorado and Florida, where she's relatives and it is treated for Parkinson's disease in a renowned clinic at the University of Florida.

“I have to say, I feel fortunate that things helped us,” he said, “even though there were some rocky parts on the way.”