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Do you know what a Medigap Policy is? These are policies offered by private insurance companies. However, there are not like the plans under Medicare Advantage Plans (the HMOs and PPOs). The basic Medigap policy reinforces your Original Medicare coverage to assist you with payment of your out-of-pocket costs, such as coinsurance, deductible, and copayments. We sometimes call this coverage “Medicare Supplement Insurance.”

If you opt for Medigap supplemental health insurance, you have many plans from which to select. However, there variances in fees from plan to plan can be substantial for comparable benefits. There are federal and state laws outlining policies Medigap policies must adhere to. These laws exist for your protection. A Medigap policy must be clearly identified as a ‘Medicare Supplement Insurance’ policy right on the front page of the policy itself. Medigap policies can cover only one individual. Thus, spouses must purchase their own policies.

Don’t get confused. These are NOT Medigap policies:

• Benefits Program
• Employer’s or union’s plans
• Indian Health Service, Tribal and Urban plans
• Long-term care insurance policies
• Medicare Advantage Plans like an HMO or PPO
• Medicare Prescription Drug Plans
• Medicaid
• TRICARE
• Veterans’ benefits

What exactly is covered by a basic Medigap Policy?

The only coverage a Medigap insurance company is permitted to offer to you is a “standardized” Medigap policy. Each standardized Medigap policy must offer identical benefits, regardless of the company offering coverage. Each policy is delineated by letters. The policies run from letter A through L. All Medigap insurance companies offering any coverage whatsoever, must also offer Plan A. However, the other lettered policies may not be available in all states. Be aware that not all plans will include basic benefits.

Medigap Benefits

• At-home Recovery (Up to Plan Limits)
• Blood (First 3 Pints)
• Foreign Travel Emergency (Up to Plan Limits)
• Hospice Care Coinsurance or Copayment
• Medicare Part A Deductible
• Medicare Part B Deductible
• Medicare Part B Excess Charges
• Medicare Part A Coinsurance and all costs after hospital benefits are exhausted
• Medicare Part B Coinsurance or Copayment for other than preventive services
• Medicare Preventive Care Part B Coinsurance
• Preventive Care Not Covered by Medicare (up to $120)
• Skilled Nursing Facility Care Coinsurance

What is not covered by a Medigap Policy?

The following are not covered:

• Eyeglasses
• Hearing aids
• Long-term care (care in a nursing home)
• Private-duty nursing
• Vision or dental care

Can I enroll in a Medigap Policy at any time?

You need to complete your enrollment during the open enrollment period, which starts of the first day of the month you are both enrolled in Medicare Part B and 65 years of age. The period lasts six months from that date.

If you attempt to enroll during that period, the insurance company cannot:

• Refuse you coverage of any plan it offers
• Delay start of coverage
• Adjust fees for a Medigap policy based on health problems
• There are instances in which a ‘pre-existing condition’ permits Medigap insurance companies to make you wait for a period of up to six months for coverage of that condition. Do your research, and make sure to ask whether you will be required to wait due to a pre-existing condition. You are not required to wait under all Medigap plans.

The insurance company will be required to reduce the waiting period or eliminate it altogether if:

• Your Medigap policy was purchased during an open enrollment period

If you purchased your policy after open enrollment you may still be entitled to reduced or eliminated waiting period if but you had health coverage that passes Medicare’s ‘Creditable Coverage’ criteria, which includes most types of health care insurance coverage.

Need to know if your basic health coverage is creditable coverage? Call Medigap insurance company or your State Insurance Department.

Your coverage cannot be considered creditable if you have had a break in coverage lasting more than 63 days in a row immediately before you buy your policy.

My open enrollment period has lapsed. What can I do now?

If you are out of your “open enrollment period,” no insurance company is required to extend you a policy. They are also permitted to increase your fees for any policy they do offer you. There are two exceptions to those scenarios. One, your private health care coverage has ended. Two, you were in a Medicare Advantage Plan. If you missed your open enrollment period, you will need to provide proof of your rights. Be prepared to provide copies of any letters, notices, or claim denials as proof of your continued health care coverage.

Please note:

• Your name must appear on all paperwork
• Retain and provide all postmarked envelopes from the insurance company in which the papers came. This helps you prove your dates of coverage.

If you missed your open enrollment period and want to sign up for Medigap insurance now, consider these tips:

• Apply before your current health coverage ends.
• To guard against a break in coverage, begin your Medigap coverage the day after your current policy ends.
• Investigate a Medicare Advantage Plan which may offer additional benefits.

Once I have Medigap, can my insurance company stop coverage?

If your Medigap policy was purchased after 1992, the insurance company cannot drop you as a client. Policies purchased after this time are guaranteed renewable.

The only conditions under which the insurance company can drop you are:

• You fail to pay your premium.
• You misrepresented facts on your Medigap policy application.
• The insurance company itself becomes insolvent or files bankruptcy.

Any policy purchased prior to 1992 could be at risk to be non-renewed. Prior to 1992, no laws were in place mandating that Medigap policies be guaranteed renewable. If the insurance company acquires state approval to cancel your Medigap policy bought prior to 1992, it can do so. If this were to occur, you have the legal right to purchase another Medigap policy from a different provider.

If you are a member of the Medicare Advantage Plan, original Medicare does not cover your expenses but this plan does. Usually, the Advantage Plan will cover prescription costs, a Medicare Part D feature. Medicare Part A & B benefits are covered under the Advantage program. The program is streamlined in that it provides all your Medicare health coverage in this one plan. Sometimes referred to as Medicare Part C, these programs are administered by private firms but approved by Medicare. Being approved by Medicare, these options are similar to PPO’s and HMO’s and are known as Medicare Advantage Plans as well as (“Advantage Medicare”).

The program options for Medicare Advantage Plans:

* (HMO) Medicare Health Maintenance Organization: This provides for less expenses than the Original Medicare Plan. In the instance of an emergency you can go to any available facility, however you will otherwise be required to select from the plans list to obtain approved hospitals, specialists, or physicians for most HMOs. Options such as extra time in the hospital are sometimes provided by some HMOs. Health care items such as Part A and Part B must be included in HMO coverage.

* (PPO) Preferred Provider Organizations: With this alternative service, there will be additional expenses if you decide to go outside the PPO network to hospitals, physicians and other providers. Normally you would use providers, hospitals and physicians within the PPO network in this Medicare Advantage Plan.

* Medicare Special Needs Plans: Prescription drug coverage under Medicare Part D is always covered in this alternative. HIV/AIDS, congestive heart failure and diabetes are a few of the conditions that people have who are covered by most all of the Medicare Special Needs Plans. Catering to the needs of those they serve they provide a list of available drugs, choose of the providers to be approved, and otherwise create their benefits. People with special illnesses or diseases are those who are allowed to join these plans.

* Private Fee for Service Plans: This program may provide more benefits than the Original Medicare Program. Medicare covered benefits may cost you more or less in this plan. The cost which you pay and the services they pay for are determined by the plan. The primary benefit of this plan is that you may go to any Medicare approved hospital or physician who accepts the programs payment.

* (MSA) Medicare Medical Savings Account: Medicare Part D prescriptions are not included in these plans. Medicare accepted services are paid by the plan after you have payed up to the high deductible. Paying a variety of expenses with the proceeds in your account are decided by you. Any Medicare approved procedure’s costs are your responsibility.
Although, you are not required to pay the regular Medicare Part B premium. This plan does not require that you pay a regular premium because it has a very high deductible. Medicare Part A and B protection is covered by Medicare Advantage Plans.

Medicare Advantage Plan: How To Qualify

If you satisfy the following conditions you should generally qualify for a Medicare Advantage Plan:

• You are not suffering from any End Stage Renal Disease (kidney transplant or permanent kidney failure which requires dialysis)
• You presently have active Medicare Part A and B protection.
• Determine the service location in which you are most interested and contact the plans about their areas. The service which you want to join must be where you live.

Medicare Advantage Plan: How To Join

Sometimes you may be able to change plans at times other than the standard one time per year. This is the reason for you to choose your plan carefully.

You must provide the date of joining Medicare Part A and/or Part B coverage, and you must provide your Medicare number from your Medicare card when you are ready to join a Medicare Advantage Plan. You may enroll online, call a Plan or by completing a paper application when you have chosen an Advantage Medicare Plan.

Medicare Advantage Plans: What is the cost?

A large number of aspects will determine the cost of an Advantage Medicare Plan. When purchasing a Medicare Advantage Plan you should consider the following questions:

• What do any extra benefits cost? Are they required for you? Does the plan carry this extra benefits?
• Will out of network providers or network providers be your preference?
• Do you need a certain specialist in health care? Will you need them immediately and frequently?
• When considering co-pays, what will each visit or procedure cost you?
• In addition to your Part B premium, are there any other monthly premium costs?
• Do any of the procedures or services have any deductibles?
• Are there any Part B premiums and does the Plan pay any of these?
• Are there any annual deductibles that the Plan charges?

Benefit Costs: What Are They?

Your services may not be covered at all and they may be higher if you see a provider who does not participate in the Plan. To assure that the plan satisfies your needs, learn your costs and find out the rules by calling the plan prior to joining.

When you turn 65, you automatically will be enrolled in Medicare Part A and Medicare Part B, provided that you are currently receiving Social Security or benefits from the Railroad Retirement Board (RRB).

If you are 65 and still working, and are not yet receiving benefits from Social Security or RRB, you will not automatically get Medicare Part A and Part B – you must sign up for these benefits. You may pre-enroll for a Medicare plan at point during the three months prior or three months following your 65th birthday. For example, if you turn 65 on June 10, you are eligible to enroll in a Medicare plan at any point between March 10 and September 10.

Your Medicare coverage becomes effective in the month you turn 65. So if your 65 birthday is on June 10, 2010, the date your Medicare coverage goes into effect would be June 1, 2010. Please note that if your birthday is on the 1st day of the month, your Medicare coverage for Part A and Part B actually goes into effect on the 1st day of the previous month. For instance, if your 65th birthday is June 1, 2010, then May 1, 2010, would be the date your Medicare coverage begins.

The Annual Election Period

The Annual Election Period extends from November 15 – December 31. If any changes are made during this period, they will go into effect the following January.

Open Enrollment Period

January 1 through March 31 is the designated Open Enrollment Period for Medicare Advantage Plans. During this time, you are not permitted to make any changes to your existing drug coverage. If you are currently enrolled in a drug coverage plan, you cannot drop out of it. If you don’t have a drug coverage plan, you can’t enroll in one during this three-month timespan. You may make only one change to a plan that is similar to the existing coverage.

The purpose of Medicare Part D is to offer coverage for prescription drug costs, which can be expensive. This coverage is provided by private insurance companies, who have contracted with and been approved by the government. If you already have Medicare Part A or Part B, you are eligible for Medicare Part D. If you’re interested in Medicare Part D, utilize our Comparison Tool to assist you in selecting a plan. You can even sign up right now on Medicare.com. If you’d prefer, you can phone one of our representatives to assist you with your enrollment. Dial 1-866-754-8910.

Each year there is a standard enrollment period during which you can change your plan. You can also enroll during that period as well. November 15 through December 31 is the annual enrollment period for Part D.

I’m not sure how to choose a plan. What should I look for?

• Costs – The Medicare Plan Comparison Tool will help you easily and quickly line up costs on your selected plans to help you decide which plan will work best for you. This tool compares not only premiums, but deductibles and co-pays. You can also input the specific medications you take to get a full picture of your yearly out-of-pocket costs.
• Physicians/Providers – If you have a Medicare Advantage Plan (such as an HMO or PPO) and your Part D is provided through that plan, then you want to ensure that your current providers are part of that plan. If your physician is considered out of network, there are often additional fees. Sometimes a referral is required for you to see that physician. These are concerns you want to investigate.
• Travel Costs – Do you travel out of state? If so, you will want to know whether your Part D provided through your Medicare Advantage Plan will cover your medications in that particular state.

How much will this cost me in 2010?

• Premium - Your Part D coverage will cost you a monthly premium. This cost will fluctuate depending on the plan you chose.
• Deductible - Most plans require a yearly deductible. The average is $310. Typically, you will cover your medication expenses out of your own pocket until the total reaches $310. Once you have met your deductible, then you will only be responsible for 25% of the cost of your prescriptions thereafter until you reach the limit of $2830.
• Initial Coverage Limit - Your coverage is limited to $2830. After you have exceeded this amount, the coverage on your prescriptions ends. After that point, you will pay for your prescription costs out of pocket. Once you have paid for $4550 of your own prescription drugs, you reach the Coverage Gap or Donut Hole. (The $4550 amount includes deductibles and coinsurance fees.)
• Catastrophic Coverage - If your out of pocket expenses exceed $4550, you are now eligible for catastrophic coverage, which means that you will no longer cover your prescription medicine costs at 100%. You will be responsible for only 5% of your prescriptions costs for the rest of that year.

The Catastrophic Coverage period typically only impacts 4% of senior citizens covered by Medicare Part D. Those who most commonly qualify for the Coverage Gap do so paying for medications for these conditions:

1. ACE Inhibitors
2. Alzheimer’s
3. Angiotensin Receptor Blockers
4. Anti-depressants
5. Oral Anti-Diabetics
6. Osteoporosis
7. Proton Pump Inhibitors
8. Statins

Is there anything I can do to avoid falling into the Coverage Gap?

• Select Medicare Part D plans that cover all of your medications.
• Ask about are generic alternatives for your medications.
• Use local pharmacies that provide your drugs at lower costs ($4.00 to $5.00).
• Purchase your prescriptions from a mail-order pharmacy. (A 3 month supply of your medications can be obtained from a mail-order pharmacy for the cost of two co-payments.)

Is there any extra assistance for prescription costs?

If you want extra help with your prescription expenses, then you must join a Medicare drug plan. There is financial assistance available for deductibles, premiums, and co-pays. But you must qualify to receive assistance. Your eligibility depends upon your resources and income.

If you have the following conditions, you automatically qualify:

• A state Medicaid program provides your coverafe.
• Medicaid helps you pay your Medicare Part B premiums.
• You receive Supplemental Security Income (SSI) benefits, but not Medicaid.

If you do not qualify under one of the above conditions, you can still apply for assistance.

• Regardless of whether you qualify, you still need to join a Medicare drug plan to get the extra help.
• If you qualify, and you don’t join a drug plan, then Medicare will enroll you in a Medicare drug plan.

Think you may qualify for extra help? Phone Social Security at 1-800-772-1213, or visit the Social Security website or apply in person at your State Medical Assistance (Medicaid) office.

Are there prescriptions that won’t be covered under the plan?

There is a short list of medications not covered by these plans. These medications are reffered to as “excluded drugs.” Some plans have opted to include them as an additional benefit, although the Centers for Medicare & Medicaid Services (CMS) does not require the plans to cover these drugs.

The categories of medications not required for coverage by the plans:

• Barbiturates (seizure drugs)
• Benzodiazepines (anxiety drugs)
• Cosmetic (e.g., hair growth)
• Cough and cold
• Fertility
• Nonprescription drugs
• Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
• Smoking Cessation (prescription smoking cessation drugs are covered)
• Weight loss or weight gain

Medicare Part C is a term often used to refer to Advantage Plans such as HMOs and PPOs. For those eligible, these are private health plans that are Medicare approved. That means when you sign up for a Medicare Advantage Plan, you are officially in the Medicare system.

These Advantage Plans include medical (Part B) and hospital (Part A) coverage, as well as other services deemed medically necessary. Medicare Advantage Plans usually include some extra benefits, and most times also have Part D prescription coverage. Like other HMOs and PPOs, these Advantage Plans usually require that you use a certain network of doctors and hospitals in order to receive services. One major advantage of these plans is the cost savings. That’s because the out-of-pocket expenses in these plans is usually lower than those of Medicare by itself. That said, your actual costs will depend on the policy you choose and the services you use.

Medicare Part C Plan Options:

*Medicare PPO (Preferred Provider Organization) Plans

*Medicare HMO (Health Maintenance Organization) Plans

*Medicare PPFS (Private Fee-For-Service) Plans

*Medicare SNP (Special Needs Plans)

*Medicare MSA (Medical Savings Account) Plans.

You qualify for a Medicare Part C Plan if:

*You live within the geographic location covered by the plan. * You already qualify for Medicare Part A and Part B. *You are not suffering from End-Stage Renal Disease (You need a kidney transplant or dialysis due permanent kidney failure).

Since you are only allowed to switch plans once each year from November 15 through December 31, its is important to pick your plan wisely. There are, however, special circumstances which will allow you to change plans outside this window.

Brief Overview of Part B Coverage
Medicare Part B is an additional layer of benefit protection for citizens eligible to receive Medicare. The rationale for this added category is to ensure availability of health services that do not fall under the provisions of Part A. Broadly speaking, Part B provides payment for professional services rendered outside the hospital context as well as ancillary procedures and care for which Part A does not pay. Among these services are:

• Physician services – rendered either in a hospital setting or at an office visit, inpatient or outpatient
• Lab work and imaging studies
• Rehab therapy and physical therapist services
• Ambulance transportation
• Certain types of home-based care
• Medically required equipment and supply items

Medicare Part B must be specifically selected by its recipients and monthly contributions and an annual deductible will be required. The premium amount is withheld from recipients’ Social Security disbursements. Services, procedures and supplies eligible under Part B are subject to a 20 percent co-pay borne by the insured. The amount assessed for the premium goes up each year in January. Anyone failing to register for Medicare Part B at their initial period of eligibility may be burdened by increased monthly premiums for the remainder of their life.

How Can I Tell If I Am Covered by Part B?

Your Medicare enrollment card will state whether you receive Part B benefits. Those registered for Part B will have an indication of that fact on their card. Anyone not previously electing Part B can always decide to enroll at a later date. But, if the initial period of Part B enrollment eligibility has passed (the period 90 days prior and 90 days following the 65th birthday), Part B coverage may be more expensive.

Anyone wishing to sign up for Part B can do so by visiting a Social Security branch office or by telephoning the Social Security Administration toll free at 1-800-722-1213. Part B is not without cost, as a monthly assessment will be withheld from Social Security disbursements or retirement benefits. The Part B premium for 2010 will fall somewhere between $96.40 and $353.60, and is determined by income level. Further, there will be an annual deductible of $155 in 2010 for Part B coverage. Once the deductible amount has been met by the insured, Part B benefits commence. The majority of expenses will be subject to a 20 percent co-pay.

Upon enrollment, a trio of plan choices will be provided. It is important to select wisely, as the coverage differs depending on which is chosen. The available options are:

• Original Medicare Coverage Plan
• Medicare Advantage (comparable to HMOs or PPOs)
• Medicare fee-for-service coverage for private services

MEDICARE PART A: The portion of Medicare which was the initial protection, assists in covering hospital expenses and is titled as: Medicare Part A.

MEDICARE PART B: An additional section of Medicare covers the expenses for various supplies and doctors visits beyond the hospital and approved clinics. This program was developed to add to the protection for those people who have qualified for basic Medicare coverage. This is Medicare Part B.

MEDICARE PART C: Plans created which were Medicare approved including medical coverage through private health organizations: such as PPO’s and HMO’s, also known as Medicare Advantage Plans. These are included under Medicare Part C.

MEDICARE PART D: The most recent addition to Medicare is for prescription drug protection. It requires membership in Medicare prior to applying for the drug coverage. This excellent new protection is part of Medicare Part D.

From having read the brief descriptions included above, you should have a basic understanding of your eligibility. Medicaid and Medicare benefit programs are supervised by the Centers for Medicare & Medicaid Services. Be aware that Medicare will not pay for all health and medical expenses, but it assists in paying for health care. Generally, those who are 65 and otherwise pass the qualification standards may be approved for this program offered by the U.S. Government. There are exceptions where younger people may qualify, such as those suffering from Lou Gehrig’s Illness, permanent kidney failure, and people with disabilities.