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Medigap Insurance

A Medigap policy is health insurance sold by private insurance companies to fill the �gaps� in Original Medicare Plan coverage. Medigap policies help pay some of the health care costs that the Original Medicare Plan doesn�t cover. If you are in the Original Medicare Plan and have a Medigap policy, then Medicare and your Medigap policy will pay both their shares of covered health care costs.

Insurance companies can only sell you a �standardized� Medigap policy. These Medigap policies must all have specific benefits so you can compare them easily.

You may be able to choose up to 12 different standardized Medigap policies (Medigap Plans A through L). Medigap policies must follow Federal and State laws. These laws protect you. A Medigap policy must be clearly identified on the cover as �Medicare Supplement Insurance�. Each plan, A through L, has a different set of basic and extra benefits.

It�s important to compare Medigap policies because costs can vary. The benefits in any Medigap Plan A through L are the same for any insurance company. Each insurance company decides which Medigap policies it wants to sell.

Generally, when you buy a Medigap policy you must have Medicare Part A and Part B. You will have to pay the monthly Medicare Part B premium. In addition, you will have to pay a premium to the Medigap insurance company.

You and your spouse must each buy separate Medigap policies. Your Medigap policy won�t cover any health care costs for your spouse.

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You can return your Medigap policy within 30 days after receiving it and get your money back with no questions asked. Be sure to keep a record of the date you received the policy. Read the policy as soon as you get it. If you return the policy to the company, use certified mail with a return receipt as proof that it was returned within the 30-day time limit.

Medicare Advantage plans do not have a 30-day free look period. If you drop your coverage, you may not be able to get it back.

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Look into Medicare prescription drug coverage. Medicare Part D can help you pay your prescription drug costs. There are exclusions for certain drugs, however, and Medicare Part D won�t pay for drugs covered by Medicare parts A or B. Medicare Part D plans are offered by private insurers approved by CMS. Coverage is not automatic. If you want it, you must select a Medicare-approved prescription drug plan and enroll in it. You are eligible if you have Medicare Part A or Part B.

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Medicare Select

Medicare Select is a type of Medigap policy that generally requires you to use doctors and other providers in the plan�s network for your routine care. If you use out-of-network providers, you�ll have to pay more of the cost. Medicare Select coverage can be issued by an insurance company or a Medicare HMO. If you leave a Medicare Select plan, the company must make available any non-Medicare Select Medigap policy it has on the market with comparable or lesser benefits.

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Medicare Advantage

You may have the option to join a Medicare Advantage plan (formerly called Medicare + Choice or Medicare Part C). CMS enters into annual contracts with insurance companies and managed care plans to provide Medicare Advantage coverage. Medicare Advantage plans include health maintenance organizations (HMOs), preferred provider plans (PPOs), private fee-for-service plans (PFFS), special needs plans, and medical savings accounts.

You can only join a Medicare Advantage plan if a plan is available in your area and you have Medicare Part A and Part B. Some plans may have additional eligibility requirements. Plans provide their members with a handbook upon enrollment that outlines the complaints and appeals process for denial of services.

Medicare Advantage plans might offer additional benefits and be cheaper than original Medicare. However, they�re not right for everyone. Your choice of providers in a Medicare Advantage plan may be restricted. Some plans will require you to use doctors and other providers in their �networks� for routine, nonemergency care. For other types of plans, your providers must agree to accept the plan�s terms and conditions before treating you.

Depending on where you live, you may have the option to choose between Medicare or a Medicare Advantage plan. If you are in a Medicare Advantage plan, you don�t need a Medigap policy. Medicare Advantage plans provide at least the same benefits as Medicare. There are several types of Medicare Advantage plans:

• managed care plans, which include HMOs, PPOs, provider-sponsored organizations, and religious fraternal benefit society plans
• private fee-for-service plans
• special needs plans
• Medicare medical savings accounts.

Medicare pays a monthly premium to the Medicare Advantage plan to provide your health care. The plan may require you to pay an additional premium and may charge you a copayment each time you go to the doctor or get a prescription.

To join a Medicare Advantage plan, you must have both Medicare parts A and B and live in an area that has a plan. Some plans have other eligibility criteria. Not all plans are available in all areas of the state. Call Medicare or visit the Medicare web page and select the Compare Health Plans and Medigap Policies in Your Area interactive page. You may also call TDI�s Consumer Help Line to learn which plans are available in your area.

Medicare HMOs typically require you to use only physicians and hospitals in the HMO�s network. A Medicare HMO with a point-of-service option allows you to choose your own doctors, but you will have to pay extra. With a private fee-for-service plan, you can generally go to any doctor or provider and receive care anywhere in the United States. The doctor and provider, however, must agree to treat you and to accept the plan�s payment terms.

If your Medicare Advantage plan terminates its contract in your service area, you have the right to purchase Medigap plans A, B, C, F, K, or L offered in Texas without regard to your medical history or condition. If your Medicare Advantage plan ends services in your area, it must explain to you in writing your options and timeframes to buy a Medigap policy.

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Medicare

The Centers for Medicare & Medicaid Services (CMS) administers Medicare, the nation's largest health insurance program, which covers nearly 40 million Americans. Medicare is a Health Insurance Program for people age 65 or older, some disabled people under age 65, and people of all ages with End-Stage Renal Disease (permanent kidney failure treated with dialysis or a transplant).

• People age 65 or older.
• People under age 65 with certain disabilities.
• People of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).

Part A (Hospital Insurance)
Most people don't have to pay for Part A.

Part B (Medical Insurance)
Most people pay monthly for Part B.

You can choose different ways to get the services covered by Medicare. Depending on where you live, you may have different choices. In most cases, when you first get Medicare, you are in the Original Medicare Plan. You may want to consider a Medicare Prescription Drug Plan to add drug coverage. Or, you may want to consider a Medicare Advantage Plan (like an HMO or PPO) that provides all your Part A, Part B, and often Part D coverage. You make a choice when you are first eligible for Medicare. Each year you can review your health and prescription needs and switch to a different plan in the fall.

As long as you have both Part A and Part B, items covered by Part A and Part B are covered whether you have the Original Medicare Plan, or you belong to a Medicare Advantage Plan (like an HMO or PPO). For more information see the Your Medicare Coverage database.

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