1 info sheet Medicare is the basic federal health insurance for older persons and for younger people with disabilities. Because Medicare has gaps in coverage, many people also buy a Medigap policy to supplement their Medicare coverage. This tip sheet describes the various Medigap plans and benefits, and offers advice on how to choose between them. It includes information of special interest to those on low incomes, with disabilities, and with coverage through their former employers. How to be a smart shopper for Medigap insurance Medigap Insurance It is no secret that premiums for Medigap policies have been increasing. Insurance companies can increase their premiums due to inflation or high claims costs. Think twice about buying a policy that strains your budget today since the premiums will likely increase. When shopping for a policy you may want to research companies financial ratings using rating guides that may be available in your local public library and then consider the following: Price. It is very important to compare premiums when shopping for Medigap insurance. There are great variations in the premiums that different companies charge for exactly the same coverage. When evaluating premiums, be sure you are comparing identical plans. A key to price shopping is understanding that companies use three different methods to calculate annual premiums: - Issue age. When the policy is issued, your premium is set at the level required for your age. For example, if you buy the policy at age 65, you will always pay the rate that the company charges people who are 65, regardless of your current age. - Attained age. Your premium is based upon your current age and increases automatically as you grow older. Typically, these plans will appear to be less expensive at younger ages, but they may cost considerably more in later years. - No age rating. A few companies charge one premium for all policyholders. For people over age 75, this type of policy may be less costly. Consider what one policy is likely to cost you over the next five or ten years compared to premiums for other policies. Be alert for discounts that some policies make available to couples or nonsmokers. Open enrollment period. Companies are prohibited from denying Medigap coverage to Medicare beneficiaries during a one-time open enrollment period at age 65, but you may have to wait as long as six months for pre-existing conditions to be covered. This window is available to Medicare beneficiaries only during the six-month period following their 65th birthday or, if older, on the first day they enroll in Medicare Part B. Special rules apply for people who work after age 65. Younger people with disabilities who receive Medicare should check with their state insurance department because special rules may allow them to purchase a policy. NOT FDIC INSURED MAY LOSE VALUE NO BANK GUARANTEE
2 info sheet Medigap Insurance/2 Medical underwriting. In most states, For 63 days following one of the events above the companies can refuse to issue a Medigap beneficiary is guaranteed issuance of a Medigap policy policy based on applicants health conditions without exclusion because of pre-existing condition (except during the open enrollment period and without being charged a higher premium. Some and when guaranteed issue conditions people may be able to go back to their previous [i.e., when companies must issue a policy Medigap, others can get Plans A, B, C, or F or may be regardless of pre-existing conditions] apply). entitled to A-J depending on the circumstances of their This is called medical underwriting. Many enrollment in the plan. (see pages 2-4 for descriptions companies medically underwrite all of their of Plans A-J.) policies. Companies whose policies are mostly guaranteed issue, however, still medically Benefits in standard Medigap plans underwrite Plans H, I, and J, except during the open enrollment period. All Medigap policies issued since 1992 must match one of 10 standard benefit plans, labeled A through J. Once Waiting period. Companies can refuse to pay claims for pre-existing health conditions for up you understand Medicare coverage and the benefits to six months after you buy a policy. Not all provided in the 10 Medigap insurance plans, you can companies have this restriction, and some have a select the one that best meets your needs. Below are shorter waiting period. If you have had other descriptions of the gaps in Medicare coverage that are coverage, such as a group health plan, or a filled by the standard Medigap plans. Medigap policy for more than six months before applying, this restriction will not apply to you. Basic benefits (included in all 10 plans) Additional protections. Medicare beneficiaries Medicare Part A: hospital services. All plans pay who choose a MEDICARE+CHOICE PLAN have the co-payment of $194/day for hospital days additional protections if any of these events per benefit period; $388/day for days have occurred: ; and 100% of up to 365 additional days an individual lost his or her retiree coverage per lifetime. or all of the benefits supplementing Medicare Medicare Part B: medical services. All plans were dropped; cover the 20% co-payment of Medicare s the beneficiary joined a managed care plan allowed amount for medical expenses and that terminates a contract with Medicare or the 50% co-payment for mental health services ceases operations; after an annual $100 deductible. the individual moves outside the service Blood. All plans pay for the first three area of a managed care plan; or pints yearly. an individual has first tried a Medicare Part A: inpatient hospital deductible MEDICARE+CHOICE PLAN and has (included in Plans B through J) less than 12 months experience with Pays the $776 deductible for hospital stays in the plan before choosing to disenroll. each new benefit period. You may need this benefit if it would be difficult for you to pay this deductible. Remember, this is a deductible you could pay more than once per year.
3 info sheet Medigap Insurance/3 Medicare Part A: skilled nursing home Personal care is assistance with activities of daily co-payment (included in Plans C through J) living such as bathing, eating, dressing, using the toilet, and moving around your home. This Pays $97 per day for days of daily benefit will pay toward one personal care visit skilled care in a nursing home per benefit for every home health visit paid for by Medicare. period. Only a small portion of Medicare This benefit does not pay for long-term care. beneficiaries require daily skilled care in a nursing home. Because Medigap policies pay Medicare Part B: excess doctor charges only for services covered by Medicare, the (100% coverage in Plans F, I, and J; 80% Medigap coverage is also limited. coverage in Plan G) Medicare Part B: deductible (included in Plans Pays the difference between the doctor s C, F, and J) actual charges and the Medicare-approved amount. Under federal law, physicians who Pays for the first $100 of Medicare-covered do not accept assignment cannot charge you medical services in each calendar year. more than 115% of the Medicare-approved Although this benefit is very popular, it is amount. This benefit pays either 80% or likely to cost as much or more than the 100% of those excess fees for services approved maximum benefit you can receive. and paid for by Medicare. If most or all of your Foreign travel emergency (included in Plans doctors accept Medicare assignment, you C through J) probably do not need this benefit. Covers medically necessary emergency care that Preventive screening (included in Plans E and J) begins during the first two months of each trip Pays up to $120 per year for health care outside the United States. After you pay the $250 screening and other preventive health services calendar-year deductible, the benefit covers 80% not covered by Medicare, as long as they are of emergency care in another country while you ordered by your physician. This benefit typically are traveling, for three months or less. There is a adds about $120 to the cost of a policy. lifetime maximum of $50,000. The benefit is useful if you travel abroad or if you live in a Outpatient prescription drugs (basic coverage in border state. But if you plan to live abroad for Plans H and I; extended coverage in Plan J) several months per year, this benefit does not Provides limited coverage for drugs prescribed by provide adequate health care coverage. your doctor. This benefit requires that you keep At-home recovery (included in Plans D, G, I, good records of your prescription drug expenses and J) because you have to file the claims yourself. Pays up to $40 per visit for no more than seven Basic coverage: after you pay a $250 calendar-year visits per week for personal care services, but deductible, the basic coverage pays 50% only when you also require skilled home health of outpatient prescription drug charges up care that is covered by Medicare following an to a maximum of $1,250 in each calendar year. illness, injury, or surgery. The personal care must Your prescriptions would have to cost be ordered by your doctor and can be used for $2,750 per year for you to receive the up to eight weeks after the Medicare visits stop. maximum benefit of $1,250. The maximum annual benefit is $1,600.
4 info sheet Medigap Insurance/4 Extended coverage: after you pay a $250 Not all consumers have a choice of all 10 plans calendar-year deductible, the extended for two reasons: coverage pays 50% of charges up to a - Some companies offer only two or three of maximum benefit of $3,000 in each calendar these plans. year. Your prescription costs would need to - You will be restricted to purchasing from a exceed $6,250 each year for you to receive the company whose policies have been approved maximum benefit. for sale in your state. Check with your state insurance department for a current list. Comparing Medigap plans Some companies allow you to switch among Some consumers will have a choice of 10 standard Plans A through G at any time without being plans. Others will not because many insurance rejected. For example, if you originally buy companies do not offer all 10 plans. It is common for a Plan C but later find that Plan G better suits company to offer only three or four. To decide which your needs, some companies let you make plan is most appropriate for you, consider your health this change. needs and economic circumstances. People who are Prescription coverage has significant restrictions. very sick or who already have high drug or medical The most any plan will pay is 50% after a yearly expenses will be able to get some plans only if they are deductible and with an annual limit. Even under eligible for open enrollment. Plan J your prescription costs would need to exceed $6,250 each year for you to get the Some things to remember maximum benefits. As you look at the chart on page 6 and read about the The hospital deductible is applied per benefit benefits offered, these observations may prove helpful: period and could occur several times a year. There may be no savings in having the cost Plan A is the least expensive and least of the $100 Part B deductible and preventive comprehensive, while Plan J is the most screening coverage -- the typical cost may be expensive and most comprehensive. the same as the benefit. Plans F, G, I, and J may be attractive to people The at-home recovery benefit may provide limited whose doctors do not accept assignment. These help to those who were receiving the home plans pay the difference between the doctor s health benefit and live alone and/or do not have limiting charges that can be up to 15% over a family support system to provide care. Medicare s approved payment amount. Extensive and comprehensive custodial care may Plans H, J, and I offer some protection against be covered only under a separate private longterm care insurance policy. high prescription costs. Most companies will not sell you these plans if you already have high bills for prescription drugs. Only when you first enroll in Part B can you select any plan and be guaranteed coverage.
5 info sheet Medigap Insurance/5 The need to insure for excess doctor charges can Standard Medigap Benefit Plans be reduced in two ways: Plan A offers the least expensive and least - Select doctors who accept assignment. This comprehensive coverage. It is only appropriate for means that they accept Medicare-approved people who can afford some out-of-pocket medical charges as payment in full. costs, or for people covered by an employer plan who - Ask a doctor to accept assignment. Some will have to pay deductibles and coinsurance that this do so, particularly a specialist whom you Medigap plan might cover. would see on a limited basis or for a specific procedure. Federal law prohibits doctors in Plan B offers the same coverage as Plan A except that the Medicare program from charging more Plan B also covers the $776 deductible charge for the than 115% of the Medicare-approved amount. first day you are in a hospital. If your income is limited Some states reduce or prohibit the amount a and you are concerned about this cost, Plan B may be doctor charges Medicare patients in excess your best choice. of the approved amount. You should check with your state s insurance department. Plan C is appropriate if you want more coverage than Although Medicare can help to pay for up to 100 Plans A or B offer, and if most of your doctors accept days in a skilled-nursing home, Medicare pays Medicare assignment. It is likely to cost about the same only for an average of 28 days in a nursing home as Plans D, E, and G. because of the strict eligibility requirements for skilled nursing care. If approved, Medicare will pay 100% for day 1-20 and all but $97 per day for Plan D makes sense for people who anticipate a need days for this skilled care. for the at-home recovery benefit and who see doctors who accept Medicare assignment. An option to Plans F and J, that may not be approved in all states, adds a $1,500 annual deductible to these policies before the benefits Plan E is appropriate for people who are basically of Plan F or J are paid. Plans with this high healthy and who want preventive health services deductible option will have lower premiums. on a regular basis. Remember, if you buy this policy, you will be paying for $120 worth of health screening Remember: If Medicare does not pay for a service, your Medigap policy will not pay either. and preventive health services, whether or not you Medigap pays only after Medicare has paid the use them. approved amount of the charge. Retiree plans may be significantly different than a Medigap Plan F makes the most sense for people who see policy. Check with your plan administrator for doctors who do not accept Medicare assignment. Keep more information. in mind that doctors are now prohibited from charging more than 15% above the Medicare-approved amount. If your costs for these charges are relatively small or most of your doctors take assignment, you may be better off with a different plan.
6 info sheet Medigap Insurance/6 Plan G is appropriate for consumers whose doctors don t accept Medicare assignment and who also want the at-home recovery benefit. Only 80% of the excess doctor charges are covered under this plan, and the Part B deductible ($100) isn t covered either. The cost Plan I is more expensive than Plan H because it also includes coverage for excess doctor charges and the at-home recovery benefit. If you want comprehensive coverage and can easily afford the premiums, this plan may be most appropriate. of this plan is usually comparable to Plans C, D, and E. Plan J is the most comprehensive and expensive plan Plan H is usually the least expensive plan offering prescription drug coverage. It makes sense for people who want drug coverage and whose doctors accept available and includes all the possible benefits in the plans discussed above. This plan is appropriate only for people who can afford the cost. Medicare assignment. The drug benefit is limited; you will be reimbursed for no more than 50% of your drug bills, and the maximum reimbursement is $1,250. Medigap benefits by plan Medigap benefits A B C D E F G H I J Basic benefits Part A: hospital deductible Part A: skilled nursing home co-payment Part B: deductible Foreign travel emergency At-home recovery Part B: excess 100% 80% 100% 100% doctor charges Preventive screening Outpatient basic basic extended prescription drugs Notes: - States may allow only some of the 10 benefit plans to be sold. - States may approve innovative additional benefit plans under certain circumstances. - These standard benefit plans do not apply to policies sold in Massachusetts, Minnesota, and Wisconsin. - Availability of plans will vary from company to company. - Plans F and J now offer a $1,500 deductible option.
7 info sheet Medigap Insurance/7 MEDICARE+CHOICE options HMO with Point of Service (POS). These plans are similar to HMOs described above, except About one in every six Medicare beneficiaries enrollees may choose to receive services from (6.3 million) is now enrolled in a MEDICARE+CHOICE providers outside the network for additional organization, primarily a Medicare managed care plan. out-of-pocket costs. Although the majority of MEDICARE+CHOICE Provider-Sponsored Organization (PSO). organizations will remain in the program this year, PSOs are a relatively new form of managed care many will increase premiums, as well as reduce or similar to HMOs, except that they are owned and restructure benefits. As a result, enrollee out-of-pocket operated by the locally based doctors and costs will likely increase. A major factor behind this hospitals that provide most of the services. increase is the rising cost of offering prescription Services received outside of the provider drug coverage one of the most attractive features network will not be paid for except for for beneficiaries. Be aware that some managed care emergency medical care. plans are dropping doctors and hospitals from their Preferred Provider Organization (PPO). Similar network, and some doctors and hospitals are to the HMO with POS option above in which withdrawing from managed care plans. enrollees can receive services at discounted rates from a network of providers set up by the plan. It is important to note that the availability and cost Unlike HMOs, many PPOs do not require their of these plans vary widely based upon your age, place enrollees to stay in the network or get approval of residence, and the level of benefits and coverage from a primary care physician (gatekeeper) prior you desire. to seeing a specialist. Benefits and costs may change if you use services outside the network. Medicare managed care plans include Some advantages of Medicare managed care plans may include Health Maintenance Organization (HMO). HMOs are the most popular form of managed - additional benefits such as prescription drugs care plans and are required by law to provide and eyeglasses the same service available under original - predictable out-of-pocket costs Medicare. Enrollees must use doctors, hospitals, and other providers from the network set up - smaller premium than Medigap plans by the HMO; services received outside the - almost no paperwork network are not covered, except for emergency - coordination of medical services through a or urgent care. Many HMOs offer additional primary care physician (gatekeeper) services, such as hearing aids, vision exams, - an emphasis on preventive care and some prescription drug coverage not offered under the original Medicare program. HMO Some disadvantages of Medicare managed care plans enrollees generally do not need to buy may include a separate Medigap insurance policy, usually resulting in lower out-of-pocket costs. HMOs - smaller choice of physicians and other have the right to charge monthly premiums, providers co-payments, and to change benefits at their - inability to go to specialists without a referral annual contract renewal. from a primary care doctor
8 info sheet Medigap Insurance/8 - limited coverage outside the service area months before your 65th birthday. Medicare may be - If the managed care plan drops service your secondary coverage and the usual penalties for not in your area, or you move away, your applying for Medicare Part B at age 65 will not apply. return to original Medicare with a Medigap policy may cost more due to newly acquired Low-income Medicare beneficiaries health conditions. If you cannot afford to pay your Medicare premiums - Beginning in 2002 you will be able to and other costs, you may be eligible to get help from disenroll from an managed care plan your state. You may qualify for one of the following only during the open enrollment period assistance programs: each autumn. Other types of plans may become available in the Medicaid. If you have a low income and future, such as religious fraternal benefit society few assets, you may be eligible for Medicaid, plans, medical savings accounts, and private fee-forservice plans. government sets basic requirements and a federal-state assistance program. The federal guidelines, and partially funds this program. Special considerations Each state provides some funding and may select other optional components, thus causing the Employer or union health insurance plans coverage to vary by state. In some states you may If you continue coverage through your employer or be eligible if your high medical bills force you to union after you retire, it is probably not a Medigap spend down much of your income and assets. policy and is not standardized or subject to Medigap If you qualify, Medicaid covers most of your regulations. However a retiree policy may offer better health care expenses including extended nursing benefits than a Medigap, particularly on prescription home care not covered under Medicare. coverage. If you drop or lose this coverage and wish to Qualified Medicare Beneficiary (QMB). Medicare purchase a Medigap policy, you may be subject to beneficiaries who are not eligible for Medicaid waiting periods for pre-existing conditions, higher may qualify for the QMB program if their income premiums, or possibly denial of coverage. and assets are limited. Income must be at or below the national poverty level (in most states Recently, many employers have cut health benefits in 1999 it was $707 per month for an individual for retirees, increased deductibles and co-payments, and $942 per month for a couple) and total individual assets cannot be more than $4,000 for or required retirees to pay a higher share of the an individual and $6,000 for a couple. QMB pays premiums. Find out from your company or union what the Medicare deductible ($776 for inpatient care; rights your employer has to make changes in your $100 per year for doctor s visits), the Medicare coverage. After you review the premium, if any, and Part B premium, and co-payments. Some state coverage the employer policy offers, you may wish to QMB programs also pay for additional medical compare the price and coverage with other options. services such as prescriptions. Specified Low-Income Medicare Beneficiaries Different rules apply to people or spouses of people (SLMB). The SLMB program pays the Part B who plan to work past age 65. Nevertheless, be sure to premiums only for individuals with slightly get all pertinent information from your Social Security higher monthly incomes and low assets. office and your employer s benefits department several Monthly income in most states in 1999 could
9 info sheet not exceed $844 per month for an individual and $1,126 per month for a couple. If you feel that you may be eligible for Medicaid, QMB, or SLMB contact the local state Medical Assistance office. Phone to obtain the phone number for your state. People with disabilities under age 65 If you are under age 65 and eligible for Medicare due to a disability or end-stage renal disease, you may want a Medigap policy. Unfortunately, only a few companies offer Medigap policies to people with disabilities who are younger than 65. Ask your state insurance department for a list of companies that sell Medigap policies to younger Medicare beneficiaries. Since younger Medicare beneficiaries do not have a six-month open enrollment period at the time of eligibility as those 65 and older do, when a disabled person becomes 65 they are entitled to an open enrollment period. Some states have more generous requirements. Resources for Further Information MFS Heritage Planning SM MedicareMap ask your investment professional for a copy Medicare (The Official U.S. Government site) review Medicare & You, the annual handbook, online; get answers to the top 20 Medicare/Medicaid questions; compare health plan options and nursing homes Detlefs, Dale and Myers, Robert J Mercer Guide to Social Security and Medicare. William M. Mercer, 2000, 200 p., $ United Seniors Health Cooperative. All rights reserved. MFS Fund Distributors, Inc., 500 Boylston St., Boston, MA Medigap Insurance/9 H pdf United Seniors Health Cooperative (USHC) 409 Third Street, SW, #200 Washington, DC USHC is a non-profit, independent consumer organization, which sells a number of helpful publications. These include Managing Your Health Care Finances, Long-Term Care Planning: A Dollar & Sense Guide, and the United Seniors Health Report newsletter. To learn more about USHC s publications and services, call Ask for a complimentary copy of the newsletter and a list of publications. U.S. Health Care Financing Administration (HCFA) HCFA administers the federal Medicare and Medicaid programs and offers publications, including the Guide to Health Insurance for People with Medicare, Learning About Medicare Health Plans, and Medicare and You, which is revised annually to reflect legislative and regulatory changes. Call the national Medicare hotline at for free copies of these publications, for help with Medicare, or to report questionable practices. Medicare and You is available on audiotape, on TTY, and in Spanish. You can also look on their Web site: This material is not intended to replace the advice of a qualified professional. Prior to making any commitments regarding the information discussed, please be sure to consult with the appropriate qualified professional. This material was prepared by Ceridian Performance Partners (CPP); accordingly CPP (not MFS Fund Distributors, Inc.) is solely responsible for the accuracy of the content. Contact your investment professional for more information or to construct a personalized Heritage Planning Profile to help your parents, your children, or yourself.