Medigap Plan Benefits

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Long-term care insurance

Medigap plans are insurance policies which pay for some of the deducible and/or co-insurance costs that Medicare does not pay. Medigap plans are required to be labeled A through L and must contain the benefits listed below which are indicated with "Yes" regardless of which company sells it. This allows a comparison of premiums between different insurance companies for the same Medigap plan. Insurance companies, however, don't have to sell all twelve of the Medigap plans.

Updated for 2009

Yes indicates that the benefit is covered by the Plan

Benefits

F¹

J¹

Basic benefits coinsurance for days 61-150 of a hospital stay, all costs of an additional 365 days in a hospital in lifetime, coinsurance for physician and other Part B services after deductible is met, and 1^st 3 pints of blood.

Yes

Part A - Hospital deductible.

Yes

50%

75%

Skilled nursing facility coinsurance for days 21-100.

Yes

50%

75%

Part B deductible.

Yes

Part B excess charges 100% of the excess charges of Medicare's approved amount.

Yes

80%

Yes

Emergency care outside the U.S. 80% of cost for medically necessary emergency care, after a $250 deductible. Expenses must occur during 1^st 60 days outside U.S. up to a lifetime benefit of $50,000.

Yes

At-home recovery $40 per visit for up to 40 visits annually while receiving Medicare approved Home Health care.

Yes

Preventive services up to $120 a year if ordered by a doctor.

Yes

Annual Out-of-Pocket Limit ²

$4,620 ²

$2,310 ²

¹ Plans F & J also offer a high deductible option where you pay the first $2,000 (in 2009) during the calendar year before the plan pays anything.

² For plans K & L, after you meet your annual out-of-pocket limit (last line above) the plan pays for everything for the remainder of the calendar year.

There is a limited open enrollment period when Medicare eligible beneficiaries can enroll in Medigap plans regardless of preexisting conditions. The initial enrollment period is the first 6 months after you become eligible for Medicare Part B.

Medigap plans and traditional Medicare coverage don't cover eye exams, eyeglasses, hearing aids, or dental care. However, some Medicare approved HMOs may cover some of these.

Medicare and Medigap plans don't cover medical care received outside of the U.S. unless listed above.

Medicare and Medigap plans don't cover long-term custodial care at home or in a nursing home. Medicare fully covers 20 days of short-term skilled care in a skilled nursing facility, after a hospital stay of 3 days or longer, and partially covers days 21 to 100.

There are long-term care (LTC) insurance policies (separate from Medigap polices) which cover care at home or in a nursing home. These policies have different limitations, such as:

Some LTC policies pay cash once you meet eligibility requirements which can be spent on the care of your choice.
Other LTC policies only cover care in a specifically defined location.
Most policies have an elimination or exclusion period during which the policy doesn't pay.
There may be a waiting period between the time you sign-up and when the policy starts.
Consider a rider to protect against inflation if the costs of care should rise.
An insurance company's definition of a covered service may not mean what you think. Skilled nursing home care, for example, is not the same as long-term or custodial nursing home care.
Finally, some LTC policies require that the patient have a certain number of limitations of everyday activities before it will pay.

Ask your insurance agent about the definition of each covered service, as well as, how much the LTC policy costs.

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