Are you wondering, “do I really need Medigap insurance?”, for most people the answer is Yes! Medicare Supplements are additional insurance policies that Medicare beneficiaries can purchase to cover the gaps in their Original Medicare (Medicare Part A and Medicare Part B) health insurance coverage.... (aka, “Medigap”) is worth every penny. It is not a waste of money. And it offers many valuable benefits. In this article, we’ll explain why.
- There are no out-of-pocket limits on Original Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage.... coverage. A serious illness or accident can spin up hospital and doctor bills very quickly.
- Medicare only covers about 80 percent of a beneficiary’s major medical costs. The other 20 percent is paid by the beneficiary, via A deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share.... and Coinsurance is a percentage of the total you are required to pay for a medical service. ... payments, or by the beneficiary’s Medigap insurance.
- With Original Medicare and a Medigap policy, most costs are covered up-front, making health care easier to budget in retirement.
- Medicare beneficiaries have a guaranteed issue right to buy Medicare supplement health insurance when they first qualify for their benefits. When this right expires, medical underwriting will determine eligibility.
- Medigap plans do not offer additional benefits such as prescription drug coverage or routine care for dental, vision, or hearing.
Don’t Let Your Opportunity Slip Away
This is so important, we feel the need to say it first. When you’re first eligible for Medicare (Parts A and B), you also have a one-time opportunity to apply for Medicare supplement insurance without having to go through medical underwriting. This benefit, known as Medicare supplement Guaranteed-issue is a right granted to Medicare beneficiaries and applies to Medicare Supplement insurance (aka, Medigap plans). All states and the federal government enforce this essential right, which protects Medicare beneficiaries from medical underwriting...., is only available once, and the window of opportunity is only six months. It’s your only chance to get coverage, regardless of any preexisting conditions.
Do you know the answer to these popular questions?
Most retirees have a fixed budget and can't afford to pay that much out of pocket. Without a Medicare supplement, you will not be protected from catastrophic medical costs. For more on this subject, see Do I Really Need Supplemental Insurance with Medicare?
Going with just Original Medicare and no supplemental coverage is financially unwise. The coverage gaps in Medicare are considerable, leaving you to pay the expensive deductibles and 20 percent of all your outpatient coverage out-of-pocket. Is Medicare supplement insurance worth the cost? Yes, it's worth every penny. For more information, read Are Medicare Supplement Plans Worth It?
A Medicare Advantage plan may be a better choice if you are exceptionally healthy or if you can get an employer-sponsored plan. The reason is that Medicare Advantage plans have an out-of-pocket maximum that protects you from serious medical bills. Healthy people rarely have large medical bills, so they get to take advantage of low premiums. People with an employer-sponsored plan generally get help with their copays.
If you're not in great health and don't have access to an employer-sponsored plan, Original Medicare plus a Medigap plan offers better coverage and generally allows you more choice in where you receive your care. To compare plans, visit this page and enter your zip code.
Is Medigap Insurance Worth It?
Medicare supplement plans, sometimes called a Medigap plan, are supplemental Medicare policies that help pay some of the shared healthcare costs baked into the Medicare system. Oftentimes people look at the monthly A premium is an amount that an insurance policyholder must pay for coverage. Premiums are typically paid on a monthly basis. In the federal Medicare program, there are four different types of premiums. ... for a Medigap plan and want to know if the extra coverage is really necessary? And more importantly, are Medigap plans worth the cost?
Medicare Only Pays About 80%
The first thing to understand is that Medicare Part A for inpatient care and Medicare Part B is medical coverage for people with Original Medicare. It covers doctor visits, specialists, lab tests and diagnostics, and durable medical equipment. Part A is for hospital inpatient care.... for outpatient care) is an 80/20 shared cost system. Medicare pays about 80% of all major medical costs and the beneficiary pays the rest. When you realize that a simple visit to the emergency room can cost hundreds of dollars, and a short stay in the hospital runs into the thousands, you quickly come to the conclusion that not having some additional coverage for major medical costs is very risky. That’s where a Medicare supplement insurance plan comes in.
Medigap Plans Cover Some of the 20% Gap in Orginal Medicare
There are 10 lettered Medicap plans (A through N). Each lettered plan represents a standardized insurance policy and covers the nine gaps in Medicare. These include:
- Medicare Part A Coinsurance & Hospital Costs
- Medicare Part A Skilled Nursing Facility Coinsurance
- Medicare Part A Deductible (per benefit period)
- Medicare Part A Hospice Care Coinsurance or Copayment
- Medicare Part B Deductible (annual)
- Medicare Part B Coinsurance or Copayment
- A Medicare Part B excess charge is the difference between a health care provider’s actual charge and Medicare’s approved amount for payment....
- Blood (first 3 pints)
- Foreign Travel Emergency
Medicare Part A is your Medicare Part A is hospital inpatient coverage for people with Original Medicare, whereas Part B is medical coverage for doctor visits, tests, etc.... and Medicare Part B is your medical coverage. Without additional coverage, you are responsible for the shared costs listed above. This surprises many people getting their Medicare benefits for the first time. And that’s why it’s so important to understand one basic fact. Healthcare in the United States is very expensive, and most people simply can’t afford to pay their share of hospital costs out-of-pocket. Medicare Parts A and B pay about 80 percent of your major medical costs. The beneficiary pays the other 20 percent out of pocket or through additional insurance.
IMPORTANT NOTE: Medicare supplements only cover the gaps in Original Medicare. So, if Medicare Part A and Medicare Part B do not cover a specific benefit, private insurance companies can’t cover it with a Medigap policy. This includes a prescription drug plan. Prescription drug coverage is available through stand-alone Medicare Part D is Medicare's prescription drug plan program. Plans are offered by private insurance companies and cover outpatient prescriptions.... plans.
Is it Better to Have Medicare Advantage or Medigap?
Most people looking into Medigap insurance want to know if it is a better option than Medicare Advantage. The answer is different for everyone. To answer this fundamental question for yourself, you need to consider several key factors, including:
- Your health
- Your financial situation
- Your retiree benefits
- Your travel plans
- Where you live
Your health now and in the future is a serious factor in choosing the best Medicare insurance. Sure, both Original Medicare and Medicare Advantage cover the same core major medical benefits. But, did you know that Medicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B).... are not required to cover your Medicare Part A and Medicare Part B benefits in the same way as Original Medicare?
This fact highlights one of the biggest disadvantages of Medicare Advantage. Here’s the difference.
With Original Medicare, a beneficiary’s out-of-pocket expenses are cut and dry. The beneficiary pays approximately 20 percent of all Medicare-covered costs (i.e., deductibles and coinsurance) and Medicare picks up the remaining 80 percent.
Medigap plans are designed to help beneficiaries pay the 20 percent gap by covering the various deductibles and coinsurance costs. Medicare Advantage plans also cover about 80 percent of all major healthcare costs. But, you can’t buy additional coverage for your 20 percent share.
So, if you are not in excellent health, your Out-of-pocket costs (aka, out-of-pocket medical expenses) are costs that a beneficiary must pay because their health insurance does not cover them. Out-of-pocket costs are found in the deductibles, copayments, and coinsurance outlined in each health..., through copays, will hit your wallet until you reach your plan’s out-of-pocket maximum (MOOP). And, as of 2021, that limit can be as high as $7,550 per year for in-network care.
In other words, if you are not a healthy person, Medicare Advantage can get very expensive. Private insurance companies are in business to make money, and the monthly premiums on their top insurance plans and the copayment they attach to various healthcare services reflect this.
Your Financial Situation
It may not seem fair, because we all paid into Medicare during our working years, but people with higher incomes and lower incomes get better Medicare insurance. Why is that?
Ask any financial advisor or health insurance expert and they will tell you that Original Medicare, combined with a Medigap Plan F or Plan G policy, is the best health insurance you can get if you have Medicare benefits. The reason this is true is that it completely removes the financial risk of high medical bills.
With Original Medicare plus a Medicare Supplement Plan F is the most comprehensive Medicare supplement plan available. This plan covers all Original Medicare deductibles, coinsurance, and copayments, leaving you with no out-of-pocket costs on all Medicare-approved services.... or Plan G, the bulk of all healthcare expenses as you age are covered up-front. For people with low incomes—those who qualify for both Medicare and Medicaid—the Medicare program offers additional assistance to help pay premiums, deductibles, and A copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service..... For these dual-eligible people, there are a growing number of Medicare Advantage Special Needs Plans (SNPs) that cover all Part A, Part B, and Part D benefits.
NOTE: No matter which Medicare insurance option you choose, you must continue to pay your monthly Medicare Part B premium for outpatient coverage. MA plan premiums and Medigap premiums do not replace what you owe for your Part B coverage. In other words, there’s no such thing as a free Medicare Advantage plan.
Your Retiree Benefits
You may not be wealthy or poor, but if you have retiree benefits that include health insurance, Medicare Advantage might be a good option. Many large companies, governments, and the railroad offer their retirees a Medicare Advantage group health plan and contribute to a portion of the costs. Many of these plans are quite generous, making them an excellent option, particularly for those who can’t afford a Medicare supplement.
Your Travel Plans
One of the big benefits of Original Medicare is that it travels with you anywhere you go in the USA or its territories. It doesn’t cover you when you travel abroad, but most Medigap policies do. People with Original Medicare coverage and a Medicare Supplement Plan C, also called Medigap Plan C, is one of the most comprehensive of the 10 standardized supplemental Medicare plans available in most states. In fact, only Medicare Plan F offers more coverage...., D, F, G, M, or N are covered at 80 percent when they have a foreign travel emergency. This isn’t the case with Medicare Advantage.
Yes, a Medicare Advantage plan will cover you in the USA if you have a medical emergency that necessitates a hospital stay, but it won’t cover you outside the USA, and you can’t see a doctor outside your coverage area for regular care. All of these costs will come out of your own pocket.
Where You Live
Where you live is a factor because counties with large metro areas generally have better healthcare provider networks and more private insurance health plan options. Also, as of 2021, some health plans are lowering their out-of-pocket limits to be more competitive. San Diego County and Los Angeles County are two good examples.
Both of these large counties have Medicare Advantage plans with a MOOP of less than $1,000. In small, rural counties, private health insurance options may be few or completely non-existent. For example, as of 2021, Alaska still does not have any Medicare Advantage plan options.
There are over 400 U.S., counties without private plans, leaving Original Medicare and Medigap the only option. The good news here is that the cost of Medicare supplement insurance generally tends to cost less in rural areas than it does in big cities. Not always, but generally.
It is also important to note that larger metro areas have more healthcare providers, which means your options for both specials and primary care doctors are generally excellent with the top Medicare Advantage plan. It also means that many of these same doctors and specialists are difficult to get appointments with if you have Original Medicare.
Why Do Medicare Advantage Plans Cost Less?
A big difference between Medicare Advantage and supplemental Medicare insurance is when you pay your healthcare costs. With Medicare Advantage, you pay most of the costs when you use services. With a Medigap plan, you pay most costs in advance.
This causes great confusion for many people and it gets them in trouble. Unlike Medicare Advantage, there are no Medicare supplement plans with no premiums. But, there are also no surprises. Here’s why:
- A Medigap plan pays its portion of approved expenses not covered by Medicare, including copayments, coinsurance, and deductibles.
- There is a variety of Medigap plans to meet your needs. Some plans cover all costs allowed by law.
- With a Medigap plan, there’s no network, so you can choose any doctor or hospital that accepts Original Medicare.
- A Medigap policy is guaranteed to renew each year (so long as you don’t commit fraud by lying on your application or fail to pay your premiums).
Why Do People Choose Medicare Supplement Plans?
There are several key benefits of supplemental plans. They include:
- Freedom to choose healthcare providers without referrals;
- Better coverage on deductibles and coinsurance;
- Coverage while traveling (both in the U.S. and abroad); and
- Coverage that’s easy-to-understand.
One way to truly understand the incredible value of Original Medicare plus a Medigap policy is to look at hospital insurance (Medicare Part A) coverage. All Medicare supplements cover the Part A hospital coinsurance, and most cover all or some of the Part A deductible, too.
These are, by far, the biggest medical care costs in Original Medicare. A recent Kaiser Family Foundation (KFF) study found that most people in a Medicare Advantage plan would incur higher hospitalization costs for a short inpatient stay than people with Original Medicare alone.
This fact should be a red flag warning to anyone considering Medicare Advantage, particularly people with a chronic health condition that may require inpatient care.
But is a Medicare Supplement Really Necessary?
Health insurance, like auto insurance, is a financial tool. We all buy insurance for different reasons, but most commonly we get it to protect us financially. To answer whether or not the cost is “worth it” depends on your personal financial situation.
In most areas, the average cost of supplemental insurance is less than most people think. Many people look at the best Medigap plans and get turned off by the premiums. But, there are more options than If you're turning age 65 this year, Medicare Supplement Plan G is the most comprehensive Medicare supplement you can buy. It's also the most popular. You might be thinking that Medicare Supplement Plan F is... (the best you can buy today) if your budget can’t afford it.
If you are in good health and believe you’ll stay that way into your 70s, you might be a good candidate for Medicare Supplemental Plan N is one of the ten standardized Medigap plans. Although it is one of the newest plans available, Medicare Plan N is quickly becoming a favorite with Baby Boomers aging into their.... This policy helps healthy people save money on premiums by charging you a small copay when you see your doctor (up to $20) or use the hospital emergency room (up to $50). With Plan N you’re also responsible for excess charges if your doctor does not accept Medicare’s standard rates for services.
There are other Medigap plans that let you share some of the costs so you can get a lower rate. We suggest that you speak with your insurance agent to get more advice. Call 1-855-728-0510 (TTY 711) and speak with a licensed HealthCompare insurance agent. There’s no obligation, and they offer more plan options than any other national agency.
What Are The Disadvantages of Medicare Supplement Plans?
Here are the cons of Original Medicare and a Medigap plan:
- A shrinking pool of doctors who accept patients that are not in a network plan;
- No extras; and
- Higher up-front costs.
What are the Benefits of Medicare Advantage?
Most Medicare Advantage plans are a form of managed care, primarily HMO (health maintenance organization) and PPO (preferred provider organization) plans. These types of plans favor healthy people.
In fact, the whole idea behind HMO plans is keeping people healthy to reduce costs. When you are healthy, the other advantage of Medicare’s private health plans really comes into play. That being their extra benefits.
Unlike Original Medicare, with or without Medigap coverage, Medicare Advantage plans can add additional benefits. The most common extra benefit is a prescription drug plan (Medicare Part D plan). But plans also add routine dental, vision, and hearing benefits, too.
Prescription drug coverage can add up quickly. Basic Part D prescription drug coverage, which you’ll need to buy if you keep your Original Medicare, can be as low as $20 but average about $34 per month. That gives beneficiaries that enroll in a Medicare Part C plan with Part D coverage a $408 benefit (annualized average value).
With basic dental and vision plans costing between $35 and $50 per month, insurance plans with these extra benefits offer healthy people greater cost savings.
Are Medicare Advantage Plans Bad Like People Say?
Above we talked about the differences between supplemental Medicare insurance and Medicare Advantage, and that may lead you to ask if Medicare Advantage plans are bad? In a word, no, but they are not the right choice for everyone.
Many people aging into their Medicare benefits now are used to employer group health plans that look a lot like Medicare Advantage plans. That’s because group health plans and Medicare Advantage use the familiar HMO (health maintenance organization) and PPO (preferred provider organization) managed healthcare delivery models.
When you and your family were young and healthy, the HMO and PPO style of healthcare delivery saves money. But, as we age, many people discover that their out-of-pocket costs actually go up with an HMO or PPO plan.
That’s because people with one or more chronic health conditions see their doctor and need emergency care more frequently, and they end up paying more copayments. For this very reason, Medicare Advantage has a built-in safety net system, which is a maximum out-of-pocket (MOOP) limit, which is currently $7,550 per year.
It can be lower, however, most plans are at the maximum allowed. But, the MOOP does not include your premiums or your cost of medications. So your actual out-of-pocket costs could be much higher.
You might be wondering if Medigap plans have a MOOP. Some do and some don’t. For example, the high-deductible versions of Plan F and Plan G have an annual deductible that must be met before the policy begins paying. This, plus the Part B deductible for Plan G, becomes the out-of-pocket maximum for these plans. Plans K and L, with their shared costs, are similar. They both have an annual maximum that must be met before the plan covers its share.
In MedicareWire’s opinion, Medicare Advantage plans are only a safe option if you are extremely healthy and have no family history of chronic illnesses later in life, or if you receive assistance paying the out-of-pocket costs. This is the case if your former employer or union offers retiree healthcare benefits, or if you are dual-eligible (Medicare and Medicaid is a public health insurance program that provides health care coverage to low-income families and individuals in the United States....), or if you qualify for a Special Needs Plan (SNP).
If none of these situations apply to you, a Medicare supplement plan is the better option.
Medicare Supplement & Medicare Advantage Eligibility
The final discussion about which type of Medicare is best comes down to eligibility and enrollment. Sadly, many people who would be best served by Original Medicare and supplemental insurance go with Medicare Advantage, because they think it costs less.
When people learn their out-of-pocket expenses with a Medicare Advantage plan are unaffordable, it’s often too late to make a switch. But why?
The unavoidable truth is that Medicare supplements are not health insurance. They are a form of indemnity insurance. As a result, the Affordable Care Act medical insurance laws do not apply.
The Medicare is a federal health insurance program for people ages 65 and older and people with certain disabilities...., and most states, only require insurance companies to issue a Medigap policy, without restrictions, for a very limited time. That time is when you first turn age 65 and have a guaranteed issue right.
Once that right expires, insurance companies can and will turn you down due to preexisting conditions. This fact about Medicare supplement insurance exposes another big advantage of Medicare Advantage plans.
Generally speaking, Medicare does not allow private health insurers to deny enrollees who want to join their Medicare Advantage plans due to a preexisting condition. There are a few exceptions, such as end-stage renal disease (kidney failure). The Centers for Medicare & Medicaid Services cover these medical expenses directly.
And finally, we come to enrollment. With a Medicare supplement, you can apply for coverage anytime you want. You can also switch plans or carriers or drop coverage anytime you want.
Just remember, when after your guaranteed issue right expires, insurance carriers have the right to ask you health questions and deny coverage if you don’t pass their underwriting process. With Medicare Advantage plans, you can’t enroll or disenroll whenever you want.
With Medicare Advantage, enrollment and dis-enrollment are only available during certain enrollment periods. The most common of these is the annual In health insurance, open enrollment is a period during which a person may enroll in or change their selection of health plan benefits. Health plan enrollment is ordinarily subject to restrictions.... period, which occurs in the Fall. When you first qualify for your Medicare benefits, you get an individual enrollment period (IEP).
Speak with Your Agent
It’s important to have a candid conversation with your insurance agent about your health and financial situation. Don’t make this important decision alone. Ask your agent if a Medigap policy is right for you. Be specific and ask about hospital stays, long-term care, and other important insurance topics. If you don’t have an agent, or you want a second opinion, Call 1-855-728-0510 (TTY 711) and speak with a licensed HealthCompare insurance agent. There’s no obligation, and they offer more plan options than any other national agency.
Citations & References:
- 2020 Medicare Parts A & B Premiums and Deductibles | CMS
- Trump Administration Announces Historically Low Premiums and New Insulin Benefit as Medicare Open Enrollment Begins | CMS
- Institutional Special Needs Plans (I-SNPs) | CMS
- Medicare costs at a glance | Medicare https://www.medicare.gov/your-medicare-costs/medicare-costs-at-a-glance
- How to compare Medigap policies | Medicare https://www.medicare.gov/supplements-other-insurance/how-to-compare-medigap-p…
- What’s Medicare Supplement Insurance (Medigap)? | Medicare
- Medicare Advantage Plans | Medicare
- A Dozen Facts About Medicare Advantage in 2019 | KFF
- Sources of Supplemental Coverage Among Medicare Beneficiaries in 2016 | KFF
- Medicare Advantage | KFF
- Home | State Health Insurance Assistance Programs http://www.shiptacenter.org/
- FastStats – Hospital Utilization http://www.cdc.gov/nchs/fastats/hospital.htm
- NCHS Pressroom – 2008 Press Release – Ambulatory Medical Care Utilization Est… http://www.cdc.gov/nchs/pressroom/08newsreleases/visitstodoctor.htm
- Medicare Supplemental Policies: Do You Need One? | HuffPost Life http://www.huffingtonpost.com/david-belk/medicare-supplemental-policies_b_390…