Who Needs Medigap Insurance?

If you are covered by Medicare and are wondering whether you really need a Medicare Supplement Insurance policy, also known as Medigap, you’re not alone. The Medicare website contains hundreds of pages of information, few of which are easy reading. It’s hard to get an answer to the big question: Why should anyone who has Medicare get a Medigap plan? Below is our answer.

Key Takeaways

  • Medigap pays some or all of the costs Medicare doesn’t cover, depending on the level of coverage you choose.
  • The costs of what Medicare doesn’t cover can be substantial, especially if you need extensive treatment or long-term hospitalization.
  • Many private insurance companies offer Medigap policies, so be sure to shop around.

What Is Medigap?

Medigap is a supplement to Medicare coverage. Depending on the type of coverage, Medigap policies are designed to provide more coverage for routine services Medicare does cover and, in some cases, all or part of the expenses Medicare does not cover—such as long-term care, vision, or dental coverage.

The purpose of a Medigap plan is to be reimbursed for the costs you pay directly out of your own pocket. These plans are offered by private insurance companies, so you’ll have to do some comparison shopping to get the one that fits your needs and financial situation. Keep in mind that lettered plans from each company have the same benefits, according to government mandate.

As is the case with any health insurance plan, you will pay a higher price for higher coverage. And a less expensive plan will have a higher deductible.

Why Buy More Insurance?

As noted above, Medicare isn’t a blanket insurance policy. This means it does have holes in it. Original Medicare, as the government calls what we now know as Parts A and B—and Medicare prescription drug coverage, Part D—pays most of your expenses.

But it’s far from all of the costs you may face if you become seriously ill or get injured. Even routine services come with copayments and deductibles. This is where Medigap insurance kicks in.

Medicare Deductible

Here are a few examples. If you are admitted to the hospital, you have 100% hospitalization coverage after the $1,484 annual deductible under Original Medicare Part A, as of 2021. That’s the basic bed and board. However, you may owe up to 20% of some other costs, such as anesthesiologist fees.

If you are in the hospital for more than 60 days, you have to pay $371 per day. There are similar copayments for long stays in nursing facilities and hospices. Regular doctor visits and outpatient medical care may cost you too. Your deductible for 2021 is $203, but after that, you’ll pay up to 20% of the Medicare-approved amount for most doctor services. There’s no upper limit.

If you do not have coverage for dental expenses, you may want to look into a standalone dental insurance plan. Many plans provide coverage for the types of dental procedures that seniors may need, including crowns, root canals, dentures, and tooth replacements.

Medicare Donut Hole

Prescription drugs can also eat into your budget if you need expensive medications. You should know that you can purchase standalone prescription coverage. That’s Part D in Medicare terminology.

Under the Affordable Care Act (ACA), the prescription price donut hole has been closing each year, but it’s not completely gone yet. At a certain level—$4,130 in 2021—you enter the notorious donut hole in coverage that requires you to pay up to 25% of covered brand-name and generic drug costs. When costs go above $6,550 in 2021, you pass through the donut hole and owe only 5% of the cost of drugs.

How Does Medigap Work?

You may already know that Medicare Parts A and B comprise basic coverage, while Part D is an optional prescription drug plan you can buy from a private provider and attach to your Medicare. Part C, also known as Medicare Advantage, replaces all of the basic government coverage with a private insurance plan; if you choose Part C, you do not need a Medigap Plan.

But if you go for Original Medicare, plus Part D—and do want a Medigap plan for more complete coverage—there are more letters to learn (this time for “plans” rather than “parts”). Each letter represents a standard level of coverage. For Medigap plans, the most popular choices are F and G.

Medicare Plan F

This is the most comprehensive plan and has been the most popular choice for years. The average cost per month for the most popular Medigap F Plan is approximately $326.

As of January 1, 2020, however, Plan F is no longer available to people newly eligible for Medicare. People who already have Plan F will be able to keep it, and people who were eligible for Medicare before 2020 but didn’t have a Medigap plan may still be allowed to get Plan F if they wish.

Medicare Plan G

This plan will likely replace Plan F in popularity, as it has virtually the same coverage except for reimbursement of the Part B deductible—a perk that is no longer included in any plans offered to Medicare newbies as of 2020. The average Plan G should be cheaper than Plan F. However, costs vary widely according to an applicant’s zip code, gender, and tobacco use, and they increase with age.

Medigap Plan G has almost the same coverage as the popular Plan F—which has been retired as of January 1, 2020, for anyone newly eligible for Medicare—lacking only the reimbursement of the Plan B deductible.

Which Plan Is Best?

Here’s the short answer: If you want 100% coverage of everything, an F or G plan (depending on your eligibility) is your choice. The other plans offer progressively less coverage for lower upfront costs.

For a more detailed answer, you can do one of the following:

  • Speak with a qualified insurance agent or Medicare advisor to find the plan that fits you.
  • Read the Medicare publication Choosing a Medigap Policy, where you’ll find descriptions of each policy type and what it covers.

Medigap vs. Medicare Advantage

A Medigap policy is a supplement to your Original Medicare coverage that pays expenses that Original Medicare doesn’t cover. A Medicare Advantage Plan (Medicare Part C) is a private replacement for the public Medicare program. Most of these plans are set up as health maintenance organizations (HMOs) that replace all of the services of Original Medicare and add additional services, such as preventive healthcare, within a preselected network of doctors and hospitals.

A Medigap plan will probably give you more freedom of choice than Medicare Advantage, provided your physician or facility accepts Medicare. It is a better option for snowbirds and others who travel a great deal or have homes in more than one location.

You can’t have Medigap and a Medicare Advantage Plan at the same time. In many cases, having both would mean you’d be paying for duplicate coverage. An insurer will sell you a Medigap policy if you’re leaving Medicare Advantage. This allows you to start your Medigap coverage the day after your Advantage plan runs out.

Is My Spouse Covered?

No. A Medigap policy covers only one person and doesn’t cover expenses incurred by your spouse. Medicare isn’t like an employer-sponsored plan; you can’t enroll your spouse under your coverage. This means you and your spouse have to purchase separate plans to be covered for supplemental insurance.

Can My Plan Be Canceled?

No, that’s illegal. As long as you pay your premiums, your policy is renewable for the rest of your life. You can only be dropped if any of the following apply:

  • You stop paying premiums.
  • You lied on your original Medigap application.
  • The company goes bankrupt.

If you choose to cancel your Medigap policy, you must do so by contacting the insurance company directly.

The CARES Act of 2020

On March 27, 2020, President Trump signed into law a $2 trillion coronavirus emergency stimulus package called the CARES (Coronavirus Aid, Relief, and Economic Security) Act. It expands Medicare’s ability to cover treatment and services for those affected by COVID-19. The CARES Act also:

  • Increases flexibility for Medicare to cover telehealth services.
  • Authorizes Medicare certification for home health services by physician assistants, nurse practitioners, and certified nurse specialists.
  • Increases Medicare payments for COVID-19–related hospital stays and durable medical equipment.

The changes will likely continue into 2021 or whenever the pandemic ends.

How much does Medigap cost?

Since Medigap is privatized insurance, each insurance company offers different premiums for its Medigap policies. The price might be determined by a number of factors, like your age, inflation, or how long you’ve been enrolled.

Why do I need Medigap?

Medigap policy supplements your Original Medicare coverage, covering more expenses. Medigap provides more choice and covers a larger network of healthcare providers than other options. If you travel or need coverage that Original Medicare doesn’t provide, Medigap might be a good option for you.

Is my spouse covered by Medigap?

No. Medigap only covers one person. Both spouses will need to purchase separate plans.

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