2004

Guide

To Health Insurance 

For People With Medicare

Large Print Edition

Choosing A Medigap Policy

A Guide For People With Medicare

Use this official government guide to learn about an

important way to help you cover health care costs.

CENTERS FOR MEDICARE & MEDICAID SERVICES

Developed jointly with the National Association of Insurance Commissioners

Choosing 

A Medigap

Policy

A Guide To Health Insurance

For People With Medicare
This official government guide can help you:

● Learn what a Medigap policy is.

● Decide if you want to buy a Medigap policy.

● Understand when you can buy a Medigap policy.

● Choose the Medigap policy that best meets your

needs.

● Know where to go if you have questions.

How to use this Guide

There are two ways to find the information you need:

1. The “Table of Contents” on pages 1 - 3 can help you

find the sections you need to read.

2. The “Index” on pages 187 - 192 lists every topic in

this Guide and the page number to find it on.

Tip: Pages 66, 112, 118, 148, and 176 are “Notes

Pages.” Use these pages to write down any

questions you might have or information you gather.
1 ----- Table of Contents

Welcome -----Pages 5 - 10

What is Medicare ----- Page 6

Medicare Health Plans ----- Page 7

Original Medicare Plan and Medigap Policies at a glance

----- Pages 8 - 9

Medicare Advantage (formerly Medicare + Choice) Plans 

----- at a glance ----- Pages 9 - 10

Section 1: Words To Know -----Pages 11 - 20

Where words underlined are defined ----- Pages 11 - 20

Section 2: Medigap Overview -----Pages 21 - 66

What it is and isn’t ----- Pages 21 - 24

Why you might need a Medigap policy ----- Pages 24 - 25

Gaps in the Original Medicare Plan ----- Pages 26 - 27

Who can buy a Medigap policy ----- Page 28

What is Medicare SELECT ----- Page 28

What’s covered and what’s not covered ----- Page 29

Types of Medigap policies: Medigap Plans A through J

----- Pages 30 - 36

Information on Medigap costs ----- Pages 37 - 44 

----- How much policies cost, ways of pricing policies, 

----- and what can affect the cost

Buying a Medigap policy ----- Pages 45 - 48 

----- Best time to buy and information on Medigap 

----- Open Enrollment Period

Medicare Modernization Act of 2003 ----- Page 49
2 ----- Table of Contents 

Section 2: Medigap Overview (continued)

Pre-existing conditions ----- Pages 50 - 51

Creditable coverage (past health care coverage)

----- Pages 52 - 54 

Switching (Changing) Medigap policies ----- Pages 55 - 56

Losing Medigap coverage ----- Pages 57 - 58

How your bills get paid ----- Pages 59 - 60

Private contracts ----- Pages 61 - 62

Illegal insurance practices ----- Pages 63 - 64

Reliable insurance companies ----- Page 65

Section 3: Steps to Buying a Medigap Policy

-----Pages 67 - 92

Steps to buying a Medigap policy ----- Pages 68 - 92

Section 4: Medigap Rights and Protections

-----Pages 93 - 112

Medigap rights and protections (guaranteed issue rights)

----- Pages 93 - 112

Section 5: Medigap and Disability or ESRD

-----Pages 113 - 118

Information on disability and End-Stage Renal Disease

----- Pages 113 - 118
3 ----- Table of Contents 

Section 6: Original Medicare Plan -----Pages 119 - 148

Medicare Part A and Part B ----- Pages 119 - 120

Medicare Part A coverage chart ----- Pages 121 - 125

Medicare Part B coverage charts ----- Pages 126 - 139

Enrolling in Medicare ----- Pages 140 - 147

Section 7: Other Ways To Pay Health Care Costs

-----Pages 149 - 168

Other kinds of insurance and ways to pay health care 

----- costs ----- Pages 149 - 168

Section 8: Massachusetts, Minnesota, and Wisconsin 

----- Medigap Plans -----Pages 169 - 176

Information for Massachusetts ----- Pages 170 - 171

Information for Minnesota ----- Pages 172 - 173

Information for Wisconsin ----- Pages 174 - 175

For information about Medigap policies sold in other

States, see pages 30 - 36.

Section 9: For More Information -----Pages 177 - 186

Where to get information ----- Pages 177 - 178

Who to call with Medicare questions ----- Page 178

Important telephone numbers for each State

● State Health Insurance Assistance Program 

----- Pages 179 - 182

● State Insurance Department ----- Pages 183 - 186

Section 10: Index ----- Pages 187 - 192

An alphabetical list of what is in this Guide

----- Pages 187 - 192
4 ----- Table of Contents

The 2004 Choosing A Medigap Policy: A Guide To

Health Insurance For People With Medicare isn’t a

legal document. The official Medicare program provisions

are contained in the relevant laws, regulations, and

rulings.

The information in this Guide was correct when it was

printed. Changes may occur after printing. For the most

up-to-date version, look at www.medicare.gov on the

web. Select “Publications.” Or, call 1 800 633 - 4227. 

A Customer Service Representative can tell you if the

information has been updated. TTY users should call 

1 877 486 - 2048.

● End of page
This guide was written to help people with Medicare

make good health care coverage decisions. When you

first enroll in Medicare, or if you later want to change how

you get your Medicare benefits or other health care

coverage (such as buying a Medigap policy), you need to

look at all the options you have to help you:

● Get the best coverage you can afford, and

● Reduce your out-of-pocket health care costs.

This guide explains in detail how Medigap (Medicare

Supplement Insurance) policies work with the Original

Medicare Plan. A Medigap policy is private insurance that

supplements, or helps you pay for some of the costs that

Medicare doesn’t pay for.

Before you decide whether or not to buy a Medigap

policy, there are a few things you should know about

Medicare and Medicare health plans. On pages 6 - 10 is

a quick look at how Medicare health plans work with

Medigap policies.

If you already know about Medicare and Medicare health

plans, turn to Section 2 “Medigap Overview,” which

starts on page 21.

5 ----- Welcome

Words underlined are defined on pages 11 - 20.
6 ----- Welcome

What is Medicare?

Medicare is a health insurance program for:

● 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 kidney

transplant).

Medicare has:

● Medicare Part A (Hospital Insurance), and 

● Medicare Part B (Medical Insurance).

For more information about Medicare Part A and Part B,

see pages 119 - 147.

● End of page
What are Medicare Health Plans?

Medicare health plans provide different ways to get your

health care coverage in the Medicare program. Your

Medicare health plan choices include:

● The Original Medicare Plan - Available nationwide. 

If you have this plan, you may want to buy a Medigap

policy.

● Medicare Advantage (formerly Medicare + Choice)

Plans - Available in many areas. If you have one of

these plans, you don’t need a Medigap policy.

Medicare Advantage Plans include:

● Medicare Managed Care Plans

● Medicare Preferred Provider Organization Plans (PPO)

● Medicare Private Fee-for-Service Plans

● Medicare Specialty Plans

The Medicare health plan that you choose affects many

things like cost, benefits, doctor choice, convenience,

and quality. No matter how you choose to get your health

care, you are still in the Medicare program.

For help comparing your Medicare health plan choices,

use the “Medicare Personal Plan Finder” at

www.medicare.gov on the web. See page 84 for details.

You can also call 1 800 633 - 4227. TTY users should call

1 877 486 - 2048.

7 ----- Welcome
8 ----- Welcome

Original Medicare Plan and Medigap Policies 

at a glance

If you get your health care from the Original Medicare

Plan, you use your red, white, and blue Medicare card

(see sample card on page 46) to get your health care.

Usually you don’t have to pay a monthly premium for

Medicare Part A. If you want to get Medicare Part B

covered services, you must pay the monthly premium of

$66.60 in 2004 for Medicare Part B. However, you don’t

need Medicare Part B to be in the Original Medicare Plan.

Generally, you must have Medicare Part A and Part B to

buy a Medigap policy.

The Original Medicare Plan pays for many health care

services and supplies, but it doesn’t pay all of your

health care costs. There are costs that you must pay, like

coinsurance, copayments, and deductibles. These costs

are called “gaps” in Medicare coverage.

You might want to consider buying a Medigap policy to

cover these gaps in Medicare coverage. Some Medigap

policies also cover other extra benefits that aren’t

covered by Medicare, like routine yearly check-ups, 

at-home recovery, and emergency health care while

traveling outside the U.S. A Medigap policy may help you

save on out-of-pocket costs. If you buy a Medigap policy

you will also have to pay a monthly premium to the

private insurance company.

Words underlined are defined on pages 11 - 20.
9 ----- Welcome

Original Medicare Plan and Medigap policies at a

glance (continued)

Medigap policies only help pay health care costs if you

are in the Original Medicare Plan. For a list of Medicarecovered services, see pages 121 - 139. To learn what

Medigap policies cover, see pages 69 - 83.

Medicare Advantage Plans at a glance

Medicare Advantage is the new name for Medicare +

Choice. If you decide to join a Medicare Advantage Plan,

then you will use the health care card that you get from

your Medicare Advantage Plan (provider) for your health

care. These plans often give you more choices and,

sometimes, extra benefits, like extra days in the hospital.

To join a Medicare Advantage Plan, you must have

Medicare Part A and Part B. You will have to pay the

monthly Medicare Part B premium of $66.60 (in 2004) to

Medicare. In addition, you might have to pay a monthly

premium to your Medicare Advantage Plan for the extra

benefits that they offer. You should call the Medicare

Advantage Plan that you’re interested in to find out what

extra benefits they offer and how much your monthly

premium will be.
10 ----- Welcome

Medicare Advantage Plans at a glance (continued)

If you’re in a Medicare Advantage Plan, you don’t need a

Medigap policy because Medicare Advantage Plans

generally cover many of the same benefits that a

Medigap policy would cover, like extra days in the

hospital after you used the number of days that Medicare

pays for.

Note: Medicare Advantage Plans aren’t Medigap policies.

Need more information?

For more information about Medicare health plans, get a

free copy of the Medicare & You handbook (CMS Pub.

No. 10050) at www.medicare.gov on the web. Select

“Publications.” Or, call 1 800 633 - 4227. TTY users

should call 1 877 486 - 2048.

● End of page
Use this section to learn the definitions

of words.

A 

Assignment - In the Original Medicare Plan, this means a

doctor agrees to accept the Medicare-approved amount

as full payment. If you are in the Original Medicare Plan, it

can save you money if your doctor accepts assignment.

You still pay your share of the cost of the doctor’s visit.

B 

Benefit Period - The way that Medicare measures your

use of hospital and skilled nursing facility (SNF) services.

A benefit period begins the day you go to a hospital or

skilled nursing facility. The benefit period ends when you

haven’t received any hospital care (or skilled care in a

SNF) for 60 days in a row. If you go into the hospital or a

SNF after one benefit period has ended, a new benefit

period begins. If you are in the Original Medicare Plan,

you must pay the inpatient hospital deductible for each

benefit period. There is no limit to the number of benefit

periods you can have.

C 

Coinsurance - The percent of the Medicare-approved

amount that you have to pay after you pay the deductible

for Part A and/or Part B. In the Original Medicare Plan,

the coinsurance payment is a percentage of the

approved amount for the service (like 20%). 

11 ----- Section 1: Words To Know - 

Letters A through C

Section 1
C (continued)

Copayment - In some Medicare health plans, the amount

that you pay for each medical service, like a doctor’s

visit. A copayment is usually a set amount you pay for a

service. For example, this could be $10 or $20 for a

doctor’s visit. Copayments are also used for some

hospital outpatient services in the Original Medicare Plan.

Creditable Coverage - Any previous health insurance

coverage that can be used to shorten a pre-existing

condition waiting period. (See pre-existing conditions.)

D 

Deductible - The amount you must pay for health care,

before Medicare begins to pay, either for each benefit

period for Part A, or each year for Part B. These amounts

can change every year.

Durable Medical Equipment (DME) - Medical

equipment that is ordered by a doctor for use in the

home. These items must be durable, such as walkers,

wheelchairs, or hospital beds. DME is paid for under both

Medicare Part B and Part A for home health services.

Durable Medical Equipment Regional Carrier - A

private company that contracts with Medicare to pay bills

for durable medical equipment.

E 

End-Stage Renal Disease (ESRD) - Permanent kidney

failure that requires dialysis or a kidney transplant.

12 ----- Section 1: Words To Know - 

Letters C through E
E (continued)

Excess Charges - If you are in the Original Medicare

Plan, this is the difference between a doctor’s or other

health care provider’s actual charge (which may be

limited by Medicare or the state) and the Medicareapproved payment amount.

G 

Guaranteed Issue Rights (also called “Medigap

Protections”) - Rights you have in certain situations

when insurance companies are required by law to sell or

offer you a Medigap policy. In these situations, an

insurance company can’t deny you insurance coverage

or place conditions on a policy, must cover you for all

pre-existing conditions, and can’t charge you more for a

policy because of past or present health problems.

Guaranteed Renewable - A right you have that requires

your insurance company to automatically renew or

continue your Medigap policy, unless you make untrue

statements to the insurance company, commit fraud or

don’t pay your premiums.

H 

Home Health Care - Limited part-time or intermittent

skilled nursing care and home health aide services,

physical therapy, occupational therapy, speech-language

therapy, medical social services, durable medical

equipment (such as wheelchairs, hospital beds, oxygen,

and walkers), medical supplies, and other services. 

13 ----- Section 1: Words To Know - 

Letters E through H
H (continued)

Hospice Care - A special way of caring for people who

are terminally ill, and for their family. This care includes

physical care and counseling. Hospice care is covered

under Medicare Part A (Hospital Insurance).

L 

Lifetime Reserve Days - In the Original Medicare Plan,

60 days that Medicare will pay for when you are in a

hospital more than 90 days during a benefit period.

These 60 reserve days can be used only once during

your lifetime. For each lifetime reserve day, Medicare

pays all covered costs except for a daily coinsurance

($438 in 2004).

Limiting Charge - In the Original Medicare Plan, the

highest amount of money you can be charged for a

covered service by doctors and other health care

suppliers who don’t accept assignment. The limiting

charge is 15% over Medicare’s approved amount. The

limiting charge only applies to certain services and

doesn’t apply to supplies or equipment.

Long-Term Care - A variety of services that help people

with health or personal needs and activities of daily living

over a long period of time. Long-term care can be

provided at home, in the community, or in various types

of facilities, including nursing homes and assisted living

facilities. Most long-term care is custodial care. Medicare

doesn’t pay for this type of care if this is the only kind of

care you need.

14 ----- Section 1: Words To Know - 

Letters H through L
M 

Medicaid - A joint Federal and State program that helps

with medical costs for some people with low incomes

and limited resources. Medicaid programs vary from

State to State, but most health care costs are covered if

you qualify for both Medicare and Medicaid.

Medical Underwriting - The process that an insurance

company uses to decide, based on your medical history,

whether or not to take your application for insurance,

whether or not to add a waiting period for pre-existing

conditions (if your State law allows it), and how much to

charge you for that insurance.

Medically Necessary - Services or supplies that:

● are proper and needed for the diagnosis or treatment

of your medical condition,

● are provided for the diagnosis, direct care, and

treatment of your medical condition,

● meet the standards of good medical practice in the

local area, and

● aren’t mainly for the convenience of you or your

doctor.

Medicare Advantage Plan - A Medicare program that

gives you more choices among health plans. Everyone

who has Medicare Parts A and B is eligible, except those

who have End-Stage Renal Disease (unless certain

exceptions apply).

15 ----- Section 1: Words To Know - 

Letter M
M (continued)

Medicare-Approved Amount - In the Original Medicare

Plan, this is the Medicare payment amount for an item or

service. This is the amount a doctor or supplier is paid by

Medicare and you for a service or supply. It may be less

than the actual amount charged by a doctor or supplier.

The approved amount is sometimes called the “Approved

Charge.”

Medicare Carrier - A private company that contracts

with Medicare to pay Part B bills.

Medicare Managed Care Plan - A type of Medicare

Advantage Plan that is available in some areas of the

country. In most managed care plans, you can only go to

doctors, specialists, or hospitals on the plan’s list. Plans

must cover all Medicare Part A and Part B health care.

Some managed care plans cover extras, like prescription

drugs. Your costs may be lower than in the Original

Medicare Plan.

Medicare Preferred Provider Organization (PPO) 

Plan - A type of Medicare Advantage Plan in which you

use doctors, hospitals, and providers that belong to the

network. You can use doctors, hospitals, and providers

outside of the network for an additional cost.

16 ----- Section 1: Words To Know - 

Letter M
M (continued)

Medicare Private Fee-for-Service Plan - A type of

Medicare Advantage Plan in which you may go to any

Medicare-approved doctor or hospital that accepts the

plan’s payment. The insurance plan, rather than the

Medicare program, decides how much it will pay and

what you pay for the services you get. You may pay more

for Medicare-covered benefits. You may have extra

benefits the Original Medicare Plan doesn’t cover.

Medicare SELECT - A type of Medigap policy that may

require you to use hospitals and, in some cases, doctors

within its network to be eligible for full benefits.

Medicare Specialty Plan - A type of Medicare

Advantage Plan that provides more focused health care

for some people. These plans give you all your Medicare

health care as well as more focused care to manage a

disease or condition such as congestive heart failure,

diabetes, or End-Stage Renal Disease. 

Medigap Policy - A Medicare supplement insurance

policy sold by private insurance companies to fill “gaps”

in Original Medicare Plan coverage. Except in

Massachusetts, Minnesota, and Wisconsin, there are ten

standardized plans labeled Plan A through Plan J.

Medigap policies only work with the Original Medicare

Plan.

17 ----- Section 1: Words To Know - 

Letter M 
O 

Open Enrollment Period - A one-time-only six month

period when you can buy any Medigap policy you want

that is sold in your State. It starts in the first month that

you are covered under Medicare Part B and you are age

65 or older. During this period, you can’t be denied

coverage or charged more due to past or present health

problems.

Original Medicare Plan - A fee-for-service health plan

that lets you go to any doctor, hospital, or other health

care supplier who accepts Medicare and is accepting

new Medicare patients. You must pay the deductible.

Medicare pays its share of the Medicare-approved

amount, and you pay your share (coinsurance). In some

cases you may be charged more than the

Medicare-approved amount. The Original Medicare Plan

has two parts: Part A (Hospital Insurance) and Part B

(Medical Insurance).

P 

Pre-existing Condition - A health problem you had

before the date that a new insurance policy starts.

Premium - The periodic payment to Medicare, an

insurance company, or a health care plan for health care

coverage.

18 ----- Section 1: Words To Know - 

Letters O through P
19 ----- Section 1: Words To Know - 

Letters P through S

P (continued)

Programs of All-inclusive Care for the Elderly (PACE) -

PACE combines medical, social, and long-term care

services for frail people. PACE is available only in States

that have chosen to offer it under Medicaid. To be

eligible, you must: 

● be 55 years old or older, 

● live in the service area of the PACE program, 

● be certified as eligible for nursing home care by the

appropriate state agency, and

● be able to live safely in the community.

The goal of PACE is to help people stay independent and

living in their community as long as possible, while

getting the high-quality care they need.

S 

Skilled Nursing Facility Care - A level of care that

requires daily involvement of skilled nursing or

rehabilitation staff and can’t be done on an outpatient

basis. Examples of skilled nursing care include getting

intravenous injections and physical therapy. Needing

custodial care, such as help with bathing and dressing,

can’t, in itself, qualify you for Medicare coverage in a

skilled nursing facility. However, if you qualify for skilled

nursing or rehabilitation care, Medicare covers all of your

care needs in the facility.
20 ----- Section 1: Words To Know - 

Letter S

S (continued)

Skilled Nursing Facility - A nursing facility with the staff

and equipment to give skilled nursing care and/or skilled

rehabilitation services and other related health services.

State Health Insurance Assistance Program - A State

program that gets money from the Federal Government

to give free local health insurance counseling to people

with Medicare.

State Insurance Department - A State agency that

regulates insurance and can provide information about

Medigap policies and any insurance-related problem.

State Medical Assistance Office - A State agency that

is in charge of the State’s Medicaid program and can give

information about programs to help pay medical bills for

people with low incomes. Also provides help with

prescription drug coverage.

● End of page
This section includes information about

what Medigap policies are, what they

cover and don’t cover, cost information,

and more.

What is a Medigap policy?

A Medigap policy is a health insurance policy sold by

private insurance companies to fill the “gaps” in the

Original Medicare Plan. Medigap policies help you 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 will pay

its share and your Medigap policy will pay its share of

your health care costs.

Important: Starting January 1, 2006, there will be

changes to some Medigap policies. See page 49 for

more information.

Currently, there are ten standardized Medigap plans

called “A” through “J.” Medigap policies must follow

Federal and State laws. These laws protect you. The front

of a Medigap policy must clearly identify it as “Medicare

Supplement Insurance.” Each plan, A through J, has a

different set of benefits. Plan A covers only the basic

(core) benefits, listed on page 30. These basic benefits

are included in all the Medicare plans (A through J).

Medigap Plans B through J offer extra benefits (see

pages 31 - 36). Plan J offers the most benefits.

21 ----- Section 2: Medigap Overview 

Section 2
22 ----- Section 2: Medigap Overview 

What is a Medigap policy? (continued)

If you live in Massachusetts, Minnesota, or Wisconsin,

different types of standardized Medigap policies are sold

in your State (see pages 170 - 175). 

Insurance companies can only sell you one of the ten

standardized Medigap policies. Medigap policies are

standardized so you can compare them easily. Two of the

standardized Medigap policies may have a high

deductible option (see page 43). In addition, any

standardized Medigap policy may be sold as a “Medicare

SELECT” policy (see page 44). No matter where you live

(except for Massachusetts, Minnesota, and Wisconsin)

Medigap policies must offer the same benefits within

Medigap plans (A through J). See pages 30 - 36 for a list

of the ten standardized Medigap policies.

It’s important to compare Medigap policies because

costs can vary. Remember, the standardized Medigap

policies that insurance companies offer must provide the

same benefits. The only difference between Medigap

policies sold by different insurance companies might be

the cost. Also, insurance companies that sell Medigap

policies don’t have to offer each Medigap plan (A through J).

Each insurance company decides which Medigap policies

they want to sell. Make sure the insurance company

offers the Medigap policy that you want.
23 ----- Section 2: Medigap Overview 

What is a Medigap policy? (continued)

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 of $66.60 (in 2004) to

Medicare. In addition, you will have to pay a premium to

the Medigap insurance company. As long as you pay

your premium, your Medigap policy is guaranteed

renewable. This means it is automatically renewed each

year. Your coverage will continue year after year as long

as you pay your premium.

You and your spouse must buy separate Medigap

policies. Your Medigap policy won’t cover any health

care costs for your spouse.

Important: In some States, insurance companies may

refuse to renew a Medigap policy bought before 1990. At

the time these Medigap policies were sold, State law

might not have required that Medigap policies be

guaranteed renewable.

Medigap policies only help pay health care costs if you

have the Original Medicare Plan. You don’t need to buy a

Medigap policy if you are in a Medicare Advantage Plan

(like a Medicare Managed Care Plan). In fact, it is illegal

for anyone to sell you a Medigap policy if they know you

are in one of these plans.

It is also illegal for an insurance company to sell you a

Medigap policy if you have health insurance coverage

through your State Medicaid program. There are certain

exceptions (see page 160).
24 ----- Section 2: Medigap Overview 

What isn’t a Medigap policy?

A Medigap policy isn’t:

● Coverage you get from your employer or union,

● A Medicare Advantage (formerly Medicare + Choice)

Plan,

● Medicare Part B, or 

● Medicaid.

Why would I want to buy a Medigap policy?

You may want to buy a Medigap policy because

Medicare doesn’t pay for all of your health care. There

are “gaps” or costs that you must pay in the Original

Medicare Plan. The chart on pages 26 - 27 gives some

examples of these gaps. A Medigap policy will cover

some, but not all the gaps in the Original Medicare Plan.

If you are in the Original Medicare Plan, a Medigap policy

might help you:

● Lower your out-of-pocket costs, and

● Get more health insurance coverage.
25 ----- Section 2: Medigap Overview 

Why would I want to buy a Medigap policy? (continued)

What you pay out-of-pocket in the Original Medicare Plan

will depend on the following:

● Whether your doctor or supplier accepts “assignment”

(This means he or she takes the Medicare-approved

amount as payment in full),

● How often you need health care,

● What type of health care you need,

● Whether you buy a Medigap policy,

● Which Medigap policy you buy, and

● Whether you have other health insurance.

● End of page
26 ----- Section 2: Medigap Overview 

Gaps in the Original Medicare Plan

Some examples of gaps in Medicare-covered services 

What YOU Pay in 2004 (These amounts can change

each year.)

Hospital Stays

For each benefit period YOU PAY:

● $876 for the first 60 days

● $219 per day for days 61 - 90

● $438 per day for days 91 - 150

Skilled Nursing Facility Stays

For each benefit period YOU PAY:

● Nothing for the first 20 days

● Up to $109.50 per day for days 21 - 100

Blood

● YOU PAY the cost of the first three pints.

Medicare Part B Yearly Deductible

● YOU PAY the $100 per year deductible.

This will go up to $110 in 2005.

(Continued to next page)
Gaps in the Original Medicare Plan (continued)

Medicare Part B Covered Services

YOU PAY:

● 20% of the Medicare-approved amount for most

covered services

● 50% of the Medicare-approved amount for outpatient

mental health treatment*

*All Medigap policies sold today must pay 50%

coinsurance for outpatient mental health treatment

services.

● Copayment for outpatient hospital services

Note: Some Medigap policies also cover other extra

benefits that aren’t covered by Medicare. Some examples

of these benefits include the following:

● Routine yearly check-ups,

● At-home recovery,

● Medicare Part B excess charges (the difference

between your doctor’s charge and the Medicareapproved amount) that only apply if your doctor

doesn’t accept assignment,

● Prescription drugs,**

**Starting January 1, 2006, there will be a change in

Medigap policies that cover prescription drugs.

Medigap Plans H, I, and J may still be sold, but

without the prescription drug benefit. 

27 ----- Section 2: Medigap Overview 
28 ----- Section 2: Medigap Overview 

Who can buy a Medigap policy?

To buy a Medigap policy, you generally must have

Medicare Part A and Part B. If you are under age 65 and

you are disabled or have End-Stage Renal Disease

(ESRD), you might not be able to buy a Medigap policy

until you turn 65. More information about Medigap

policies for people under age 65 starts on page 113.

Can I keep seeing the same doctor if I buy a Medigap

policy?

In most cases, yes. If you are in the Original Medicare

Plan and you have a Medigap policy, you can go to any

doctor, hospital, or other health care provider who

accepts Medicare. However, if you have the type of

Medigap policy called Medicare SELECT, you must use

specific hospitals and, in some cases, specific doctors to

get your full insurance benefits.

What is Medicare SELECT?

Medicare SELECT is a type of Medigap policy sold in

some States. If you buy a Medicare SELECT policy, you

are buying one of the ten standardized Medigap Plans A

through J. With a Medicare SELECT policy, you must use

specific hospitals and, in some cases, specific doctors to

get full insurance benefits (except in an emergency). For

this reason, Medicare SELECT policies generally cost

less than other Medigap policies.

Note: You don’t need a Medigap policy if you are in a

Medicare Advantage Plan.
29 ----- Section 2: Medigap Overview 

What isn’t covered by Medigap policies?

● Long-term care,

● Vision or dental care,

● Hearing aids,

● Private-duty nursing, or

● “Unlimited” outpatient prescription drugs.

Note: Medigap Plans H, I, and J currently cover some

outpatient prescription drugs (see pages 34 - 35). This

will change in 2006 (see page 49).

What do Medigap policies cover?

Each standardized Medigap policy must cover basic

(core) benefits (see page 30). Medigap policies pay most,

if not all, of the Original Medicare Plan coinsurance and

outpatient copayment amounts. These policies may also

cover Original Medicare Plan deductibles. Some Medigap

policies cover extra benefits to help pay for things

Medicare doesn’t cover (see pages 31 - 36).

If you live in Massachusetts, Minnesota, or Wisconsin,

see pages 170 - 175.

Note: Medigap Plans F and J have a high-deductible

option (see page 43). You must pay the deductible first

before the Medigap policy pays anything.
30 ----- Section 2: Medigap Overview 

Medigap Plans A through J basic (core) benefits include:

Note: The amounts in this chart are for 2004. These

amounts can change each year.

● Medicare Part A coinsurance and hospital benefits

Medigap policies pay:

■ $219 per day for days 61 - 90 of a hospital stay.

■ $438 per day for days 91 - 150 of a hospital stay.

■ Up to 365 more days of a hospital stay during your

lifetime after you use all Medicare hospital benefits.

● Medicare Part B coinsurance or copayment

Medigap policies cover you after you meet the Part B

$100 yearly deductible. This will go up to $110 in 2005.

● Blood

Medigap policies pay for the first three pints of blood

or equal amounts of packed red blood cells per

calendar year, unless you or someone else donates

blood to replace what you use.

See pages 31 - 36 for more information about Medigap 

Plans A through J.
31 ----- Section 2: Medigap Overview 

Types of Medigap Policies: Medigap Plans A Through J

Medigap policies (including Medicare SELECT) can only

be sold in ten standardized plans. The chart listed below

and on pages 32 - 36 gives you a quick look at all the

Medigap plans and their benefits. If you need more

information, call your State Insurance Department (see

pages 183 - 186).

Plan A covers:

● Basic Benefits

Plan B covers:

● Basic Benefits

● Medicare Part A Deductible

Plan C covers:

● Basic Benefits

● Skilled Nursing Coinsurance

● Medicare Part A Deductible

● Medicare Part B Deductible

● Foreign Travel Emergency

(Chart continued on page 32)
Types of Medigap Policies: Medigap Plans A Through J

(continued)

Plan D covers:

● Basic Benefits

● Skilled Nursing Coinsurance

● Medicare Part A Deductible

● Foreign Travel Emergency

● At-Home Recovery

Plan E covers:

● Basic Benefits

● Skilled Nursing Coinsurance

● Medicare Part A Deductible

● Foreign Travel Emergency

● Preventive Care*

* Medigap policies cover some preventive care that isn’t

covered by Medicare.

(Chart continued on page 33)

32 ----- Section 2: Medigap Overview 
33 ----- Section 2: Medigap Overview 

Types of Medigap Policies: Medigap Plans A Through J

(continued)

Plan F* covers:

● Basic Benefits

● Skilled Nursing Coinsurance

● Medicare Part A Deductible

● Medicare Part B Deductible

● Medicare Part B Excess Charge (100%)

● Foreign Travel Emergency

* Plan F has a high-deductible option (see page 43).

Plan G covers:

● Basic Benefits

● Skilled Nursing Coinsurance

● Medicare Part A Deductible

● Medicare Part B Excess Charge (80%)

● Foreign Travel Emergency

● At-Home Recovery

(Chart continued on page 34)
34 ----- Section 2: Medigap Overview 

Types of Medigap Policies: Medigap Plans A Through J

(continued)

Plan H covers:

● Basic Benefits

● Skilled Nursing Coinsurance

● Medicare Part A Deductible

● Foreign Travel Emergency

● Basic Drug Benefit ($1,250 Limit)

Plan I covers:

● Basic Benefits

● Skilled Nursing Coinsurance

● Medicare Part A Deductible

● Medicare Part B Excess Charge (100%)

● Foreign Travel Emergency

● At-Home Recovery

● Basic Drug Benefit ($1,250 Limit)

(Chart continued on page 35)
Types of Medigap Policies: Medigap Plans A Through J

(continued)

Plan J* covers:

● Basic Benefits

● Skilled Nursing Coinsurance

● Medicare Part A Deductible

● Medicare Part B Deductible

● Medicare Part B Excess Charge (100%)

● Foreign Travel Emergency

● At-Home Recovery

● Extended Drug Benefit ($3,000 Limit)

● Preventive Care**

* Plan J has a high-deductible option (see page 43).

** Medigap policies cover some preventive care that isn’t

covered by Medicare.

(Chart continued on page 36)

35 ----- Section 2: Medigap Overview 
36 ----- Section 2: Medigap Overview 

Types of Medigap Policies: Medigap Plans A Through J

(continued)

Important Notes

● All Medigap plans must cover the basic benefits listed

on page 30.

● For details about the Medigap plan extra benefits

listed in the chart (Skilled Nursing Coinsurance,

Medicare Part A and Part B Deductible, Medicare 

Part B Excess Charge, Foreign Travel Emergency,

At-Home Recovery, Prescription Drugs, and Preventive

Care), see pages 73 - 83.

● This chart doesn’t apply if you live in Massachusetts,

Minnesota, or Wisconsin, see pages 170 - 175.

● Starting January 1, 2006, you won’t be able to buy

Medigap policies covering prescription drugs (see

page 49). For more information about Medigap policies

or the new Medicare prescription drug benefit, look at

www.medicare.gov on the web. Select “Medicare

Personal Plan Finder” or “Prescription Drug and Other

Assistance Programs.” Or, call 1 800 633 - 4227.

● End of page
37 ----- Section 2: Medigap Overview 

How much do Medigap policies cost?

The cost of Medigap policies can vary widely. There can

be big differences in the premiums that insurance

companies charge for exactly the same coverage. As

you shop for a Medigap policy, be sure you are comparing

the same Medigap policy (Plans A through J). Although this

Guide can’t give actual costs of Medigap policies, you can

get this information by calling insurance companies, or by

looking at the “Medicare Personal Plan Finder” at

www.medicare.gov on the web. For more information

about the Medicare Personal Plan Finder, see page 84.

How do insurance companies set the price of 

Medigap premiums?

Each insurance company sets the price of their policy

premiums. How they set the price affects how much you

pay. The examples on pages 38 - 41 help show how

costs may vary based on how insurance companies set

their premiums. Monthly premiums may vary by insurance

company and by Medigap policy (Plans A through J). The

amounts in the examples aren’t actual costs.

● End of page
38 ----- Section 2: Medigap Overview 

How do insurance companies set the price of 

Medigap premiums? (continued)

1. Pricing based on one price for everyone who

buys the same policy.

Some insurance companies charge the same monthly

premium for everyone with the same Medigap policy,

regardless of age. Insurance companies call these

“community-rated (or no-age-rated) policies.”

Premiums for these Medigap policies remain the same

except for inflation. Premiums may be higher for younger

buyers at first than for policies priced by age. However, if

you keep this policy for a while, the premiums will

eventually be lower than those policies priced by age. 

Example: Premium based on same premium for

everyone

Mr. Smith is 65. He buys a Medigap policy and pays a

$165 monthly premium.

Mrs. Perez is 72. She buys the same Medigap policy as

Mr. Smith. She also pays a $165 monthly premium

because with this type of policy, everyone pays the same

price.

Note: Look at pages 55 - 56 if you are thinking about

switching Medigap policies to save money. 
How do insurance companies set the price of 

Medigap premiums? (continued)

2. Pricing based on your age when you first buy 

the policy.

An insurance company can base your monthly premium

on the age you are when you buy their Medigap policy.

Insurance companies call these “issue-age-rated

policies.” Premiums are lower for younger buyers.

Premiums for these policies won’t go up each year as

you get older except for inflation.

Example: Premium based on your age when you first

buy the policy

Mr. Han is 66. He buys a Medigap policy and pays a

$160 monthly premium.

Mrs. Wright is 73. She buys the same Medigap policy as

Mr. Han. Since she is older at the time of purchase, her

monthly premium is $175. 

Note: Look at pages 55 - 56 if you are thinking about

switching Medigap policies to save money. 

39 ----- Section 2: Medigap Overview 

● End of page
How do insurance companies set the price of 

Medigap premiums? (continued)

3. Pricing based on your current age.

An insurance company can base your monthly premium

on your current age so your premium goes up each year.

Insurance companies call these “attained-age-rated

polices.” They may also go up because of inflation.

Premiums for these Medigap policies are usually the

lowest at first for younger buyers. However, the premiums

go up every year and can eventually become the most

expensive.

Example: Premium based on current age

Mrs. Anderson buys a Medigap policy at age 65. She

pays a $140 monthly premium. Her premium will go up

every year.

● At age 66 her premium will go up to $146.

● At age 67 her premium will go up to $152.

40 ----- Section 2: Medigap Overview 

(Example continued to next page)
How do insurance companies set the price of 

Medigap premiums? (continued)

3. Pricing based on your current age. (continued)

Example: (continued)

Mr. Dodd buys his Medigap policy at age 72. He pays a

$180 monthly premium. His premium is higher than 

Mrs. Anderson’s because it is based on his current age.

Mr. Dodd’s premium will go up every year as he gets

older.

● At age 73 his premium will go up to $185.

● At age 74 his premium will go up to $190.

Note: Look at pages 55 - 56 if you are thinking about

switching Medigap policies to save money. 

41 ----- Section 2: Medigap Overview 

● End of page
Are there other factors that may affect the cost of my

Medigap policy?

Yes. The cost of your Medigap policy may be affected

● By Discounts: Insurance companies may offer

discounts to females, non-smokers, and/or if you are

married.

● By Medical Underwriting: Some insurance

companies may use medical underwriting. You must

answer medical questions on an application. Fill it out

carefully and completely or your Medigap policy could

be voided. The insurance company uses this

information to decide whether to sell you a Medigap

policy, how much they will charge you, and whether

you will have to wait for coverage to start. Some

companies may add a waiting period for pre-existing

conditions if your State law allows (see pages 50 - 51).

Insurance companies can’t use medical underwriting if

you are in your Medigap open enrollment period (see

pages 45 - 48) or you have special rights (called

Medigap protections) to buy a Medigap policy 

(see pages 93 - 111).

42 ----- Section 2: Medigap Overview 

Words underlined are defined on pages 11 - 20.
Are there other factors that may affect the cost of my

Medigap policy? (continued)

● If you buy a high-deductible option: Insurance

companies may offer a “high-deductible option” on

Medigap Plans F and J (see chart on pages 33 and 35).

If you choose this option, you must pay the first $1,690

in Medigap-covered costs (the deductible in 2004)

before the Medigap policy pays anything. This amount

can change each year.

High-deductible option policies often have lower

premiums, but if you need a lot of Medicare covered

health care services, supplies, and equipment, your 

out-of-pocket costs will be higher. You may not be able

to change plans.

In addition to the $1,690 (in 2004) deductible that you

must pay for the high-deductible option for Plans F 

and J, you must also pay deductibles for:

■ Prescription drugs ($250 per year for Plan J only,

because Plan F doesn’t cover prescription drugs), and

■ Foreign travel emergency ($250 per year for Plans F

and J).

43 ----- Section 2: Medigap Overview 

● End of page
Are there other factors that may affect the cost of my

Medigap policy? (continued)

● If you buy a Medicare SELECT policy: Medicare

SELECT is a type of Medigap policy sold by some

insurance companies in some States. If you buy a

Medicare SELECT policy, you are buying one of the

ten standardized Medigap Plans A through J. Medigap

SELECT policies require you to use specific hospitals

and, in some cases specific doctors to get full

insurance benefits (except in an emergency). Generally,

Medicare SELECT policies cost less than other

Medigap policies. 

If you have a Medicare SELECT policy and you don’t

use a Medicare SELECT hospital or doctor for 

non-emergency services, your costs will be higher. You

will have to pay some or all of what Medicare doesn’t

pay. Medicare will pay its share of approved charges

no matter which hospital or doctor you choose.

44 ----- Section 2: Medigap Overview 

● End of page
45 ----- Section 2: Medigap Overview 

When is the best time to buy a Medigap policy?

The best time to buy a Medigap policy is during your

Medigap open enrollment period.

Your Medigap open enrollment period lasts for six

months. It starts on the first day of the month in which

you are both:

● Age 65 or older, and

● Enrolled in Medicare Part B.

Once your six-month Medigap open enrollment period

starts, it can’t be changed.

During this period, an insurance company can’t:

● Deny you insurance coverage,

● Place conditions on a policy (like making you wait for

coverage to start), or

● Charge you more for a policy because of past or

present health problems.

If you buy a Medigap policy during your Medigap open

enrollment period, the insurance company must shorten

the waiting period for pre-existing conditions (see pages 

50 - 51) by the amount of previous health coverage you

have. This is called “creditable coverage” (see pages 

52 - 54).

If you are eligible for Medicare because you’re disabled or

have End-Stage Renal Disease (ESRD), see pages 113 - 116.
46 ----- Section 2: Medigap Overview 

How can I tell if I’m in my Medigap open enrollment

period?

You can tell if you are in your Medigap open enrollment

period by looking at your red, white, and blue Medicare

card (see sample card below). The lower right corner of

this card shows the dates that your Medicare Part A and

Part B coverage started. If you are age 65 or older, add

six months to the date that your Medicare Part B

coverage starts. If that date is in the future, you are still in

your Medigap open enrollment period. If that date is in

the past, you have missed your Medigap open enrollment

period (see example on the next page).

Example: Medicare Card

Note: There are earlier versions of this card that are

slightly different. They are still valid.
47 ----- Section 2: Medigap Overview 

How can I tell if I’m in my Medigap open enrollment

period? (continued)

Example: Medigap Open Enrollment Period

It is October 1, 2004, and Mr. Rodriguez wants to buy a

Medigap policy. He needs to know if he is in his Medigap

open enrollment period. He looks at his Medicare card.

His Medicare Part B coverage started August 1, 2004. To

figure out if he is in his open enrollment period, he must

add six months to his Medicare Part B start date and see

if it is before or after the current date.

August 1, 2004 + six months = January 31, 2005

Since it is October 1, 2004, he is still in his open

enrollment period. Mr. Rodriguez has until January 31,

2005, to buy a Medigap policy during his Medigap open

enrollment period.

What if I missed my Medigap open enrollment period?

If you apply for a Medigap policy after your open

enrollment period has ended, the Medigap insurance

company is allowed to use medical underwriting (see

page 42) to decide whether to accept your application,

and how much to charge you for the policy. If you are in

good health, the insurance company is likely to accept

your application, but there is no guarantee that you will

get the Medigap policy (unless you become eligible for

one of the Medigap protections listed on pages 96 - 97).
48 ----- Section 2: Medigap Overview 

Should I enroll in Medicare Part B and start my

Medigap open enrollment period if I am age 65 or

older and still working or covered under my spouse’s

plan?

You may want to wait to enroll in Medicare Part B if you

or your spouse are working and have group health

coverage, through an employer or union, based on your

or your spouse’s current employment. Your Medigap

open enrollment period won’t start until you sign up

for Medicare Part B. Remember, once you’re age 65 or

older and enrolled in Medicare Part B, your Medigap

open enrollment period starts and can’t be changed.

However, if your employer group health plan pays after

(or “secondary to”) Medicare, it may require you to enroll

in Medicare Part B in order to get benefits under that

plan.

● End of page
49 ----- Section 2: Medigap Overview 

What is the Medicare Modernization Act of 2003 and

how will it affect Medigap policies?

The Medicare Modernization Act of 2003 is bringing

many new and exciting changes to the Medicare

program. These new changes will give you even more

choices in how you get your health care benefits,

including coverage for prescription drugs.

Starting January 1, 2006, some Medigap policies will

change because of the Medicare Modernization Act. After

that date, you won’t be able to buy Medigap policies that

cover prescription drugs. This is because Medicare will

offer prescription drug coverage in 2006. Medigap Plans

H, I, and J may still be sold, but without the prescription

drug benefit. If you already have a Medigap policy that

covers prescription drugs, you may be able to keep it

under certain conditions. In addition, new types of

Medigap policies might be available. More information

about these changes will be available in 2005.

If you have questions about Medigap policies or the new

Medicare prescription drug benefit, you can look at

www.medicare.gov on the web. Select “Medicare

Personal Plan Finder” or “Prescription Drug and Other

Assistance Programs.” Or, call 1 800 633 - 4227. 

TTY users should call 1 877 486 - 2048.
50 ----- Section 2: Medigap Overview 

Pre-existing conditions

What is a pre-existing condition?

A pre-existing condition is a health problem you had

before the date a new insurance policy starts.

Will my pre-existing condition be covered if I buy a

Medigap policy?

In some cases, if you have a health problem before your

Medigap policy started, a Medigap insurance company

can refuse to cover that health problem for up to six

months. This is called a “pre-existing condition waiting

period.” The insurance company can only use this kind of

waiting period if your health problem was diagnosed or

treated during the six months before the Medigap policy

started. This means that the insurance company can’t

make you wait for coverage of a pre-existing condition

just because it thinks you should have known to see a

doctor for a health problem.

Words underlined are defined on pages 11 - 20.

● End of page
51 ----- Section 2: Medigap Overview 

Pre-existing conditions (continued)

Medigap open enrollment period

If you buy a Medigap policy during your Medigap open

enrollment period, and you had at least six months of

previous health coverage that qualifies as “creditable

coverage” (see pages 52 - 54), the company can’t give

you a pre-existing condition waiting period. If you had

less than six months of creditable coverage, this waiting

period will be reduced by the number of months of

creditable coverage you had.

Special Medigap Protections (Guaranteed Issue Rights)

If you buy a Medigap policy when you have special

Medigap protections (also called guaranteed issue rights),

the insurance company can’t use a pre-existing condition

waiting period. For more information about Medigap

protections, see pages 93 - 111.

If you want to know if you will have a pre-existing

condition waiting period if you switch Medigap policies,

see pages 55 - 56.

● End of page
52 ----- Section 2: Medigap Overview 

Creditable coverage

What is creditable coverage?

Creditable coverage is generally any other health

coverage you had before you applied for the Medigap

policy. If you buy a Medigap policy during your Medigap

open enrollment period, creditable coverage can reduce

the time you have to wait before your pre-existing health

problems will be covered by the Medigap policy.

These types of coverage count as creditable coverage:

● A group health plan (like an employer or union plan)

● A health insurance policy

● Medicare Part A or Medicare Part B

● Medicaid (see pages 158 - 160)

● A medical program of the Indian Health Service or

tribal organization

● A state health benefits risk pool (sometimes called a

state high risk pool)

● TRICARE (the health care program for military

dependents and retirees [see page 163])

● A Federal Employees Health Benefit Plan

● A public health plan

● A health plan under the Peace Corps Act
53 ----- Section 2: Medigap Overview 

Creditable coverage (continued)

What is creditable coverage? (continued)

Important: Whether you had creditable coverage

depends on whether you had any “breaks in coverage”

when you were without health coverage of any kind for

more than 63 days in a row. You can only count

creditable coverage that you had after that break in

coverage. If you have had one or more breaks in

coverage, but each break was shorter than 63 days, then

you can add the periods of coverage together. This will

count towards your creditable coverage.

Note: Hospital indemnity insurance, specified disease

insurance, vision or dental policies, and long-term care

policies aren’t considered creditable coverage.

● End of page
● End of page

54 ----- Section 2: Medigap Overview 

Creditable coverage (continued)

What is creditable coverage? (continued)

Example: Creditable Coverage 

Mr. Smith is 65 and is being treated for heart disease. His

Medicare Part A and Part B started November 1, 2003.

Before this date, he had no health insurance coverage.

On March 1, 2004, Mr. Smith buys a Medigap policy. His

Medigap insurance company refuses to cover his heart

disease condition for six months (the pre-existing

condition waiting period). However, since Mr. Smith had

Medicare Part A and Part B from November 1 to March 1,

the insurance company must use his four months of

Medicare coverage as creditable coverage to shorten this

six-month waiting period. Now his waiting period will only

be two months instead of six months. During these two

months, after Medicare pays its share, Mr. Smith will

have to pay the rest of the costs for the care of his heart

disease. He will also have to pay his Medigap premiums.

The Medigap policy will pay for other covered care.
55 ----- Section 2: Medigap Overview (cont.)

Switching (Changing) Medigap policies

What if I want to switch to a different Medigap policy?

Before switching policies, compare benefits and

premiums. Some of the older Medigap policies may offer

better coverage, especially for prescription drugs and

long-term care. On the other hand, older Medigap

policies may have bigger premium increases than newer

standardized Medigap policies.

If you decide to switch, don’t cancel your first Medigap

policy until the second Medigap policy is in place, and

you have decided to keep the second Medigap policy.

Once you have applied for the second Medigap policy,

you have 30 days to decide if you want to keep the new

Medigap policy. This is called your “free look” period.

Do I have to wait a certain length of time before I can

switch to a different Medigap policy?

No, but the length of time you had your policy will affect

how your new policy covers you for pre-existing

conditions. Your new Medigap policy generally must

cover all pre-existing conditions if you have had your

current policy at least six months.

Words underlined are defined on pages 11 - 20.
Switching (Changing) Medigap policies (continued)

Do I have to wait a certain length of time before I can

switch to a different Medigap policy? (continued)

Your new Medigap policy might not cover all pre-existing

conditions if you’ve had your current Medigap policy for

less than six months. However, the amount of time

you’ve had your current Medigap policy must count

towards the amount of time you must wait before your

new policy covers your pre-existing condition.

If there is a benefit in the new Medigap policy that wasn’t

in your old policy, the company can make you wait up to

six months before covering you for that benefit.

Do I have to switch Medigap policies if I have an older

Medigap policy?

No. If you have an older Medigap policy, you can keep it.

You don’t have to switch to one of the newer

standardized Medigap plans. But, if you decide to switch

your Medigap policy, you won’t be able to go back to

your older Medigap policy if you bought it before 1992

when standardized policies were first sold.

56 ----- Section 2: Medigap Overview 

● End of page
Losing Medigap coverage

Can my Medigap insurance company drop me?

In most cases, no. If you bought your Medigap policy

after 1990, the law says that your insurance company

must automatically renew your Medigap policy as long as

you pay your premium. This means that the policy is

guaranteed renewable. Your insurance company can drop

you if you lie (for example, you commit fraud under the

policy). Other than that, there is only one situation where

you may lose a Medigap guaranteed renewable policy: if

the insurance company goes bankrupt. If this happens,

and State law doesn’t make some other coverage

available, you have the right to buy a Medigap Plan A, B,

C, or F that is sold in your State (see Medigap

Protections, Situation #6 on page 107).

Insurance companies in some States may refuse to

renew Medigap policies that you bought before 1990.

This is because these old Medigap policies may not have

been required to be guaranteed renewable. In order for

an insurance company to refuse to renew one of these

older Medigap policies, the company must get the State’s

approval and cancel all Medigap policies of this type that

they sold in your State. If this happens, you have the right

to buy a Medigap Plan A, B, C, or F that is sold in your

State (see example on page 58 and Medigap Protections,

Situation #6 on page 107).

57 ----- Section 2: Medigap Overview 

Words underlined are defined on pages 11 - 20.
58 ----- Section 2: Medigap Overview 

Losing Medigap coverage (continued)

Can my Medigap insurance company drop me?

(continued)

Example: Guaranteed renewable

In 1987, Mr. Jones bought a Medigap policy. The

Medigap policy Mr. Jones bought isn’t guaranteed

renewable because he bought it before 1990, and it

didn’t say it was guaranteed renewable. The insurance

company won’t renew Mr. Jones’s policy because it has

decided (and got the State’s approval) to cancel all

Medigap policies of this type in the State. Therefore, 

Mr. Jones has the right to buy Medigap Plan A, B, C, or F

that is sold in his State from any insurance company that

offers them.

● End of page
59 ----- Section 2: Medigap Overview 

How your bills get paid

Does the Medigap insurance company pay my doctor

or provider directly?

In most cases, Medigap claims are sent directly to the

insurance company because most Medigap insurance

companies arrange to get your claims information directly

from Medicare carriers. A Medicare carrier is a private

company that has a contract with Medicare to pay Part B

bills.

However, if your Medigap insurance company doesn’t

have this automatic claims service, you can arrange to

have your claims sent directly to your Medigap insurance

company so your doctor or provider is paid directly.

● First, your doctor or provider has to sign an agreement

with Medicare to accept assignment of all Medicare

claims for all their Medicare patients.

● Then, you tell your doctor’s office to put on the

Medicare claim form that you want Medigap insurance

benefits paid to the doctor or supplier. Your doctor

should put your Medigap policy number and the

company name on the Medicare claim form. You will

need to sign the claim form or have your doctor keep

your signature on record. Make sure this information is

correct.
How your bills get paid (continued)

Does the Medigap insurance company pay my doctor

or provider directly? (continued)

When these conditions are met, the Medicare carrier will

process the claim and send it to the Medigap insurance

company. The Medicare carrier will send you a Medicare

Summary Notice. Your Medigap insurance company will

pay your doctor or provider directly and then send you a

notice. If you don’t get this notice, you may ask for it

from your Medigap insurance company.

What happens if my Medigap insurance company

doesn’t pay my doctor or provider directly?

If the Medigap insurance company doesn’t pay your

doctor directly when the above two conditions are met,

you should report this to your State Insurance

Department (see pages 183 - 186). For more information

on Medigap claim filing by the Medicare carrier, call your

Medicare carrier. Call 1 800 633 - 4227 to get the

telephone number of the Medicare carrier in your State.

TTY users should call 1 877 486 - 2048.

60 ----- Section 2: Medigap Overview 

Words underlined are defined on pages 11 - 20.

● End of page
Private contracts

What is a private contract?

Some doctors don’t accept Medicare payments. If you

want to get care from a doctor who doesn’t accept

Medicare payment, you may be asked to sign a private

contract.

A private contract is a written agreement between you

and a doctor (like a physician, podiatrist, dentist, or

optometrist) who has decided not to give services

through the Medicare program. The private contract only

applies to the services you get from the doctor who

asked you to sign it. You can’t be asked to sign a private

contract in an emergency situation or when you get

urgently needed care.

Note: You still have the right to see other Medicare

doctors for services.

If you sign a private contract with your doctor:

● You will have to pay whatever this doctor or provider

charges you for the services you get. Medicare’s

limiting charge won’t apply.

● No claim will be sent to Medicare, and Medicare won’t

pay if one is submitted.

● Your Medigap policy, if you have one, won’t pay

anything for this service.

61 ----- Section 2: Medigap Overview 
62 ----- Section 2: Medigap Overview 

Private contracts (continued)

If you sign a private contract with your doctor:

(continued)

● Medicare health plans won’t pay any amount for the

services you get from this doctor.

● Many other insurance plans won’t pay for the services

either. Call your insurance company before you get the

service if you have any questions.

● Your doctor must tell you whether Medicare would pay

for the service if you get it from another doctor who

participates in Medicare.

● Your doctor must tell you if he or she has opted out of

or been excluded from the Medicare program.

You can always choose to get services not covered under

Medicare and pay for these services yourself. In this

case, you don’t have to sign a private contract, and your

doctor doesn’t have to stop giving services through

Medicare.

Note: It is important that you talk to someone in your

State Health Insurance Assistance Program before

signing a private contract (see pages 179 - 182).
63 ----- Section 2: Medigap Overview 

Watch out for illegal insurance practices

It is illegal for anyone to do the following:

● Pressure you into buying a Medigap policy, or lie or

mislead you to switch from one company or policy to

another.

● Sell you a second Medigap policy when they know that

you already have one, unless you tell the insurance

company in writing that you plan to cancel your

existing Medigap policy.

● Sell you a Medigap policy if they know you have

Medicaid, except in certain situations (see page 160).

● Sell you a Medigap policy if they know you are in a

Medicare Advantage (formerly Medicare + Choice) Plan.

● Claim that a Medigap policy is part of the Medicare

program or any other Federal program. Remember,

Medigap is private health insurance.

● Sell you a Medigap policy that can’t legally be sold in

your State. Check with your State Insurance

Department (see pages 183 - 186) to make sure that

the Medigap plan you are interested in can be sold in

your State.
64 ----- Section 2: Medigap Overview 

Watch out for illegal insurance practices (continued)

● Misuse the names, letters, symbols, or emblems of the

U. S. Department of Health and Human Services

(DHHS), Social Security Administration (SSA), Centers

for Medicare & Medicaid Services (CMS), or any of

their various programs like Medicare.

If you believe that a Federal law has been broken, call the

Inspector General’s hotline at 1 800 447 - 8477. In most

cases, however, your State Insurance Department can

help you with insurance-related problems (see pages 

183 - 186).

● End of page
Ways to check if an insurance company is reliable

Buying a Medigap policy is an important decision. You

want to make sure that you are buying from a reliable

insurance company. 

To help you find out if an insurance company is reliable,

you can take the following actions:

● Call the State Insurance Department in your State (see

pages 183 - 186). Ask if they keep a record of

complaints against insurance companies and ask

whether these can be shared with you.

● Call the State Health Insurance Assistance Program in

your State (see pages 179 - 182). These programs can

give you free help with choosing a Medigap policy.

● Go to your local public library. Your local public library

can help you:

✓ Get information on an insurance company’s

financial strength by independent rating services

such as, Weiss Rating, Inc., A.M. Best, and

Standard & Poors, and

✓ Look at information on the web.

● Talk to someone you trust, like a family member, your

insurance agent, or a friend who has a Medigap policy.

65 ----- Section 2: Medigap Overview 

Words underlined are defined on pages 11 - 20.
66 ----- Section 2: Medigap Overview 

Notes
This section provides useful steps to help

you choose the best Medigap policy for

you.

Steps to buying a Medigap policy

Buying a Medigap policy is an important decision. Only

you can decide if a Medigap policy is the right kind of

Medicare supplement health insurance coverage for you.

If you decide to buy a Medigap policy, shop carefully.

Look for a Medigap policy that you can afford and that

gives you the coverage you need most. As you shop for a

Medigap policy, keep in mind that different insurance

companies may charge different amounts for the same

type of Medigap policy, and not all insurance companies

offer all of the Medigap policies.

67 ----- Section 3: Steps to Buying a Medigap Policy

Section 3

● End of page
The steps to buying a Medigap policy include the following:

Step 1: Look at which benefits best meet your needs

(see below and pages 69 - 83).

Step 2: Find out which insurance companies sell

Medigap policies in your State (see pages 84 - 85).

Step 3: Call the insurance companies and compare

costs (see pages 86 - 89).

Step 4: Choose the best Medigap policy for you (see

page 90).

Step 5: Buy the Medigap policy (see pages 91 - 92).

Step 1. Look at which benefits best meet your needs.

Use the chart on pages 69 - 83 to help you decide which

Medigap policy benefits you need. The chart explains

what Medicare pays, what you pay if you don’t have a

Medigap policy, and what you pay if you have a Medigap

policy. It will also help you when you begin to shop for

the Medigap policy that is right for you.

Important: You should think about your current and

future health care needs. Answer “yes” or “no” (place a

checkmark) to the question “Do I need or want this

benefit?” As you get older, your health care needs might

increase.

After you have checked off all of the benefits you need or

want on pages 69 - 83, you should find out which

insurance companies sell Medigap policies in your State

that cover those benefits (see pages 84 - 85).

68 ----- Section 3: Steps to Buying a Medigap Policy
Medigap Basic (Core) Benefits Chart

Remember, Medigap Plan A covers only the basic (core)

benefits listed on pages 70 - 72. Medigap Plans B

through J include the basic (core) benefits and some

extra benefits. See pages 73 - 83 for the extra benefits.

Note: This chart doesn’t apply if you live in

Massachusetts, Minnesota, or Wisconsin, see pages 

170 - 175. The amounts shown in this chart are for 2004.

These amounts can change each year. 

Place a checkmark next to either “yes” or “no” to the

question “Do I need or want this basic (core) benefit?”

Use this information when talking to insurance

companies to help choose the Medigap policy you want.

Insurance companies usually offer some, but not all, of

the Medigap plans.

69 ----- Section 3: Steps to Buying a Medigap Policy

● End of page
Medigap Basic (Core) Benefits Chart (continued)

Medicare Part A hospital benefits

What Medicare pays in 2004... 

Medicare pays its share of a covered hospital stay. 

What YOU pay in 2004 if you DON'T have a Medigap

Policy...

● $219 per day for days 61 - 90 of the hospital stay.

● $438 per day for days 91 - 150 of the hospital stay.

● All costs for each additional day after the 150th day of

the hospital stay after you have used all your lifetime

reserve days.

What YOU pay in 2004 if you HAVE a Medigap Policy

that covers this benefit...

● Nothing for days 61 - 90 of the hospital stay.

● Nothing for days 91 - 150 of the hospital stay.

● No costs that Medicare would have paid for up to 365

more days of hospital stays during your lifetime after

you use all Medicare hospital benefits.

● All costs after you have used all Medicare hospital

benefits and the 365 days of additional Medigap

hospital stay coverage.

Medigap policies that cover this benefit...

A, B, C, D, E, F, G, H, I, J

Do I need or want this basic (core) benefit?

___ Yes ___ No

70 ----- Section 3: Steps to Buying a Medigap Policy

(Chart continued to next page)
Medigap Basic (Core) Benefits Chart (continued)

Medicare Part B coinsurance or copayment

What Medicare pays in 2004... 

Medicare pays nothing for your first $100* (yearly

deductible) of Part B covered services. Then it generally

pays 80% of the Medicare-approved amount for

Medicare Part B covered services and supplies.

What YOU pay in 2004 if you DON'T have a Medigap

Policy...

After you pay for the first $100* (yearly deductible) of Part B

covered services (like doctor services and outpatient

hospital care), you generally pay 20% of the

Medicare-approved amount for Medicare Part B covered

services and supplies.

What YOU pay in 2004 if you HAVE a Medigap Policy

that covers this benefit...

After you pay for the first $100* (yearly deductible) of Part B

covered services (like doctor services and outpatient

hospital care), you generally pay nothing for any

Medicare-approved amount for Medicare Part B covered

services and supplies.

Medigap policies that cover this benefit...

A, B, C, D, E, F, G, H, I, J

Do I need or want this basic (core) benefit?

___ Yes ___ No

*The Medicare Part B deductible will go up to $110 in

2005.

71 ----- Section 3: Steps to Buying a Medigap Policy

(Chart continued to next page)
72 ----- Section 3: Steps to Buying a Medigap Policy

Medigap Basic (Core) Benefits Chart (continued)

Blood 

What Medicare pays in 2004... 

Medicare pays nothing for the first 3 pints of blood or

equal amounts of packed red blood cells per calendar

year.

What YOU pay in 2004 if you DON'T have a Medigap

Policy...

You pay the total cost for the first 3 pints of blood or

equal amounts of packed red blood cells per calendar

year, unless you or someone else donates blood to

replace what you use.

What YOU pay in 2004 if you HAVE a Medigap Policy

that covers this benefit...

You pay nothing for the first 3 pints of blood or equal

amounts of packed red blood cells per calendar year.

Medigap policies that cover this benefit...

A, B, C, D, E, F, G, H, I, J

Do I need or want this basic (core) benefit?

___ Yes ___ No
Medigap Extra Benefits Chart

Extra Medigap benefits, and the Medigap policies that

cover them, are shown on pages 74 - 83. Look to see

which Medigap policies cover the benefits you are most

interested in (see the column “Medigap policies that

cover this benefit”). Keep in mind, extra benefits will

increase your monthly premium, but may save you 

out-of-pocket costs if you use the benefits. Choose the

Medigap policy that best meets your needs, and fits your

budget. Remember, all Medigap policies must include the

basic (core) benefits listed on pages 70 - 72.

Answer the question “Do I need or want this extra

benefit?” by placing a checkmark next to “yes” or “no.”

Use this information when talking to insurance

companies to help choose the Medigap policy you want.

Insurance companies usually offer some, but not all, of

the Medigap plans. For more detailed information about

what Medicare covers, see pages 121 - 139.

The amounts shown in this chart are for 2004.

73 ----- Section 3: Steps to Buying a Medigap Policy

(Chart continued to next page)
74 ----- Section 3: Steps to Buying a Medigap Policy

(Chart continued to next page)

Medigap Extra Benefits Chart

Skilled Nursing Facility (SNF) Care Coinsurance

(Skilled nursing and rehabilitative services in a skilled

nursing facility after a related 3-day hospital stay.)

What Medicare pays in 2004... 

Medicare pays all covered costs for the first 20 days of

SNF care. After day 20, Medicare pays all but up to

$109.50 for the 21st - 100th day of SNF care.

What YOU pay in 2004 if you DON'T have a Medigap

Policy...

● Nothing for the first 20 days.

● Up to $109.50 per day for days 21 - 100.

● All costs after day 100.

What YOU pay in 2004 if you HAVE a Medigap Policy

that covers this benefit...

● Nothing for the first 20 days.

● Nothing for days 21 - 100.

● All costs after day 100.

Medigap policies that cover this benefit...

C, D, E, F, G, H, I, J

Do I need or want this extra benefit?

___ Yes ___ No
75 ----- Section 3: Steps to Buying a Medigap Policy

(Chart continued to next page)

Medigap Extra Benefits Chart (continued)

Medicare Part A Deductible

What Medicare pays in 2004... 

Medicare pays all but a total of $876 for a hospital stay of

1 - 60 days.

What YOU pay in 2004 if you DON'T have a Medigap

Policy...

For each benefit period, you pay a total of $876 for a

hospital stay of 1 - 60 days.

What YOU pay in 2004 if you HAVE a Medigap Policy

that covers this benefit...

You pay nothing for days 1 - 60 of a hospital stay.

Medigap policies that cover this benefit...

B, C, D, E, F, G, H, I, J

Do I need or want this extra benefit?

___ Yes ___ No
76 ----- Section 3: Steps to Buying a Medigap Policy

(Chart continued to next page)

Medigap Extra Benefits Chart (continued)

Medicare Part B Deductible

What Medicare pays in 2004... 

Medicare pays nothing for your first $100* (yearly

deductible) of Part B covered services (like doctor

services and outpatient hospital care).

What YOU pay in 2004 if you DON'T have a Medigap

Policy...

You pay for the first $100* (yearly deductible) of Part B

covered services and supplies (listed on pages 126 - 139).

What YOU pay in 2004 if you HAVE a Medigap Policy

that covers this benefit...

You pay nothing for the first $100* (yearly deductible) of

Part B covered services and supplies.

Medigap policies that cover this benefit...

C, F, J

Do I need or want this extra benefit?

___ Yes ___ No

*The Medicare Part B deductible will go up to $110 in

2005.
77 ----- Section 3: Steps to Buying a Medigap Policy

(Chart continued to next page)

Medigap Extra Benefits Chart (continued)

Medicare Part B Excess Charge

(difference between a doctor or other health care

provider’s actual charge and Medicare’s approved 

payment amount).

What Medicare pays in 2004... 

If your doctor doesn’t accept assignment, and charges

more than the Medicare-approved amount, Medicare

won’t pay the difference.

What YOU pay in 2004 if you DON'T have a Medigap

Policy...

You pay the total difference between what Medicare pays

and the doctor who doesn’t accept assignment charges.

This is called the excess charges.

What YOU pay in 2004 if you HAVE a Medigap Policy

that covers this benefit...

If you have Plans F, I, or J you pay none of the excess

charges.

If you have Plan G, you pay 20% of the excess charges.

Medigap policies that cover this benefit...

F, G, I, J

Do I need or want this extra benefit?

___ Yes ___ No
Medigap Extra Benefits Chart (continued)

Foreign Travel Emergency

What Medicare pays in 2004... 

Generally, Medicare pays nothing for emergency health

care outside the U.S.

What YOU pay in 2004 if you DON'T have a Medigap

Policy...

You pay 100% for emergency health care outside the

U.S. There are some exceptions for some care in Canada

and Mexico.

What YOU pay in 2004 if you HAVE a Medigap Policy

that covers this benefit...

You pay the first $250, and then 20% of the remaining

costs of emergency health care during the first 60 days of

each trip. There is a $50,000 lifetime maximum.

Medigap policies that cover this benefit...

C, D, E, F, G, H, I, J

Do I need or want this extra benefit?

___ Yes ___ No

78 ----- Section 3: Steps to Buying a Medigap Policy

(Chart continued to next page)
79 ----- Section 3: Steps to Buying a Medigap Policy

(Chart continued to next page)

Medigap Extra Benefits Chart (continued)

At-Home Recovery

(Home Health Care, see page 123)

What Medicare pays in 2004... 

Medicare pays the full Medicare-approved amount of all

Medicare-approved home health services.

What YOU pay in 2004 if you DON'T have a Medigap

Policy...

● You pay nothing for Medicare-approved home health

services.

● You pay 100% for non-Medicare covered services.

What YOU pay in 2004 if you HAVE a Medigap Policy

that covers this benefit...

● You pay nothing for Medicare-approved home health

services.

● You pay nothing for up to 8 additional weeks of 

at-home help after skilled care is no longer needed.

● Medigap policies will pay up to $40 each visit and

$1,600 each year. 

Medigap policies that cover this benefit...

D, G, I, J

Do I need or want this extra benefit?

___ Yes ___ No
Medigap Extra Benefits Chart (continued)

Prescription Drugs

Starting January 1, 2006, you won’t be able to buy

Medigap policies covering prescription drugs. For more

information, look at www.medicare.gov on the web.

Select “Prescription Drug and Other Assistance

Programs.” Or, call 1 800 633 - 4227.

What Medicare pays in 2004... 

Medicare doesn’t cover most outpatient prescription

drugs. 

In 2004, Medicare-approved prescription drug discount

cards will be available.

What YOU pay in 2004 if you DON'T have a Medigap

Policy...

You pay 100% for most outpatient prescription drugs. 

80 ----- Section 3: Steps to Buying a Medigap Policy

(Prescription drugs continued to next page)
81 ----- Section 3: Steps to Buying a Medigap Policy

(Chart continued to next page)

Medigap Extra Benefits Chart (continued)

Prescription Drugs (continued)

What YOU pay in 2004 if you HAVE a Medigap Policy

that covers this benefit...

You pay for the first $250 of outpatient prescription drugs

each year. Then you pay 50% for all prescription drugs

not covered by Medicare. Plans H and I have a $1,250

per year limit. For Plans H and I to be of full value, you

should have at least $2,750 in drug costs per year (you

pay $1,250 plus $250; plan pays $1,250). Plan J has a

$3,000 per year limit. For Plan J to be full value, you

should have at least $6,250 in drug costs per year (you

pay $3,000 plus $250; plan pays $3,000). Purchase of

these plans is only guaranteed during your open

enrollment period.

Medigap policies that cover this benefit...

H, I, J

Do I need or want this extra benefit?

___ Yes ___ No
Medigap Extra Benefits Chart (continued)

Medicare-covered Preventive Services

Note: Some Medicare-covered preventive services waive

the Part B deductible.

What Medicare pays in 2004... 

After you pay the $100* yearly deductible for Part B,

Medicare will pay 75 - 100% of some preventive services

under Part B. For a full list of preventive services, see

pages 131 - 139.

What YOU pay in 2004 if you DON'T have a Medigap

Policy...

You pay a $100* yearly deductible for Part B. You pay 

20 - 25% for most Medicare-covered preventive services.

You pay nothing for some shots. You pay 100% for

routine yearly check-ups and tests like serum cholesterol

screening, hearing testing, and diabetes screening.

What YOU pay in 2004 if you HAVE a Medigap Policy

that covers this benefit...

After you pay the $100* yearly deductible for Part B, you

pay nothing for most Medicare-covered preventive services.

*The Medicare Part B deductible will go up to $110 in

2005.

82 ----- Section 3: Steps to Buying a Medigap Policy

(Preventive Services continued to next page)
Medigap Extra Benefits Chart (continued)

Non-Medicare covered Preventive Services

What Medicare pays in 2004... 

Medicare pays nothing.

What YOU pay in 2004 if you DON'T have a Medigap

Policy...

You pay 100% for non-Medicare covered preventive

services. 

What YOU pay in 2004 if you HAVE a Medigap Policy

that covers this benefit...

You may pay nothing for routine yearly check-ups and

any non-Medicare covered preventive services your

doctor recommends. This benefit has a $120 per year

limit. You pay 100% after you have met your yearly limit.

Medigap policies that cover this benefit...

E, J

Do I need or want this extra benefit?

___ Yes ___ No

83 ----- Section 3: Steps to Buying a Medigap Policy

● End of page
84 ----- Section 3: Steps to Buying a Medigap Policy

Step 2. Find out which insurance companies sell

Medigap policies in your State.

To find out which insurance companies sell Medigap

policies in your State, you can do any of the following:

● Call your State Health Insurance Assistance Program

(see pages 179 - 182). Ask if they have a Medigap rate

comparison shopping guide for your State. These

types of guides usually list the insurance companies

that sell Medigap policies in your State and compare

the costs of policies from each insurance company.

● Call your State Insurance Department (see pages 

183 - 186).

● Look at www.medicare.gov on the web. Select

“Medicare Personal Plan Finder.”

This website will help you find information on all your

health plan options, including the Medigap policies in

your area. You can also get information on the

following:

✓ Some insurance companies that sell Medigap

policies in your State,

✓ How to contact these insurance companies,

✓ What the policies must cover, and

✓ How insurance companies decide what to charge

you for a Medigap policy premium.
Step 2. Find out which insurance companies sell

Medigap policies in your State. (continued)

If you don’t have a computer, your local library or

senior center may be able to help you look at this

information.

● Call 1 800 633 - 4227. A Customer Service

Representative will help you get information on all your

health plan options, including the Medigap policies in

your area. You will get your Medicare Personal Plan

Finder results in the mail within three weeks. TTY users

should call 1 877 486 - 2048.

You should plan to call more than one insurance

company that sells Medigap policies in your State since

costs can vary between companies. Check the

companies you call to be sure they are honest and

reliable (see page 65).

85 ----- Section 3: Steps to Buying a Medigap Policy

● End of page
Step 3. Call the insurance companies and compare

costs.

Call different insurance companies and ask the questions

listed on pages 87 - 89. Friends and relatives can tell you

about their Medigap policies and the quality of service, but

their Medigap policies might not fit your needs. Shop

around for the best Medigap policy for you at a price you

can afford.

You should ask each insurance company the questions

listed below. If you aren’t in your Medigap open

enrollment period or in another situation where you have

a guaranteed issue right to buy a Medigap policy 

(see pages 93 - 117), ask questions about how your

costs could be affected. Remember, there are different

ways insurance companies can price a Medigap policy 

(see pages 38 - 41).

86 ----- Section 3: Steps to Buying a Medigap Policy

(Continued to next page)
87 ----- Section 3: Steps to Buying a Medigap Policy

(Continued to next page)

Medigap Policy Comparison Worksheet

Use this worksheet to compare costs and benefits you

are considering. Make sure you get the agents’ and the

insurance companies’ names, addresses, and

telephone numbers.

Ask each insurance company...

Is this insurance company licensed in this State? 

(The answer should be yes.)

Insurance Company 1: ______________________________

Insurance Company 2: ______________________________

Insurance Company 3: ______________________________

Which Medigap policies do you sell? (Insurance

companies usually offer some, but not all, of the plans.

Make sure they sell the plan you want.)

Insurance Company 1: ______________________________

Insurance Company 2: ______________________________

Insurance Company 3: ______________________________

What is the cost, this year, of the Medigap policy I am

interested in?

Insurance Company 1: ______________________________

Insurance Company 2: ______________________________

Insurance Company 3: ______________________________
88 ----- Section 3: Steps to Buying a Medigap Policy

(Continued to next page)

Medigap Policy Comparison Worksheet (continued)

What has the cost of this Medigap policy been for the

past few years?

Insurance Company 1: ______________________________

Insurance Company 2: ______________________________

Insurance Company 3: ______________________________

How is the price decided?

● What type of pricing does this insurance company

use?

● Is there a discount if I am a female, a non-smoker, or

married? 

Insurance Company 1: ______________________________

Insurance Company 2: ______________________________

Insurance Company 3: ______________________________

Are there any additional (“innovative”) benefits or

discounts included in this policy?

Insurance Company 1: ______________________________

Insurance Company 2: ______________________________

Insurance Company 3: ______________________________
Medigap Policy Comparison Worksheet (continued)

If you aren’t in your Medigap open enrollment period

or in another situation where you have a guaranteed

issue right, ask:

● Will you accept my application?

● Do you review my health records or application

(medical underwriting) to decide how much to charge

me for a Medigap policy?

● If you have a pre-existing condition ask, “Will my 

pre-existing condition mean a delay in the start of my

benefits?”

Insurance Company 1: ______________________________

Insurance Company 2: ______________________________

Insurance Company 3: ______________________________

● End of page

89 ----- Section 3: Steps to Buying a Medigap Policy
Step 4. Choose the best Medigap policy for you.

After you call the insurance companies, compare their

costs, and check to see if the companies are reliable.

Then choose the Medigap policy that is best for you.

To make your final choice, make sure:

● You carefully review the Medigap policy benefits.

● You can afford the cost of the Medigap policy.

● The Medigap policy covers the benefits you need and

want.

● You feel good about and trust the insurance company

and/or the insurance agent.

● You talk with someone you trust, like a family member,

friend, doctor, insurance agent, or your State Health

Insurance Assistance Program (see pages 179 - 182)

about your choice.

Once you have checked the items above, you are now

ready to move on to Step 5 (see page 91).

90 ----- Section 3: Steps to Buying a Medigap Policy

● End of page
Step 5. Buy the Medigap policy.

Once you have decided on the insurance company and

the Medigap policy you want, you can buy your policy.

The insurance company must give you a clearly worded

summary of your Medigap policy. Read it carefully. If you

don’t understand it, ask questions. Remember the

following when you buy your Medigap policy:

● Fill out your application carefully and completely.

Answer all of the medical questions. If the insurance

agent fills out the application, review it to make sure

it’s correct. However, if you buy your Medigap policy

during your open enrollment or guaranteed issue

period, you can’t be asked these medical questions.

● Don’t buy more than one Medigap policy. If you

already have a Medigap policy, it is illegal for an

insurance company to sell you a second policy unless

you put in writing that you are going to cancel the first

Medigap policy. However, don’t cancel your first

Medigap policy until the second one is in place, and

you have decided to keep the second Medigap policy.

Once you have received the second Medigap policy,

you have 30 days to decide if you want to keep the

new Medigap policy. This is called your “free look”

period. The 30-day free look period starts when your

Medigap policy is issued to you.

91 ----- Section 3: Steps to Buying a Medigap Policy
Step 5. Buy the Medigap policy. (continued)

● It is best to pay for your Medigap policy by check,

money order, or bank draft. Make it payable to the

insurance company, not the agent. Get a receipt with

the insurance company’s name, address, and

telephone number for your records.

● Ask for your Medigap policy to become effective when

you want coverage to start, or when your previous

Medigap policy coverage ends. If, for any reason, the

insurance company won’t give you the start date you

want, call your State Insurance Department (see pages

183 - 186).

● Make sure you get a copy of your policy within 30

days. If you don’t get your policy in 30 days, call your

insurance company. If you don’t get your policy in 60

days, call your State Insurance Department (see pages

183 - 186).

92 ----- Section 3: Steps to Buying a Medigap Policy

● End of page
This section has detailed information

about your Medigap rights and

protections.

Medigap rights and protections (guaranteed issue

rights)

Your rights to buy a Medigap policy

In some situations, you have the right to buy a Medigap

policy outside of your Medigap open enrollment period.

These rights are called “Medigap protections.” They are

also called guaranteed issue rights because the law says

that insurance companies must sell (“issue”) you a

Medigap policy. 

In these situations, an insurance company:

● Can’t deny you Medigap coverage or place conditions

on a policy (like making you wait for coverage to start),

● Must cover you for all pre-existing conditions (see

pages 50 - 51), and

● Can’t charge you more for a Medigap policy because

of past or present health problems.

93 ----- Section 4: Medigap Rights and Protections

Section 4

● End of page
Your rights to buy a Medigap policy (continued)

In many cases, the guaranteed issue rights apply when

your health coverage changes. Remember, it is best to

apply for a Medigap policy before your current health

coverage has ended. You can apply for a Medigap policy

while you are still in your health plan and choose to start

your Medigap coverage the day after your health plan

coverage ends. This will prevent gaps in your health

coverage.

Note: If you drop your Medigap policy, you may not be

able to get it back except in very limited cases.

If you live in Massachusetts, Minnesota, or Wisconsin,

you have the same guaranteed issue rights to buy a

Medigap policy. If you have questions, call your State

Insurance Department (see pages 183 - 186).

94 ----- Section 4: Medigap Rights and Protections

● End of page
95 ----- Section 4: Medigap Rights and Protections

Your rights to buy a Medigap policy (continued)

Important: In some situations, you have a guaranteed

issue right to buy a Medigap policy because you lost

certain kinds of health coverage. You should keep a copy

of any letters, notices, and claim denials you get. Be sure

to keep anything that has your name on it. Also, keep the

postmarked envelope these papers come in as proof of

when it was mailed. You may need to send a copy of

some or all of these papers with your application for a

Medigap policy to prove you lost coverage and have the

right to these Medigap protections. The Medigap

protections in this section are from Federal law. Many

States provide more Medigap protections than Federal

law. Call your State Health Insurance Assistance Program

or State Insurance Department for more information (see

pages 179 - 186).

● End of page
96 ----- Section 4: Medigap Rights and Protections

Medigap protections if you lose or drop your health

care coverage (guaranteed issue rights)

In order to get these Medigap protections, you must

meet certain conditions listed below and on page 97.

These rights include both Medigap and Medicare

SELECT policies.

Note: There may be times when more than one situation

applies to you. When this happens, you can choose the

Medigap protection that gives you the best choice of

Medigap policies.

Situation #1:

Your Medicare Advantage or PACE program coverage

ends because the plan is leaving the Medicare program

or stops giving care in your area (see pages 98 - 100).

Situation #2:

Your employer group health plan coverage ends (see

pages 101 - 102).

Situation #3:

You have to end your health coverage because you move

out of the plan’s service area (see pages 103 - 104).

(Situations continued to next page)
97 ----- Section 4: Medigap Rights and Protections

Medigap protections if you lose or drop your health

care coverage (guaranteed issue rights) (continued) 

Situation #4:

You joined a Medicare Advantage Plan or PACE program

when you were first eligible for Medicare at age 65 and

within the first year of joining, you decide you want to

leave (see page 105).

Situation #5:

You dropped a Medigap policy to join a Medicare

Advantage Plan, Medicare SELECT policy, or PACE

program for the first time and now you want to leave and

you have been in the plan less than a year (see page 106).

Situation #6:

Your Medigap insurance company goes bankrupt and

you lose your coverage, or your Medigap policy coverage

ends through no fault of your own (see page 107).

Situation #7:

You leave your plan because your Medicare Advantage

Plan, Medicare SELECT policy, or Medigap insurance

company hasn’t followed the rules or misled you. For

example, the marketing materials were not true, or quality

standards were not met (see pages 108 - 109).
98 ----- Section 4: Medigap Rights and Protections

Medigap protections

Situation #1: Your Medicare Advantage Plan or PACE

program coverage ends because the plan is leaving

the Medicare program or stops giving care in your

area.

In this situation, your Medicare Advantage (formerly

Medicare + Choice) Plan or PACE program sends you a

letter telling you that you will no longer be covered by the

plan. You have the right to buy a Medigap Plan A, B, C,

or F that is sold in your State by any insurance company.

You can buy the Medigap policy at the best premium

price available (based on health status), with no review of

your medical records even if you have health problems.

You can apply for a Medigap policy as soon as you get

the final notification letter from your plan. When you get

this letter telling you that your plan is leaving the

Medicare program or will no longer give care in your area,

you may:

1. Switch to another Medicare Advantage Plan in your

area. The final notification letter will tell you if there are

other plans available in your area. In some cases, you

may have to wait until the plan you want to join is

accepting new members. If you join a new Medicare

Advantage Plan when your current plan coverage

ends, you won’t need (or be able to use) a Medigap

policy, or
Medigap protections (continued)

Situation #1: Your Medicare Advantage Plan or PACE

program coverage ends because the plan is leaving

the Medicare program or stops giving care in your

area. (continued)

2. Leave your Medicare Advantage Plan or PACE

program (disenroll) any time between the date you get

your final notification letter and when your health

coverage ends. Unless you join another Medicare

Advantage Plan, you will automatically return to the

Original Medicare Plan when you leave (disenroll from)

your plan or PACE program. You have 63 calendar

days from the day you leave your plan or PACE

program to apply for a Medigap policy, or

3. Stay in your plan or PACE program until the date your

coverage ends. Unless you join another Medicare

Advantage Plan, you will automatically return to the

Original Medicare Plan when your coverage ends. You

have 63 calendar days after your health coverage

ends to apply for a Medigap policy.

Note: The Programs of All-inclusive Care for the Elderly

(PACE) combines medical, social, and long-term care

services for frail people. PACE is available only in States

that choose to offer it under Medicaid. For more

information about PACE, see page 167.

99 ----- Section 4: Medigap Rights and Protections
100 ----- Section 4: Medigap Rights and Protections

● End of page

Medigap protections (continued)

Situation #1: Your Medicare Advantage Plan or PACE

program coverage ends because the plan is leaving

the Medicare program or stops giving care in your

area. (continued)

Important: You will have additional rights under Situation

#4 (see page 105) or Situation #5 (see page 106) if:

● This was the first time you were in a Medicare

Advantage Plan, 

● You were in the plan less than one year before the plan

left the Medicare program or stopped giving care in

your area, and 

● You choose to return to the Original Medicare Plan and

apply for a Medigap policy. 

If, instead, you immediately join another Medicare

Advantage Plan, you can stay in that plan for up to one

year and still have the rights described in Situations #4

and #5.
101 ----- Section 4: Medigap Rights and Protections

Medigap protections (continued)

Situation #2: Your employer group health plan

coverage ends.

You have the right to buy a Medigap policy if you are in

an employer group health plan that pays after (or

“secondary to”) Medicare, but your plan coverage ends

because of the following:

● The employer goes out of business,

● The employer stops offering a plan, or

● You are no longer eligible for coverage under the plan.

For example, you may lose eligibility for coverage in the

plan when you retire (or your spouse retires, if your

coverage is through his or her plan) because the plan

only covers current employees (and their dependents)

and doesn’t provide retiree coverage.

In this situation, you have the right to buy a Medigap Plan

A, B, C, or F that is sold in your State by any insurance

company. You can buy the Medigap policy at the best

premium price available (based on health status) with no

review of your medical records even if you have health

problems.
Medigap protections (continued)

Situation #2: Your employer group health plan

coverage ends. (continued)

You may get a letter or a notice from your employer, the

health plan, or the insurance company telling you that

your coverage is or will be cancelled. You have 63

calendar days from the date your coverage ends or from

the date on the letter or notice (whichever is later) to

apply for a Medigap policy. In some cases, you won’t get

a notice, but you may get a claim denial. If this happens,

this claim denial is the same as a letter telling you that

your coverage has ended. Remember, keep a copy of the

letter, notice, or claim denial, and the postmarked

envelope. You may need these papers to prove you lost

coverage. You will need to send a copy of the letter,

notice, or claim denial with your application to prove that

you have a right to this Medigap protection.

State law may also give you the right to buy a Medigap

policy when you lose coverage under an employer plan

that paid before (or “primary to”) Medicare. If you are

offered COBRA when your employer plan ends, and

decide to take it instead of getting a Medigap policy, you

will again have guaranteed issue rights when your

COBRA coverage ends. For more information about

COBRA, see pages 151 - 153.

COBRA is a law that lets some people keep their group

health plan coverage for a limited period of time after

they leave their employment (see pages 151 - 153). 

102 ----- Section 4: Medigap Rights and Protections
Medigap protections (continued)

Situation #3: You have to end your health coverage

because you move out of the plan’s service area.

If you have health coverage from a Medicare Advantage

(formerly Medicare + Choice) Plan or you are in a PACE

program, and you move out of the plan’s service area,

you will have to end your coverage.

If you have a Medicare SELECT policy, you can keep

your policy because it is guaranteed renewable. However,

because you have moved, you can’t use hospitals or

other health care providers that are on the policy’s list of

approved providers. This is called the policy’s “network.”

You might want to switch to another Medigap policy that

is sold in your State.

You have the right to buy a Medigap Plan A, B, C, or F

that is sold by any insurance company in your State (if

you move within the same State but outside of the plan’s

service area), or the State you are moving to (if you move

out of State). You can buy the Medigap policy at the best

premium price available, with no review of your medical

records even if you have health problems.

103 ----- Section 4: Medigap Rights and Protections

(Continued on next page)

Words underlined are defined on pages 11 - 20.
Medigap protections (continued)

Situation #3: You have to end your health coverage

because you move out of the plan’s service area.

(continued)

You must tell your current plan that you are moving and

give them a date when you will end your coverage. You

can apply for a Medigap policy as early as 60 calendar

days before the date your health coverage ends. You

must apply for a Medigap policy no later than 63

calendar days after your health coverage ends to get this

protection.

● End of page

104 ----- Section 4: Medigap Rights and Protections
Medigap protections (continued)

Situation #4: You joined a Medicare Advantage Plan or

PACE program when you were first eligible for

Medicare at age 65 and within the first year of joining,

you decide you want to leave.

You have the right to buy any Medigap policy that is sold

in your State by any insurance company. You can buy the

Medigap policy at the best premium price available, with

no review of your medical records even if you have health

problems. You must tell the plan that you want to leave

(disenroll) and give them a date to end your coverage.

This date must be before you have been in the plan for a

year. You will have from 60 calendar days before your

coverage ends until 63 calendar days after your coverage

ends to apply for a new Medigap policy.

Your rights under this situation may last for an extra 12

months if the plan you first joined leaves the Medicare

program or stops giving care in your area before you

have been in the plan for one year, AND you immediately

join another Medicare Advantage Plan or PACE program.

● End of page

105 ----- Section 4: Medigap Rights and Protections
Medigap protections (continued)

Situation #5: You dropped a Medigap policy to join a

Medicare Advantage Plan, Medicare SELECT policy, or

PACE program for the first time and now you want to

leave and you have been in the plan less than a year.

You have the right to go back to the Medigap policy you

had, if the same insurance company still sells it. You

need to tell the Medicare Advantage (formerly Medicare +

Choice) Plan, Medicare SELECT, or PACE program or

policy that you want to leave (disenroll) and give them a

date to end your coverage. This date must be before you

have been in the plan for a year.

If your former Medigap policy isn’t available, you have the

right to buy a Medigap Plan A, B, C, or F that is sold in

your State by any insurance company. You can buy the

Medigap policy at the best premium price available, with

no review of your medical records even if you have health

problems. You will have from 60 calendar days before

your coverage ends until 63 calendar days after your

coverage ends to apply for a new Medigap policy.

Your rights under this situation may last for an extra 12

months if the plan you first joined leaves the Medicare

program or stops giving care in your area before you

have been in the plan for one year, AND you immediately

join another Medicare Advantage Plan or PACE program.

106 ----- Section 4: Medigap Rights and Protections
Medigap protections (continued)

Situation #6: Your Medigap insurance company goes

bankrupt and you lose your coverage, or your

Medigap policy coverage ends through no fault of your

own.

You have the right to buy a Medigap Plan A, B, C, or F

that is sold in your State by any insurance company. You

can buy the Medigap policy at the best premium price

available, with no review of your medical records even if

you have health problems. You will have 63 calendar

days from the date your coverage ends to apply for a

new Medigap policy. Because Medigap policies are

guaranteed renewable, the only way you would lose

coverage under a Medigap policy would generally be if

the insurance company goes bankrupt.

107 ----- Section 4: Medigap Rights and Protections

● End of page
Medigap protections (continued)

Situation #7: You leave your plan because your

Medicare Advantage Plan, Medicare SELECT, or

Medigap insurance company hasn’t followed the rules,

or misled you.

In this situation, you leave the health plan because it

failed to meet its contract obligations to you. This could

include things such as quality standards weren’t met, the

company misled you, or it used untrue statements in its

marketing materials. Generally, to have this right, you

must have filed a grievance with the health plan,

Medicare, or the State Insurance Department and

received a decision that the plan was at fault.

You have the right to buy a Medigap Plan A, B, C, or F

that is sold in your State by any insurance company. You

can buy the Medigap policy at the best premium price

available, with no review of your medical records even if

you have health problems. You must tell the plan that you

want to leave (disenroll) and give them a date to end your

coverage. You will have 63 calendar days from the date

your coverage ends to apply for a new Medigap policy.

108 ----- Section 4: Medigap Rights and Protections

● End of page
Medigap protections (continued)

Situation #7: You leave your plan because your

Medicare Advantage Plan, Medicare SELECT, or

Medigap insurance company hasn’t followed the rules,

or misled you. (continued)

Remember, some States provide more Medigap

protections. Your State might let you choose from more

Medigap policies or give you a longer time to apply for a

Medigap policy when you lose your coverage. Call your

State Health Insurance Assistance Program for more

information (see pages 179 - 182).

If you live in Massachusetts, Minnesota, or Wisconsin,

you have the same guaranteed issue rights (see pages 

93 - 96) to buy a Medigap policy. If you have questions,

call your State Insurance Department (see pages 

183 - 186).

109 ----- Section 4: Medigap Rights and Protections

● End of page
110 ----- Section 4: Medigap Rights and Protections

Medigap protections (continued)

Special note for people with Medicare under age 65

If you are in a situation that gives you the right to:

● Return to a Medigap policy you previously had but

dropped, or

● Buy Medigap Plans A, B, C, or F, 

you must be allowed to return to the same Medigap

policy you dropped, if it is still available from your old

insurance company, or to buy a Medigap Plan A, B, C, 

or F that is sold by any insurance company in your State

to people under age 65. You can buy the Medigap policy

at the best premium price available, with no review of

your medical records. However, there is no Federal law

that says insurance companies must sell Medigap

policies to people under age 65. If an insurance company

does sell these Medigap policies to anyone under age 65,

they must sell one to you if you are in one of these

situations (listed on pages 98 - 109).
Medigap protections (continued)

Special note for people with End-Stage Renal Disease

(ESRD)

If you have ESRD and are in a Medicare Advantage

(formerly Medicare + Choice) Plan, and the plan leaves

Medicare or no longer provides coverage in your area,

you have a one-time right to join another Medicare

Advantage Plan. You don’t have to use your one-time

right to join a new Medicare Advantage Plan immediately.

If you change directly to the Original Medicare Plan after

your plan leaves or stops providing coverage, you will still

have a one-time right to join a Medicare Advantage Plan

at a later date during a time that people can enroll in a

Medicare health plan.

Where to get more information about Medigap

protections

● Call your State Health Insurance Assistance Program

(see pages 179 - 182) to make sure that you qualify for

these Medigap protections. They can also help you

find the Medigap policy that is right for you.

● Call your State Insurance Department (see pages 

183 - 186) if you are denied Medigap coverage in any

of these situations.

111 ----- Section 4: Medigap Rights and Protections
112 ----- Section 4: Medigap Rights and Protections

Notes
This section has information about how

Medigap policies work if you are disabled

or have ESRD.

Medigap policies for people under age 65 and eligible

for Medicare because of a disability or End-Stage

Renal Disease (ESRD)

You may have Medicare before age 65 due to:

● A disability, or

● ESRD (permanent kidney failure requiring dialysis or a

kidney transplant).

If you are a person with Medicare under age 65 and are

disabled or have ESRD, you might not be able to buy the

Medigap policy you want until you turn 65. Federal law

doesn’t require insurance companies to sell Medigap

policies to people under age 65. However, some States

require Medigap insurance companies to sell you a

Medigap policy, at certain times (during a limited

Medigap open enrollment period), even if you are under

age 65. These States are listed on page 114. If you have

questions, you should call your State Health Insurance

Assistance Program (see pages 179 - 182).

113 ----- Section 5: Medigap and Disability or ESRD

Section 5
Medigap policies for people under age 65 and eligible

for Medicare because of a disability or End-Stage

Renal Disease (ESRD) (continued)

At the time of this printing, the following States require

insurance companies to offer at least one kind of

Medigap policy to people with Medicare under age 65.

● California

● Colorado

● Connecticut

● Kansas

● Louisiana

● Maine

● Maryland

● Massachusetts

● Michigan

● Minnesota

● Mississippi

● Missouri

● New Hampshire

● New Jersey

● New York

● North Carolina

● Oklahoma

● Oregon

● Pennsylvania

● South Dakota

● Texas

● Vermont

● Washington

● Wisconsin 

114 ----- Section 5: Medigap and Disability or ESRD

● End of page
Medigap policies for people under age 65 and eligible

for Medicare because of a disability or End-Stage

Renal Disease (ESRD) (continued)

Even if your State doesn’t require insurance companies

to sell Medigap policies to people with Medicare under

age 65, some insurance companies may voluntarily sell

Medigap policies to some people under age 65. Whether

or not your State requires insurance companies to sell to

you, Medigap policies sold to people under age 65 may

cost you more.

Remember, if you live in a State that has a Medigap open

enrollment period for people under age 65, you will still

get another Medigap open enrollment period when you

turn age 65. You may have other choices of Medigap

policies or be able to get a better rate on your Medigap

policy at that time.

Also, if you join a Medicare Advantage (formerly Medicare +

Choice) Plan and your coverage ends, you may have the

right to buy a Medigap policy (see “Special note for

people with Medicare under age 65” on page 110). If you

have questions, you should call your State Health

Insurance Assistance Program (see pages 179 - 182).

115 ----- Section 5: Medigap and Disability or ESRD

● End of page
116 ----- Section 5: Medigap and Disability or ESRD

Medigap policies for people age 65 or older and

eligible for Medicare because of a disability or

End-Stage Renal Disease (ESRD)

The first six months after you turn age 65 and are

enrolled in Medicare Part B is your Medigap open

enrollment period. It doesn’t matter that you have had

Medicare Part B before you turned age 65. During this

time:

● You can buy any Medigap policy (including those

Medigap policies that currently help pay the cost of

prescription drugs*), and

● Insurance companies can’t refuse to sell you a

Medigap policy due to a disability or other health

problem, or charge you a higher premium than they

charge other people who are 65 years old.

When you buy a Medigap policy during your Medigap

open enrollment period, the insurance company must

shorten the waiting period for pre-existing conditions by

the amount of creditable coverage you have. If you had

Medicare for more than six months before you turned 65

years old, you won’t have a pre-existing condition waiting

period because Medicare counts as creditable coverage.

(See pages 52 - 54 for more information about creditable

coverage.)

*Starting January 1, 2006, Medigap policies will no

longer be sold with outpatient prescription drug

coverage. See page 49 for more information.
Right to suspend a Medigap policy for disabled 

people with Medicare

If you are under 65, have Medicare, have a Medigap

policy, and have employer group health plan coverage,

you have a right to suspend (put on hold) your Medigap

policy. Your Medigap coverage will stop, and you don’t

have to pay the monthly premium while you are enrolled

in your or your spouse’s employer group health plan. You

won’t have to pay more when you start your Medigap

policy again than you would otherwise have to pay if you

had not suspended your policy.

If, for any reason, you lose your employer group health

plan coverage, you can get your Medigap policy back.

Within 90 days of losing your employer group health plan

coverage, you must notify your Medigap insurance

company that you want your Medigap policy back.

Your Medigap benefits and premiums will start again on

the day your employer group health plan coverage stops.

The Medigap policy must have the same benefits and

premiums it would have had if you had never suspended

your coverage. Your Medigap insurance company can’t

refuse to cover care for any pre-existing conditions

(health problems) you have (see pages 50 - 51). So, if you

are disabled and working, you can enjoy the benefits of

your employer’s insurance while knowing that you will be

able to get your Medigap policy back when you need it.

117 ----- Section 5: Medigap and Disability or ESRD
118 ----- Section 5: Medigap and Disability or ESRD

Notes
This section provides information about

the Original Medicare Plan, Medicare 

Part A and Part B, and how much you

pay for each service.

The Original Medicare Plan has two parts:

● Medicare Part A, and 

● Medicare Part B.

Medicare Part A

What it covers. Medicare Part A helps cover your

inpatient care in hospitals, including critical access

hospitals, and skilled nursing facilities (not unskilled or

long-term care). It also covers hospice care and some

home health care. You must meet certain conditions to

get these benefits.

What you pay. Most people don’t have to pay a monthly

payment, called a premium, for Medicare Part A. This is

because they or a spouse paid Medicare taxes while they

were working.

See pages 121 - 125 for more Medicare Part A coverage

information.

119 ----- Section 6: Original Medicare Plan

Section 6

Words underlined are defined on pages 11 - 20.
120 ----- Section 6: Original Medicare Plan

Medicare Part B

What it covers. Medicare Part B helps cover your

doctors’ services, outpatient hospital care, and some

other medical services that Medicare Part A doesn’t

cover, such as some of the services of physical and

occupational therapists, and some home health care.

Medicare Part B helps pay for these covered services

and supplies when they are medically necessary. It also

covers some preventive services.

What you pay. Most people pay the monthly premium of

$66.60 (in 2004) for Medicare Part B. However, the cost

will go up 10% for each full 12-month period that you

could have had Part B but didn’t sign up for it, except in

special cases (see page 160). You might have to pay this

extra amount as long as you have Part B.

You also pay a $100 Part B deductible each year before

Medicare starts to pay its share. The Part B deductible

will go up to $110 in 2005.

See pages 126 - 139 for more Medicare Part B coverage

information.

Look at www.medicare.gov on the web for more details

about what services or supplies are covered by Medicare.

Select “Your Medicare Coverage.”

Note: Medigap policies work with the Original Medicare

Plan. To see what Medigap policies pay for, see pages 

69 - 83.
121 ----- Section 6: Original Medicare Plan

*New Medicare Part A and Part B amounts will be

available by January 1, 2005.

Covered Services in the Original Medicare Plan - 

Part A

Medicare Part A (Hospital Insurance) helps cover your

medically necessary:

Hospital Stays: Semiprivate room, meals, general

nursing, and other hospital services and supplies. This

includes inpatient care you get in critical access hospitals

and mental health care. This doesn’t include private duty

nursing, or a television or telephone in your room. It also

doesn’t include a private room, unless medically

necessary. Inpatient mental health care in a psychiatric

facility is limited to 190 days in a lifetime.

What YOU Pay in 2004* in the Original Medicare Plan

For each benefit period YOU pay:

● A total of $876 for a hospital stay of 1 - 60 days.

● $219 per day for days 61 - 90 of a hospital stay.

● $438 per day for days 91 - 150 of a hospital stay. (See

Lifetime Reserve Days on page 14.)

● All costs for each day beyond 150 days.
Covered Services in the Original Medicare Plan - 

Part A (continued)

Medicare Part A (Hospital Insurance) helps cover your

medically necessary:

Skilled Nursing Facility (SNF) Care: Semiprivate room,

meals, skilled nursing and rehabilitative services, and

other services and supplies (after a related 3-day hospital

stay). 

What YOU Pay in 2004* in the Original Medicare Plan

For each benefit period YOU pay:

● Nothing for the first 20 days.

● Up to $109.50 per day for days 21 - 100.

● All costs beyond the 100th day in the benefit period.

If you have questions about SNF care and conditions of

coverage, call 1 800 633 - 4227.

122 ----- Section 6: Original Medicare Plan

*New Medicare Part A and Part B amounts will be

available by January 1, 2005.
123 ----- Section 6: Original Medicare Plan

Covered Services in the Original Medicare Plan - 

Part A (continued)

Medicare Part A (Hospital Insurance) helps cover your

medically necessary:

Home Health Care: Part-time or intermittent skilled

nursing care and home health aide services, physical

therapy, occupational therapy, speech-language therapy,

medical social services, durable medical equipment (such

as wheelchairs, hospital beds, oxygen, and walkers),

medical supplies, and other services.

What YOU Pay in 2004* in the Original Medicare Plan

● Nothing for Medicare-approved services.

● 20% of the Medicare-approved amount for durable

medical equipment.

If you have questions about home health care and

conditions of coverage, call 1 800 633 - 4227.

*New Medicare Part A and Part B amounts will be

available by January 1, 2005.
124 ----- Section 6: Original Medicare Plan

Covered Services in the Original Medicare Plan - 

Part A (continued)

Medicare Part A (Hospital Insurance) helps cover your

medically necessary:

Hospice Care: For people with a terminal illness,

includes drugs for symptom control and pain relief,

medical and support services from a Medicare-approved

hospice, and other services not otherwise covered by

Medicare. Hospice care is usually given in your home

(which may include a nursing home if it’s your home).

However, Medicare covers some short-term hospital and

inpatient respite care (care given to a hospice patient so

that the usual caregiver can rest).

What YOU Pay in 2004* in the Original Medicare Plan

● A copayment of up to $5 for outpatient prescription

drugs and 5% of the Medicare-approved amount for

inpatient respite care. The amount you pay for respite

care can change each year. Medicare generally doesn’t

pay for room and board except in certain cases. For

example, room and board aren’t covered if you get

general hospice services while a resident of a nursing

home or a hospice’s residential facility. However, room

and board are covered for inpatient respite care and

during short-term hospital stays.

● If you have questions about hospice care and

conditions of coverage, call 1 800 633 - 4227.

*New Medicare Part A and Part B amounts will be

available by January 1, 2005.
125 ----- Section 6: Original Medicare Plan

Covered Services in the Original Medicare Plan - 

Part A (continued)

Medicare Part A (Hospital Insurance) helps cover your

medically necessary:

Blood: Pints of blood you get at a hospital or skilled

nursing facility during a covered stay.

What YOU Pay in 2004* in the Original Medicare Plan

● For the first three pints of blood, unless you or

someone else donates blood to replace what you use.

*New Medicare Part A and Part B amounts will be

available by January 1, 2005.

● End of page
126 ----- Section 6: Original Medicare Plan

Covered Services in the Original Medicare Plan - 

Part B 

Medicare Part B (Medical Insurance) helps cover your

medically necessary:

Medical and Other Services: Doctors’ services (not

routine physical exams), outpatient medical and surgical

services and supplies, diagnostic tests, ambulatory

surgery center facility fees for approved procedures, and

durable medical equipment (such as wheelchairs, hospital

beds, oxygen, and walkers). Also covers a second and

third surgical opinion for surgery that isn’t an emergency,

outpatient mental health care, and outpatient physical

and occupational therapy, including speech-language

therapy. (These services are also covered for long-term

nursing home residents.)

What YOU pay in 2004* in the Original Medicare Plan

● $100 deductible (once per calendar year).

● 20% of the Medicare-approved amount after the

deductible (if the doctor or provider accepts

“assignment”).

● 20% for all outpatient physical, occupational, and

speech-language therapy services.

● 50% for most outpatient mental health care.

* New Medicare Part A and Part B amounts will be

available by January 1, 2005.

See note on page 130.
127 ----- Section 6: Original Medicare Plan 

* New Medicare Part A and Part B amounts will be

available by January 1, 2005.

Covered Services in the Original Medicare Plan - 

Part B (continued)

Medicare Part B (Medical Insurance) helps cover your

medically necessary:

Clinical Laboratory Service: Blood tests, urinalysis,

some screening tests, and more.

What YOU pay in 2004* in the Original Medicare Plan

● Nothing for Medicare-approved services.

See note on page 130.

● End of page
Covered Services in the Original Medicare Plan - 

Part B (continued)

Medicare Part B (Medical Insurance) helps cover your

medically necessary:

Home Health Care: Part-time or intermittent skilled

nursing care and home health aide services, physical

therapy, occupational therapy, speech-language therapy,

medical social services, durable medical equipment (such

as wheelchairs, hospital beds, oxygen, and walkers),

medical supplies, and other services.

What YOU pay in 2004* in the Original Medicare Plan

● Nothing for Medicare-approved services.

● 20% of the Medicare-approved amount for durable

medical equipment.

If you have questions about home health care and

conditions of coverage call 1 800 633 - 4227.

128 ----- Section 6: Original Medicare Plan

* New Medicare Part A and Part B amounts will be

available by January 1, 2005.

See note on page 130.
129 ----- Section 6: Original Medicare Plan 

* New Medicare Part A and Part B amounts will be

available by January 1, 2005.

● End of page

Covered Services in the Original Medicare Plan - 

Part B (continued)

Medicare Part B (Medical Insurance) helps cover your

medically necessary:

Outpatient Hospital Services: Hospital services and

supplies received as an outpatient as part of a doctor’s

care.

What YOU pay in 2004* in the Original Medicare Plan

● A coinsurance or copayment amount, which may vary

according to the service.

See note on page 130.
Covered Services in the Original Medicare Plan - 

Part B (continued)

Medicare Part B (Medical Insurance) helps cover your

medically necessary:

Blood: Pints of blood you get as an outpatient or as part

of a Part B covered service.

What YOU pay in 2004* in the Original Medicare Plan

● For the first three pints of blood, then 20% of the

Medicare-approved amount for additional pints of

blood (after the deductible), unless you or someone

else donates blood to replace what you use.

130 ----- Section 6: Original Medicare Plan 

* New Medicare Part A and Part B amounts will be

available by January 1, 2005.

Note: Actual amounts you must pay may be higher if the

doctor or supplier doesn’t accept assignment and you

may have to pay the entire charge at the time of

service. Medicare will then send you its share of the

charge. If you have general questions about Medicare

Part B, call your Medicare carrier. If you have questions

about durable medical equipment, including diabetic

supplies, call your Durable Medical Equipment Regional

Carrier (DMERC). For their telephone numbers, look at

www.medicare.gov on the web. Select “Helpful

Contacts.” Or, call 1 800 633 - 4227. TTY users should

call 1 877 486 - 2048.
131 ----- Section 6: Original Medicare Plan 

Covered Preventive Services in the Original Medicare

Plan - Part B

Medicare Part B covered preventive services

Bone Mass Measurements:

Once every 24 months for qualified individuals and more

frequently if medically necessary.

Who is covered...

Discuss with your doctor to see if you qualify.

What YOU pay in the Original Medicare Plan...

20% of the Medicare-approved amount (or a copayment

amount) after the yearly Part B deductible.

Note: To find out what services and supplies are covered

by Medicare, look at www.medicare.gov on the web.

Select “Your Medicare Coverage.” Or, you can get a free

copy of Your Medicare Benefits (CMS Pub. No. 10116)

by calling 1 800 633 - 4227. TTY users should call 

1 877 486 - 2048.
132 ----- Section 6: Original Medicare Plan 

Covered Preventive Services in the Original Medicare

Plan - Part B (continued)

Medicare Part B covered preventive services

Colorectal Cancer Screening: 

● Fecal Occult Blood Test (FOBT) - Once every 12 months.

● Flexible Sigmoidoscopy - Once every 48 months.

● Colonoscopy - Once every 24 months if you are at

high risk for colorectal cancer. If you aren’t at high risk

for colorectal cancer, once every ten years, but not

within 48 months of a screening flexible sigmoidoscopy.

● Barium Enema - Doctor can use this instead of flexible

sigmoidoscopy or colonoscopy. It’s covered every 24

months if you are at high risk for colorectal cancer and

every 48 months if you aren’t at high risk.

Who is covered...

All people with Medicare age 50 and older. Note: There is

no minimum age for having a colonoscopy.

What YOU pay in the Original Medicare Plan...

Nothing for the fecal occult blood test (FOBT). For all

other tests, 20% of the Medicare-approved amount after

the yearly Part B deductible.

For flexible sigmoidoscopy or colonoscopy, you pay 25%

of the Medicare-approved amount after the yearly Part B

deductible if the test is done in a hospital outpatient

department.
133 ----- Section 6: Original Medicare Plan 

● End of page

Covered Preventive Services in the Original Medicare

Plan - Part B (continued)

Medicare Part B covered preventive services

Diabetes Services:

Diabetes self-management training.

Who is covered...

Certain people with Medicare who are at risk for

complications from diabetes. Your doctor or other health

care provider must request these services.

What YOU pay in the Original Medicare Plan...

20% of the Medicare-approved amount after the yearly

Part B deductible.
134 ----- Section 6: Original Medicare Plan 

● End of page

Covered Preventive Services in the Original Medicare

Plan - Part B (continued)

Medicare Part B covered preventive services

Glaucoma Testing:

Once every 12 months. Must be done or supervised by

an eye doctor who is legally allowed to do this service in

your State.

Who is covered...

People with Medicare who are at high risk for glaucoma,

including people with diabetes, a family history of

glaucoma, or African Americans age 50 and older.

What YOU pay in the Original Medicare Plan...

20% of the Medicare-approved amount after the yearly

Part B deductible.
135 ----- Section 6: Original Medicare Plan 

● End of page

Covered Preventive Services in the Original Medicare

Plan - Part B (continued)

Medicare Part B covered preventive services

Pap Test and Pelvic Examination (includes a clinical

breast exam):

Once every 24 months. Once every 12 months if you are

at high risk for cervical or vaginal cancer, or if you are of

childbearing age and have had an abnormal Pap test in

the past 36 months.

Who is covered...

All women with Medicare.

What YOU pay in the Original Medicare Plan...

Nothing for the Pap lab test. For Pap test collection, and

pelvic and breast exams, 20% of the Medicare-approved

amount (or a copayment amount) with no Part B

deductible.
136 ----- Section 6: Original Medicare Plan 

Covered Preventive Services in the Original Medicare

Plan - Part B (continued)

Medicare Part B covered preventive services

Prostate Cancer Screening:

● Digital Rectal Examination - Once every 12 months.

● Prostate Specific Antigen (PSA) Test - Once every 12

months.

Who is covered...

All men with Medicare age 50 and older (coverage begins

the day after your 50th birthday).

What YOU pay in the Original Medicare Plan...

Generally, 20% of the Medicare-approved amount for 

the digital rectal exam after the yearly Part B deductible.

No coinsurance and no Part B deductible for the Prostate

Specific Antigen (PSA) Test.

● End of page
137 ----- Section 6: Original Medicare Plan 

Covered Preventive Services in the Original Medicare

Plan - Part B (continued)

Medicare Part B covered preventive services

Screening Mammograms:

● Once every 12 months (11 full months must have

elapsed from the last screening).

● Medicare also covers new digital technologies for

screening mammograms.

Who is covered...

All women with Medicare age 40 and older. You can also

get one baseline mammogram between ages 35 and 39.

What YOU pay in the Original Medicare Plan...

20% of the Medicare-approved amount with no Part B

deductible.

● End of page
138 ----- Section 6: Original Medicare Plan 

Covered Preventive Services in the Original Medicare

Plan - Part B (continued)

Medicare Part B covered preventive services

Shots (vaccinations): 

● Flu Shot* - Once a flu season in the fall or winter.

● Pneumococcal Pneumonia Shot - One shot may be all

you will ever need. Ask your doctor.

Who is covered...

All people with Medicare.

What YOU pay in the Original Medicare Plan...

Nothing for flu and pneumococcal pneumonia shots if the

health care provider accepts assignment.

* The flu is a serious illness that can lead to pneumonia.

It can be dangerous for people age 65 and older. and

people of any age with certain chronic medical

conditions. You need a flu shot each year because flu

viruses are always changing. The shot is updated each

year for the most current flu viruses. Also, the flu shot

only helps protect you from the flu for about one year.

There is a chance that you may still get the flu, but your

symptoms will be less severe.
139 ----- Section 6: Original Medicare Plan 

Covered Preventive Services in the Original Medicare

Plan - Part B (continued)

Medicare Part B covered preventive services

Shots (vaccinations): (continued)

● Hepatitis B Shot

Who is covered...

Certain people with Medicare at medium to high risk for

Hepatitis B.

What YOU pay in the Original Medicare Plan...

For Hepatitis B shots, 20% of the Medicare-approved

amount (or a copayment amount) after the yearly Part B

deductible.

● End of page
140 ----- Section 6: Original Medicare Plan 

How do I enroll in Medicare Part A?

Most people are enrolled automatically, without taking

any action. For more information about enrolling in

Medicare Part A, call the Social Security Administration at

1 800 772 - 1213. Or, look at www.medicare.gov on the

web. Select “Medicare Eligibility Tool.”

How do I enroll in Medicare Part B?

If you already get Social Security or Railroad Retirement

benefits, you are automatically enrolled in Medicare Part B.

If you aren’t automatically enrolled in Medicare Part B,

you will need to contact the Social Security

Administration to get enrolled. You can enroll by:

● Calling or visiting your local Social Security office. The

address and telephone number are in your local

telephone book.

● Calling the Social Security Administration at 

1 800 772 - 1213. TTY users should call 

1 800 325 - 0778.

● Looking at the Social Security Administration’s website

at www.socialsecurity.gov on the web. Some people

who meet certain conditions are able to enroll by

computer. 
141 ----- Section 6: Original Medicare Plan 

How do I enroll in Medicare Part B? (continued)

Note: If you get benefits from the Railroad Retirement

Board (RRB), you will need to call your local RRB office

or 1 800 808 - 0772 to apply.

Important: Even if your full retirement age for Social

Security or Railroad Retirement benefits is older than 65,

you are still eligible for Medicare at age 65.

When can I enroll in Medicare Part B?

Pages 142 - 144 has a summary chart that explains when

you can enroll in Medicare Part B. To learn more about

how to enroll in Medicare, get a free copy of Enrolling in

Medicare (CMS Pub. No. 11036). Look at

www.medicare.gov on the web. Select “Publications.” 

Or, call 1 800 633 - 4227. TTY users should call 

1 877 486 - 2048.

You can also get information about Medicare eligibility

and enrollment by looking at www.medicare.gov on the

web. Select “Medicare Eligibility Tool.”

For more information about enrolling in Medicare if you

are disabled or have End-Stage Renal Disease, call the

Social Security Administration at 1 800 772 - 1213.

Different eligibility rules may apply. TTY users should call

1 800 325 - 0778.
142 ----- Section 6: Original Medicare Plan 

Medicare Part B Enrollment Periods Summary Chart

Initial Enrollment Period

This is a seven-month period that begins three months

before the month you are first eligible for Medicare 

Part B. (For most people, the Initial Enrollment Period

begins three months before the month you turn 65. It

ends three months after you turn 65.) Here is an example:

The month you turn 65

1 month after the month you turn 65

2 months after the month you turn 65

3 months after the month you turn 65

If you wait until these last four months of your Initial

Enrollment Period to sign up for Medicare Part B, your

start date for your coverage will be delayed.

3 months before the month you turn 65

2 months before the month you turn 65

1 month before the month you turn 65

Sign up early to avoid a delay in getting coverage for 

Part B services. To get Part B coverage the month you

turn 65, you must sign up during these first three

months.
Medicare Part B Enrollment Periods Summary Chart

(continued)

Initial Enrollment Period (continued)

Note: If you wait until after the Initial Enrollment Period is

over, you may have to pay more for your Medicare Part B

premium (see example on page 145), except in special

cases. See Special Enrollment Period on page 144.

General Enrollment Period

This period runs from January 1 through March 31 of

each year. If you didn’t enroll in Medicare Part B when

you first became eligible (during your Initial Enrollment

Period), you can sign up during this enrollment period.

Remember, the cost of Medicare Part B will go up 10%

for each full 12-month period (see example on page

145) that you could have had Medicare Part B but didn’t

take it, except during special rules. See Special

Enrollment Period on page 144.

If you sign up during the months of January, February or

March, your coverage will begin on July 1.

143 ----- Section 6: Original Medicare Plan 
144 ----- Section 6: Original Medicare Plan 

Medicare Part B Enrollment Periods Summary Chart

(continued)

Special Enrollment Period

This enrollment period may be used if you waited to

enroll in Medicare Part B because you or your spouse (or

family member if you are disabled) were still working and

had group health plan coverage. If this applies to you,

you can sign up for Medicare Part B:

Anytime while you are still covered by the group health

plan, through your or your spouse’s (or family member if

you are disabled) current employment status.

or

During the eight months following the month the group

health plan coverage ends, or the employment ends

(whichever is first). 

For more information about the Special Enrollment

Period, see the next page.

● End of page
145 ----- Section 6: Original Medicare Plan 

How much will Medicare Part B cost if I didn’t enroll

when I first became eligible?

The cost of Medicare Part B will go up 10% for each full

12-month period that you could have had Medicare Part B

but didn’t take it, except in special cases (see page 144).

You will have to pay this extra amount (called a premium

surcharge) as long as you have Medicare Part B. Here is 

an example if you delayed enrolling for 24 months.

Example: Premium Surcharge

If you delayed enrolling in Medicare Part B for 24

months, you will have to pay a 20% premium surcharge

(10% for each full 12-month period that you could have

been enrolled), plus your standard Medicare Part B

monthly premium ($66.60 in 2004). These amounts might

change each year.

$66.60 2004 Medicare Part B standard premium

+ $13.30 (20% of $66.60 is $13.32. In this example, _______ this amount is rounded down.)

$79.90 will be your Medicare Part B monthly

premium for 2004.

Note: The example above is if you delayed enrolling in

Medicare Part B for 24 months. You don’t pay a premium

surcharge if you enroll before a full 12-month period has

passed.
146 ----- Section 6: Original Medicare Plan 

Note about Special Enrollment Period

If you are still working and plan to keep your employer’s

group health coverage, you should talk to your benefits

administrator or your State Health Insurance Assistance

Program (see pages 179 - 182) to help you decide the

best time to enroll in Medicare Part B. When you sign up

for Medicare Part B, you automatically begin your

Medigap (Medicare Supplement Insurance) open

enrollment period. Once your Medigap open enrollment

period begins, it can’t be changed or restarted. See 

pages 45 - 48 to learn more about your Medigap open

enrollment period.

If you are disabled and working (or have group health

plan coverage from a working family member), the

Special Enrollment Period rules may also apply.

Remember, most people who sign up for Medicare Part B

during a Special Enrollment Period don’t pay higher

premiums. However, if you are eligible but don’t sign

up for Medicare Part B during the Special Enrollment

Period, you will only be able to sign up during the

General Enrollment Period (see page 143), and the

cost of Medicare Part B may go up.

● End of page
147 ----- Section 6: Original Medicare Plan 

Special Enrollment Period for Medicare Part B and

TRICARE for Life

If you are a military retiree, or the spouse or dependent

child of either a military retiree or an active duty sponsor,

and you have Medicare Part A but aren’t enrolled in

Medicare Part B, you may enroll in Medicare Part B

without a premium surcharge during a Special Enrollment

Period that will continue through December 31, 2004.

Information about when the Special Enrollment Period

will begin will be announced on www.tricare.osd.mil, the

TRICARE website.

If you are a military retiree, or the spouse or dependent

child of either a military retiree or an active duty sponsor

and you are entitled to Medicare Part B between January

2001 and December 2004, and you are paying more than

$66.60 a month for Medicare Part B, your Medicare Part B

premium will be reduced to $66.60 beginning January

2004. You will get a refund for any excess premiums you

have paid. You don’t have to do anything. The premium

reduction and refund will be done automatically.

● End of page
148 ----- Section 6: Original Medicare Plan 

Notes
149 ----- Section 7: Other Ways to Pay Health Care

Costs

This section has helpful information

about other ways to pay for your health

care.

Other kinds of insurance and ways to pay health care

costs

There are other kinds of health care coverage, besides a

Medigap policy, that may pay for some of your health

care costs not covered by Medicare. Pages 151 - 168

gives you a brief description. If you think you may qualify

and want more detailed information, you can get a free

copy of the Health Care Coverage Directory for People

with Medicare (CMS Pub. No. 02231) at

www.medicare.gov on the web. Select “Publications.” 

Or, call 1 800 633 - 4227. TTY users should call 

1 877 486 - 2048. Some of the types of insurance and

other ways to pay health care costs are listed on the next

page.

Section 7

● End of page
150 ----- Section 7: Other Ways to Pay Health Care

Costs 

Health Coverage See page(s)

COBRA coverage 151 - 153

Employee or retiree coverage from an 

employer or union 154 - 155

Federally Qualified Health Centers (FQHCs) 155

Home and Community-Based 

Service/Waiver programs (HCBS) 156

Hospital indemnity insurance 156

Long-term care insurance 157

Medicaid 158 - 160

Medicare-approved drug discount cards 161

Medicare Savings Programs (help from 

your State) 162

Military retiree benefits (TRICARE) 163

Prescription drug and other assistance 

programs 164

Specified disease insurance 165

State Children’s Health Insurance 

Program (SCHIP) 166

The PACE program (Programs of 

All-inclusive Care for the Elderly) 167

Veterans’ benefits 168
151 ----- Section 7: Other Ways to Pay Health Care

Costs 

COBRA

COBRA may help...

COBRA (“Continuation Coverage” under the

Consolidated Omnibus Budget Reconciliation Act) may

provide you and your dependents with rights to keep

your health care coverage temporarily if:

● You lose your job, 

● Your working hours are reduced, 

● You leave your job voluntarily, or

● Your employer goes bankrupt.

It may also help your spouse keep health care coverage if

you die, or you get divorced.

A quick look at how it works...

COBRA allows you to keep your employer group health

plan coverage for 18 months (or up to 36 months or

sometimes even for a lifetime if you are a retiree and your

former employer goes bankrupt) if you lose the coverage

for one of the reasons listed above. There are important

timeframes that you must know about COBRA and

Medigap policies if you lose your employer coverage (see

pages 152 - 153).
152 ----- Section 7: Other Ways to Pay Health Care

Costs 

COBRA (continued)

A quick look at how it works... (continued)

COBRA and Medigap

If you lose your employer coverage, you might have to

make a decision to either elect COBRA coverage or enroll

in Medicare Part B. If you choose to enroll in Medicare

Part B, your Medigap Open Enrollment Period will start.

Once your Medigap Open Enrollment Period starts, it

can’t be changed (see pages 45 - 48). If your Open

Enrollment Period has already passed, you might be

protected by the Medigap protections listed on pages 

101 - 102 (see Situation #2).

Whether you choose to elect COBRA coverage, enroll in

Medicare Part B, or have Medigap protections, you must

follow the important timeframes below. In most cases

these timeframes overlap.

COBRA gives you a 60-day timeframe to elect COBRA

coverage. This timeframe begins either the day you lose

your employer coverage or the date when you get a

notice from your employer letting you know you have

COBRA rights, whichever occurs later.
153 ----- Section 7: Other Ways to Pay Health Care

Costs 

COBRA (continued)

A quick look at how it works... (continued)

Medigap Open Enrollment Period is a six-month period

that begins on the first day of the month in which you are

both 65 or older and enrolled in Medicare Part B. During

this period, you have the right to buy any Medigap policy.

Medigap Protections are available only if you apply

within 63 calendar days after you get a notice from your

employer letting you know that your coverage is ending.

In some cases, you won’t get a notice, but you may get a

claim denial. If this happens, you may have the right to

buy a Medigap policy (see Medigap Protections, Situation

#2 on pages 101 - 102) within 63 calendar days after you

get a notice that a claim has been denied. Remember,

this timeframe ends 63 calendar days after this notice or

claim denial. The Medigap guaranteed issue timeframe

might be different depending on the law in your State.

In most cases, the COBRA timeframe and the Medigap

guaranteed issue timeframe will overlap. To learn how

these timeframes will affect you, call your State Health

Insurance Assistance Program (see pages 179 - 182).
154 ----- Section 7: Other Ways to Pay Health Care

Costs 

Employee or retiree coverage from an employer or

union

Employee or retiree coverage from an employer or

union may help...

Employees or spouses who had health care coverage

from a current or previous employer or union.

A quick look at how it works...

In some cases, you or your spouse might be able to get

your health care coverage from an employer or union

based on you or your spouse’s current employment. This

is called “employee coverage.”

Some employers or unions might let you or your spouse

continue your health care coverage after the employment

ends. This is called “retiree coverage.”

If you have this type of coverage from an employer or

union, they may change the benefits or premiums, and

may also cancel the coverage if they choose.

There are some important timeframes that you must

know about if you or your spouse are working and have

group health coverage based on current or active

employment, see “Medigap Open Enrollment Period” on

pages 45 - 48.
155 ----- Section 7: Other Ways to Pay Health Care

Costs 

Employee or retiree coverage from an employer or

union (continued)

A quick look at how it works... (continued)

Employee and retiree coverage and Medigap

If you have employee or retiree coverage and it ends, you

may have the right to buy a Medigap policy. You may get

a notice or claim denial letting you know that your health

care coverage is ending. If this happens, you have the

right to apply for a Medigap policy (see Medigap

Protections, Situation #2 on pages 101 - 102) within 63

calendar days from the date your coverage ends or from

the notice or claim denial.

Federally Qualified Health Centers (FQHCs)

Federally Qualified Health Centers (FQHCs) may help...

People who live near a FQHC.

A quick look at how it works...

FQHCs are special health centers, usually located in

urban or rural areas, that can give routine health care at a

lower cost. Some FQHCs are Community Health Centers,

Tribal FQHC Clinics, Certified Rural Health Clinics,

Migrant Health Centers, and Health Care for the

Homeless Programs.
156 ----- Section 7: Other Ways to Pay Health Care

Costs 

Home and Community-Based Service/Waiver

programs (HCBS) 

Home and Community-Based Service/Waiver

programs (HCBS) may help...

Certain elderly and disabled individuals.

A quick look at how it works...

HCBS programs are available to some people with

Medicaid. They offer services and programs that help you

get care in your home and community. This program

allows you to stay more independent. Some examples

are: homemaker services, personal care, adult day care,

meals, and transportation.

Hospital indemnity insurance 

Hospital indemnity insurance may help...

Pay for hospital stays up to a certain number of days.

A quick look at how it works...

This kind of insurance pays a set amount of money for

each day of a hospital stay. You won’t need this

insurance if your health insurance coverage or Medigap

policy already pays for this type of care. This insurance

doesn’t fill gaps in your Medicare coverage. It usually

pays in addition to your health insurance.
157 ----- Section 7: Other Ways to Pay Health Care

Costs

Long-term care insurance

Long-term care insurance may help...

Pay for your health or personal care needs and activities

of daily living, such as bathing, dressing, using the

bathroom, and eating.

A quick look at how it works...

Long-term care insurance is sold by private insurance

companies and usually covers medical care and

non-medical care. This insurance might help you stay

independent.

There are many types of long-term care choices for older

people. Some long-term care examples are: assisted

living facilities, community services (adult day care and

meal programs), and nursing homes. Make sure you

choose the long-term care policy that is best for you.

To learn about your long-term care choices and longterm care insurance, get a free copy of Choosing Longterm Care: A Guide for People with Medicare (CMS

Pub. No. 02223) at www.medicare.gov on the web.

Select “Publications.” Or, call 1 800 633 - 4227.
158 ----- Section 7: Other Ways to Pay Health Care

Costs 

Medicaid

Medicaid may help...

People with limited incomes and resources.

A quick look at how it works...

Medicaid helps pay your medical costs. Since this is a

joint Federal and State program, coverage varies from

State to State.

People with Medicaid may get coverage for things like

nursing home care, home care, and outpatient

prescription drugs that aren’t covered by Medicare.

● End of page
159 ----- Section 7: Other Ways to Pay Health Care

Costs 

Medicaid (continued)

A quick look at how it works... (continued)

Medicaid and Medigap

If you have a Medigap policy and then get Medicaid,

there are a few things you should know:

● You can suspend (put on hold) your Medigap policy

within 90 days of getting Medicaid.

● You won’t have to pay your Medigap policy premiums

while it is suspended.

● Your Medigap policy won’t pay benefits while the

Medigap policy is suspended.

● You can suspend a Medigap policy for up to two

years.

● At the end of the suspension, you can reinstate the

Medigap policy without new medical underwriting or

pre-existing condition waiting periods.

To help you with the suspension decision, call your State

Medical Assistance Office. To get their telephone number,

call 1 800 633 - 4227. For questions about suspending a

Medigap policy, call your insurance company.
160 ----- Section 7: Other Ways to Pay Health Care

Costs 

Medicaid (continued)

A quick look at how it works... (continued)

If you already have health insurance coverage through

your State Medicaid program, an insurance company can

sell you a Medigap policy only in certain situations:

● The insurance company can legally sell you any

Medigap policy if Medicaid pays your Medigap policy

premium or if Medicaid only pays your Medicare Part B

premium.

● The insurance company can legally sell you Medigap

Plans H, I, or J if Medicaid only pays your Medicare

premiums, deductibles, or coinsurance. (This only

applies to Medigap policies sold between now and

January 1, 2006.)

In any other situation, it is illegal for an insurance

company to sell you a Medigap policy if you are getting

any Medicaid benefits.

● End of page
161 ----- Section 7: Other Ways to Pay Health Care

Costs 

Medicare-approved drug discount cards

Medicare-approved drug discount cards may help...

People save money on prescription drugs. (New in 2004)

A quick look at how it works...

In 2004, Medicare will contract with private companies to

offer new drug discount cards until a Medicare

prescription drug benefit starts in 2006. You might be able

to save on prescription drugs with a Medicare-approved

drug discount card. For more information about Medicareapproved drug discount cards, look at www.medicare.gov

on the web. Select “Prescription Drug and Other

Assistance Programs.” Or, call 1 800 633 - 4227. TTY

users should call 1 877 486 - 2048.

Drug discount cards and Medigap Policies

You might already have a drug discount card with your

Medigap policy. If the drug discount card you have with

your Medigap policy isn’t a Medicare-approved drug

discount card, you can also get a Medicare-approved

drug discount card.
162 ----- Section 7: Other Ways to Pay Health Care

Costs 

Medicare Savings Programs 

Medicare Savings Programs (help from your State as

part of the State Medical Assistance Program) may

help...

People with limited income and resources.

A quick look at how it works...

These programs can help pay your Medicare premiums

and, in some cases may also pay Medicare deductibles

and coinsurance. To be eligible for this program, you

must meet certain requirements.

These programs may not be available in Guam, Puerto

Rico, the Virgin Islands, the Northern Mariana Islands,

and American Samoa.

To find out if these programs are available in your 

area or for more information, call your State Medical

Assistance Office. To get their telephone number, call 

1 800 633 - 4227. Since the names of these programs

may vary by State, ask for information on Medicare

Savings Programs.

● End of page
163 ----- Section 7: Other Ways to Pay Health Care

Costs 

● End of page

Military retiree benefits (TRICARE) 

Military retiree benefits (TRICARE) may help...

Active duty and retired uniformed services members and

their families.

A quick look at how it works...

TRICARE is a health care program that offers medical

coverage to eligible members. The TRICARE program

includes TRICARE Prime, TRICARE Extra, TRICARE

Standard, and TRICARE for Life (TFL).

If eligible, you get all Medicare-covered benefits under

the Original Medicare Plan, plus all TFL-covered benefits.

For more information about the TRICARE programs, call

1 800 538 - 9552 or look at www.tricare.osd.mil on the

web.
164 ----- Section 7: Other Ways to Pay Health Care

Costs 

Prescription drug and other assistance programs

Prescription drug and other assistance programs may

help...

People get discounted or free prescription drugs that help

pay for their health care.

A quick look at how it works...

Some States offer programs that either offer discounted

or free prescription drugs. They also may offer other

assistance programs to help pay for your other health

care costs. To be eligible for these programs, you must

meet certain requirements. For more information, look at

www.medicare.gov on the web. Select “Prescription 

Drug and Other Assistance Programs.” Or, call 

1 800 633 - 4227. TTY users should call 

1 877 486 - 2048.

Prescription drugs and Medigap

If you are thinking about signing up for your State’s

Prescription Drug Assistance Program and you haven’t

yet bought a Medigap policy, get your Medigap policy

before you apply for prescription drug assistance. After

you get the prescription drug assistance you might not be

able to buy a Medigap policy.
165 ----- Section 7: Other Ways to Pay Health Care

Costs 

Specified disease insurance 

Specified disease insurance may help...

People with a certain type of disease.

A quick look at how it works...

This kind of insurance pays benefits for a single disease,

such as cancer, or for a group of diseases. You usually

have to buy this insurance before you are diagnosed or

treated for the specified disease.

You won’t need this insurance if your health insurance

coverage or Medigap policy already pays for this type of

care. This insurance doesn’t fill gaps in your Medicare

coverage. It usually pays in addition to your health

insurance.

● End of page
166 ----- Section 7: Other Ways to Pay Health Care

Costs 

State Children’s Health Insurance Program (SCHIP)

State Children’s Health Insurance Program (SCHIP)

may help...

Uninsured children under age 19.

A quick look at how it works...

Some States offer free or low-cost health insurance to

uninsured children whose families don’t qualify for

Medicaid. For more information about your State’s

program, look at www.cms.hhs.gov/schip/ on the web.

● End of page
167 ----- Section 7: Other Ways to Pay Health Care

Costs 

The PACE program (Programs of All-inclusive Care for

the Elderly)

The PACE program (Programs of All-inclusive Care for

the Elderly) may help...

Frail people who live in the service area of a PACE

program.

A quick look at how it works...

PACE combines medical, social, and long-term care

services for frail people. PACE might be a better choice

for you instead of getting your care through a nursing

home. PACE is available only in States that have chosen

to offer it under Medicaid. If you live in a State that offers

PACE, and you have Medicare and are eligible for PACE,

you can choose to get your Medicare benefits through

this program.

To find out if you are eligible and if there is a PACE site

near you, or for more information, call your State

Medical Assistance Office. To get their telephone number

call 1 800 633 - 4227. TTY users should call 

1 877 486 - 2048. Or, look at www.medicare.gov/Nursing/

Alternatives/PACE.asp on the web.
168 ----- Section 7: Other Ways to Pay Health Care

Costs 

Veterans’ benefits

Veterans’ benefits may help...

People who have had any military service or are a

veteran.

A quick look at how it works...

The U.S. Department of Veterans Affairs offers health

care benefits and other types of benefits and services to

eligible members. For more information about VA benefits

and services, call the U.S. Department of Veterans Affairs

at 1 800 827 - 1000.

● End of page
This section includes the different types

of standardized Medigap plans sold in

these three States. 

Information for Massachusetts, see pages 170 - 171.

Information for Minnesota, see pages 172 - 173.

Information for Wisconsin, see pages 174 - 175.

For Medigap plans sold in other States, see pages 30 - 36.

169 ----- Section 8: Massachusetts, Minnesota,

and Wisconsin Medigap Plans

Section 8

● End of page
170 ----- Section 8: Massachusetts, Minnesota,

and Wisconsin Medigap Plans 

Medigap 

Benefits

Basic Benefits

Medicare 

Part A: Inpatient Hospital

Deductible

Medicare 

Part A: Skilled-Nursing

Facility Coinsurance

Medicare Part B:

Deductible

Foreign Travel Emergency

Core

Plan

✓

Core

Plan

with

Rider*

✓

✓

Supplement 

1 Plan

✓

✓

✓

✓

✓

Supplement 

2 Plan

✓

✓

✓

✓

✓

Massachusetts – Chart Of Standardized Medigap Plans

Basic benefits included in all plans:

● Inpatient Hospital Care: Covers the Medicare Part A

coinsurance and the cost of 365 extra days of hospital

care during your lifetime after Medicare coverage ends.

● Medical Costs: Covers the Medicare Part B

coinsurance (generally 20% of the Medicare-approved

payment amount).

● Blood: Covers the first three pints of blood each year.

Note: The checkmarks in this chart mean the benefit is

covered under that plan.

* See page 171.
171 ----- Section 8: Massachusetts, Minnesota,

and Wisconsin Medigap Plans 

Medigap 

Benefits

Inpatient Days in Mental

Health Hospitals

Prescription Drugs ($35

deductible each calendar

quarter, then 100%

coverage for generic drugs

and 80% coverage for

brand name drugs)

State-Mandated Benefits 

(Annual Pap tests and

mammograms. Check your

plan for other statemandated benefits.)

Core

Plan

60 days

per

calendar

year

✓

Core

Plan

with

Rider*

✓

(Limited)

Supplement 

1 Plan

120

days per

benefit

year

✓

Supplement 

2 Plan

120

days per

benefit

year

✓

(Limited)

✓

* This plan, offered by Blue Cross and Blue Shield of

Massachusetts, also provides coverage for the following

services: routine vision services, routine dental services,

routine hearing services, fitness programs, and weight loss

programs. Contact plan for details. For more information on

these policies, call your State Insurance Department (see

pages 183 - 186) or look at www.medicare.gov on the web.

Select “Medicare Personal Plan Finder.”

Massachusetts – Chart Of Standardized Medigap Plans (cont).
172 ----- Section 8: Massachusetts, Minnesota,

and Wisconsin Medigap Plans 

*See page 173.

Minnesota – Chart Of Standardized Medigap Plans

Basic benefits included in all plans:

● Inpatient Hospital Care: Covers the Medicare Part A

coinsurance.

● Medical Costs: Covers the Medicare Part B

coinsurance (generally 20% of the Medicare-approved

payment amount).

● Blood: Covers the first three pints of blood each year.

Basic Extended

Medigap Benefits Plan Basic Plan

Basic Benefits ✓ ✓

Medicare Part A: Inpatient ✓

Hospital Deductible

Medicare Part A: Skilled- ✓ ✓

Nursing Facility Coinsurance

Medicare Part B: Deductible ✓

Foreign Travel Emergency 80% 80%*

Outpatient Mental Health 50% 50%*

Usual and Customary Fees 80%*

Preventive Care ✓ ✓

Prescription Drugs 80%*

At-home Recovery ✓
Minnesota – Chart Of Standardized Medigap Plans (cont.)

Basic Extended

Medigap Benefits Plan Basic Plan

Physical Therapy 20% 20%*

Coverage while in a 80%*

Foreign Country 

State-Mandated Benefits ✓ ✓

(Diabetic equipment and

supplies, routine cancer 

screening, reconstructive 

surgery, and immunizations.)

*The policy pays 100% after you spend $1000 of 

out-of-pocket expenses for a calendar year.

Note: The checkmarks in this chart mean the benefit is

covered under that plan.

173 ----- Section 8: Massachusetts, Minnesota,

and Wisconsin Medigap Plans 

Optional Riders

● Medicare Part A: Inpatient Hospital Deductible

● Medicare Part B: Deductible

● Usual and Customary Fees

● Preventive Care

● Prescription Drugs

● At-home recovery

Insurance companies are allowed to offer six additional

riders that can be added to a Basic plan. You may

choose any one or all of the riders to design a Medigap

plan that meets your needs.
Medigap Benefits Basic Plan

Basic Benefits ✓

Medicare Part A: ✓

Skilled-Nursing Facility 

Coinsurance

Inpatient Mental Health 

Coverage

Home Health Care

Medicare Part B: Coinsurance ✓

Outpatient Mental Health ✓

Prescription Drugs (after a ✓

deductible of $6,250, pays 80%)

Note: The checkmarks in this chart mean the benefit is

covered under that plan.

Wisconsin – Chart Of Standardized Medigap Plans

Basic benefits included in all plans: 

● Inpatient Hospital Care: Covers the Medicare Part A

coinsurance.

● Medical Costs: Covers the Medicare Part B

coinsurance (generally 20% of the Medicare-approved

payment amount).

● Blood: Covers the first three pints of blood each year.

174 ----- Section 8: Massachusetts, Minnesota,

and Wisconsin Medigap Plans 

175 days per lifetime 

in addition to Medicare

40 visits in addition to

those paid by Medicare
Wisconsin – Chart Of Standardized Medigap Plans

(continued)

Optional Riders

● Medicare Part A Deductible

● Additional Home Health Care (365 visits including

those paid by Medicare)

● Medicare Part B Deductible 

● Medicare Part B Excess Charges

● Outpatient Prescription Drugs 

● Foreign Travel 

Insurance companies are allowed to offer additional

riders to a Medigap plan.

Wisconsin also has many other state-mandated benefits

under the Medigap Basic Plan. For more information, call

your State Insurance Department (see pages 183 - 186)

or look at www.medicare.gov on the web. Select

“Medicare Personal Plan Finder.”

175 ----- Section 8: Massachusetts, Minnesota,

and Wisconsin Medigap Plans 
176 ----- Section 8: Massachusetts, Minnesota,

and Wisconsin Medigap Plans 

Notes
Use this section to learn where to get

more information.

On pages 178 - 186, you will find telephone numbers for

your State Health Insurance Assistance Program and

State Insurance Department. These telephone 

numbers were correct at the time of printing. Telephone

numbers sometimes change. You can find the most 

up-to-date telephone numbers by looking at

www.medicare.gov on the web. Select “Helpful

Contacts.” Or, call 1 800 633 - 4227. TTY users should

call 1 877 486 - 2048.

Where to get more information

● Call your State Health Insurance Assistance Program

(see pages 179 - 182) for help with:

✓ Buying a Medigap policy or long-term care

insurance, 

✓ Dealing with payment denials or appeals,

✓ Medicare rights and protections,

✓ Choosing a Medicare health plan, 

✓ Deciding whether to suspend your Medigap policy, or

✓ Questions about Medicare bills.

177 ----- Section 9: For More Information

Section 9
178 ----- Section 9: For More Information 

● End of page

Where to get more information (continued)

● Call your State Insurance Department (see pages 

183 - 186) if you have questions about the Medigap

policies sold in your area and any insurance-related

problems.

Who do I call with questions about Medicare?

If you have questions about Medicare, call 

1 800 633 - 4227. Customer Service Representatives are

available 24 hours a day, everyday. TTY users should call

1 877 486 - 2048.
A 

Alabama

1 800 243 - 5463

Alaska

1 800 478 - 6065

American Samoa

1 888 875 - 9229

Arizona

1 800 432 - 4040

Arkansas

1 800 224 - 6330

C 

California

1 800 434 - 0222

Colorado

1 888 696 - 7213

Connecticut

1 800 994 - 9422

D 

Delaware

1 800 336 - 9500

F 

Florida

1 800 963 - 5337

G 

Georgia

1 800 669 - 8387

Guam

1 888 875 - 9229

H 

Hawaii

1 888 875 - 9229

I 

Idaho

1 800 247 - 4422

Illinois

1 800 548 - 9034

Indiana

1 800 452 - 4800

Telephone Numbers for State Health Insurance

Assistance Program (States A through I)

179 ----- Section 9: For More Information 

This page has been intentionally left blank. It contains

phone number information. For the most recent phone

number information, please visit the Helpful Contacts

section of our web site. Thank you.
M (continued)

Minnesota

1 800 333 - 2433

Mississippi

1 800 948 - 3090

Missouri

1 800 390 - 3330

Montana

1 800 551 - 3191

N 

Nebraska

1 800 234 - 7119

Nevada

1 800 307 - 4444

New Hampshire

1 800 852 - 3388

New Jersey

1 800 792 - 8820

I (continued)

Iowa

1 800 351 - 4664

K 

Kansas

1 800 860 - 5260

Kentucky

1 877 293 - 7447

L 

Louisiana

1 800 259 - 5301

M 

Maine

1 800 750 - 5353

Maryland

1 800 243 - 3425

Massachusetts

1 800 243 - 4636

Michigan

1 800 803 - 7174

180 ----- Section 9: For More Information 

Telephone Numbers for State Health Insurance

Assistance Program (States I through N)

This page has been intentionally left blank. It contains

phone number information. For the most recent phone

number information, please visit the Helpful Contacts

section of our web site. Thank you.
P 

Pennsylvania

1 800 783 - 7067

Puerto Rico

1 877 725 - 4300

R 

Rhode Island

1 401 222 - 2880

S 

South Carolina

1 800 868 - 9095

South Dakota

1 800 536 - 8197

T 

Tennessee

1 877 801 - 0044

Texas

1 800 252 - 9240

U 

Utah

1 800 541 - 7735

N (continued)

New Mexico

1 800 432 - 2080

New York

1 800 333 - 4114

North Carolina

1 800 443 - 9354

North Dakota

1 800 247 - 0560

Northern Mariana 

Islands

1 888 875 - 9229

O 

Ohio

1 800 686 - 1578

Oklahoma

1 800 763 - 2828

Oregon

1 800 722 - 4134

181 ----- Section 9: For More Information 

Telephone Numbers for State Health Insurance

Assistance Program (States N through U)

This page has been intentionally left blank. It contains

phone number information. For the most recent phone

number information, please visit the Helpful Contacts

section of our web site. Thank you.
V 

Vermont

1 800 642 - 5119

Virgin Islands

1 340 776 - 8311

Virginia

1 800 552 - 3402

W 

Washington

1 800 397 - 4422

Washington D.C.

1 202 739 - 0668

West Virginia

1 877 987 - 4463

Wisconsin

1 800 242 - 1060

Wyoming

1 800 856 - 4398

182 ----- Section 9: For More Information 

Telephone Numbers for State Health Insurance

Assistance Program (States V through W)

This page has been intentionally left blank. It contains

phone number information. For the most recent phone

number information, please visit the Helpful Contacts

section of our web site. Thank you.
183 ----- Section 9: For More Information 

Telephone Numbers for State Insurance Department

(States A through I)

A 

Alabama

1 800 433 - 3966

Alaska

1 800 467 - 8725

American Samoa

1 684 633 - 4116

Arizona

1 800 325 - 2548

Arkansas

1 800 224 - 6330

C 

California

1 800 927 - 4357

Colorado

1 800 930 - 3745

Connecticut

1 800 203 - 3447

D 

Delaware

1 800 282 - 8611

F 

Florida

1 800 342 - 2762

G 

Georgia

1 800 656 - 2298

Guam

1 671 475 - 1817

H 

Hawaii

1 800 974 - 4000

I 

Idaho

1 800 721 - 3272

Illinois

1 866 445 - 5364

Indiana

1 800 622 - 4461

This page has been intentionally left blank. It contains

phone number information. For the most recent phone

number information, please visit the Helpful Contacts

section of our web site. Thank you.
M (continued) 

Minnesota

1 800 657 - 3602

Mississippi

1 800 562 - 2957

Missouri

1 800 726 - 7390

Montana

1 800 332 - 6148

N 

Nebraska

1 800 234 - 7119

Nevada

1 800 992 - 0900

New Hampshire

1 800 852 - 3416

New Jersey

1 800 446 - 7467

I (continued) 

Iowa

1 800 351 - 4664

K 

Kansas

1 800 432 - 2484

Kentucky

1 800 595 - 6053

L 

Louisiana

1 800 259 - 5300

M 

Maine

1 800 300 - 5000

Maryland

1 800 492 - 6116

Massachusetts

1 617 521 - 7794

Michigan

1 877 999 - 6442

184 ----- Section 9: For More Information 

Telephone Numbers for State Insurance Department

(States I through N)

This page has been intentionally left blank. It contains

phone number information. For the most recent phone

number information, please visit the Helpful Contacts

section of our web site. Thank you.
Telephone Numbers for State Insurance Department

(States N through U)

185 ----- Section 9: For More Information 

N (continued) 

New Mexico

1 800 947 - 4722

New York

1 800 342 - 3736

North Carolina

1 800 546 - 5664

North Dakota

1 800 247 - 0560

Northern Mariana 

Islands

1 670 664 - 3017

O 

Ohio

1 800 686 - 1578

Oklahoma

1 800 522 - 0071

Oregon

1 888 877 - 4894

P 

Pennsylvania

1 877 881 - 6388

Puerto Rico

1 888 722 - 8686

R 

Rhode Island

1 401 222 - 2223

S 

South Carolina

1 800 768 - 3467

South Dakota

1 605 773 - 3563

T 

Tennessee

1 800 525 - 2816

Texas

1 800 252 - 3439

U 

Utah

1 866 350 - 6242

This page has been intentionally left blank. It contains

phone number information. For the most recent phone

number information, please visit the Helpful Contacts

section of our web site. Thank you.
186 ----- Section 9: For More Information 

Telephone Numbers for State Insurance Department

(States V through W)

V 

Vermont

1 800 631 - 7788

Virgin Islands

1 340 773 - 6449

Virginia

1 800 552 - 7945

W 

Washington

1 800 397 - 4422

Washington D.C.

1 202 727 - 8000

West Virginia

1 888 879 - 9842

Wisconsin

1 800 236 - 8517

Wyoming

1 800 438 - 5768

This page has been intentionally left blank. It contains

phone number information. For the most recent phone

number information, please visit the Helpful Contacts

section of our web site. Thank you.
This section is an alphabetical list of

specific topics discussed in this Guide,

with page numbers.

TIP: Use the “Table of Contents” on pages 1 - 3 to help

you find the sections you want to read.

A 

Assignment ___ 11, 25, 27, 59, 77

At-Home Recovery ___ 79

Attained-Age-Rated Policies ___ 40, 41

B 

Basic Core Benefits ___ 30, 70 - 72

Basic Drug Benefit ___ 34, 80, 81

Benefit Period ___ 11, 121, 122

Blood ___ 26, 30, 72, 125, 130

C 

Changing Medigap Policies ___ 55, 56

Coinsurance ___ 11, 29 - 36, 71, 160, 162

Consolidated Omnibus Budget Reconciliation 

___Act (COBRA) ___ 102, 151 - 153

Copayment ___ 12, 27, 30, 71, 124

Cost/Pricing Policies ___ 37 - 44

Creditable Coverage ___ 12, 45, 52 - 54

187 ----- Section 10: Index (Letters A through C)

Section 10
D 

Deductible ___ 12, 29 - 36, 43, 71, 75, 76, 160, 162

Disability ___ 6, 45, 113 - 118, 146

Durable Medical Equipment ___ 12, 128

Durable Medical Equipment Regional Carrier ___ 12, 130

E 

Employee Coverage ___ 48, 52, 154, 155

Employer Group Health Plan ___ 48, 101, 102, 117, 154, 155

End-Stage Renal Disease (ESRD) ___ 6, 12, 45, 113 - 118

Excess Charges ___ 13, 27, 77

Extra Benefits ___ 29, 31 - 36, 73 - 83

F 

Federally Qualified Health Centers ___ 155

Finding Reliable Insurance Companies ___ 65

Foreign Travel Emergency ___ 31 - 35, 43, 78

G 

General Enrollment Period (Part B) ___ 143, 146

Group Health Coverage ___ 52

Guaranteed Issue Rights ___ 13, 51, 93 - 112

Guaranteed Renewable ___ 13, 23, 57

H 

High Deductible Option ___ 33, 35, 43

Home and Community-Based Service/Waiver Programs 

___(HCBS) ___ 156

Home Health Care ___ 13, 123, 128

Hospice Care ___ 14, 124

Hospital Indemnity Insurance ___ 156

188 ----- Section 10: Index (Letters D through H)
I 

Initial Enrollment Period ___ 142, 143

Inspector General’s Office ___ 64

Issue-Age-Rated Policies ___ 39

L 

Lifetime Reserve Days ___ 14

Limiting Charge ___ 14, 61

Long-Term Care Insurance ___ 157

M 

Medicaid ___ 15, 24, 52, 158 - 160

Medical Underwriting ___ 15, 42

Medically Necessary ___ 15, 120 - 130

Medicare Advantage Plan ___ 7, 9, 15, 98 - 100, 105,

___106, 108, 109

Medicare-Approved Amount ___ 16, 124, 126, 128, 

___130 - 137

Medicare-Approved Drug Discount Card ___ 161

Medicare Carrier ___ 16, 59

Medicare Managed Care Plan ___ 7, 16

Medicare Modernization Act of 2003 ___ 49

Medicare Part A (Hospital Insurance) ___ 6, 52, 70, 75, 

___119, 121 - 125

Medicare Part B (Medical Insurance) ___ 6, 24, 26, 45 - 48,

___52, 71, 76, 77, 116, 120, 126 - 139

Medicare Personal Plan Finder___ 84

Medicare Preferred Provider Organization Plan ___ 7, 16

Medicare Private Fee-for-Service Plan ___ 7, 17

Medicare Savings Programs ___ 162

189 ----- Section 10: Index (Letter I through M)
M (continued) 

Medicare Specialty Plan ___ 7, 17

Medicare Supplement Insurance ___ (see Medigap)

Medigap

___Basic (Core) Benefits ___ 30 - 36, 69 - 72

___Cost/Pricing Policies ___ 37 - 44

___Extra Benefits ___ 29, 31 - 36, 73 - 83

___Steps To Buying ___ 67 - 92

___Under age 65 ___ 110, 113 - 115

___What It Is ___ 17, 21 - 23

___What’s Covered ___ 29 - 36

___What’s Not Covered ___ 29

___When To Buy ___ 45 - 48

___Why You Might Need It ___ 24

Medigap Benefits Chart ___ 30 - 36

___For Massachusetts ___ 170 - 171

___For Minnesota ___ 172 - 173

___For Wisconsin ___ 174 - 175

Medigap Protections ___ 93 - 112

Military Retiree Benefits ___ 52, 163

N 

No-Age-Rated Policies ___ 38

O 

Open Enrollment Period (Medigap) ___ 18, 45 - 48, 113, 

___ 115, 116, 146

Original Medicare Plan ___ 7 - 9, 18, 21, 24, 28, 29, 99, 

___ 111, 119 - 148

Other Ways to Pay Health Care Costs ___ 149 - 168

190 ----- Section 10: Index (Letters M through O)
P 

PACE (Programs of All-inclusive Care 

___for the Elderly ___ 19, 98, 99, 103, 105, 106, 167

Part A (Hospital Insurance) ___ 6, 52, 70, 75, 119, 

___ 121 - 125

Part B (Medical Insurance) ___ 6, 24, 26, 45 - 48, 52, 71, 

___ 76, 77, 116, 120, 126 - 139

Pre-existing Condition ___ 18, 42, 45, 50 - 55, 93, 116, 117

Premium ___ 8, 18, 37 - 41, 55, 108, 110, 119, 159, 160

Prescription Drugs ___ 27, 34, 35, 43, 49, 55, 116, 161

Preventive Care ___ 32, 35, 131 - 139

Pricing Policies ___ 38 - 41

Private Contract ___ 61, 62

R 

Railroad Retirement Board ___ 140

Reliability ___ 65

Retiree Coverage ___ 101, 154, 155

S 

Skilled Nursing Facility (Care) ___ 19, 26, 31 - 36, 74, 

___ 119, 122

Social Security Administration ___ 140

Special Enrollment Period (Part B) ___ 144 - 146

Specified Disease Insurance ___ 165

Standardized Medigap Plans 

___ For Massachusetts ___ 170 - 171

___ For Minnesota ___ 172 - 173

___ For Wisconsin ___ 174 - 175

191 ----- Section 10: Index (Letters P through S)
S (continued) 

State Children’s Health Insurance Program ___ 166

State Health Insurance Assistance Program ___ 20, 65, 

___ 84, 111, 113, 153, 179 - 182

State Insurance Department ___ 20, 60, 65, 84, 92, 111, 

___ 183 - 186

State Medical Assistance Office ___ 20, 159, 162

Switching Medigap Policies ___ 55, 56

T 

TRICARE ___ 52, 147, 163

U 

Union Coverage ___ 48, 52, 154, 155

V 

Veterans’ Benefits ___ 168

W 

Waiting Period ___ 50, 51

www.medicare.gov ___ 84, 130, 131, 140, 149, 157, 163, 

___ 164, 177

192 ----- Section 10: Index (Letters S through W)

● End of page
U.S. DEPARTMENT OF

HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services 

7500 Security Boulevard

Baltimore, Maryland 21244 - 1850

Official Business

Penalty for Private Use, $300

Publication No. CMS - 02110 - LE

Revised April 2004

To get a free copy of the 2004 Choosing a Medigap

Policy: A Guide To Health Insurance For People With

Medicare in Spanish, on Audiotape (English), or 

in Braille, call 1 800 633 - 4227. TTY users should call 

1 877 486 - 2048.

¿Necesita usted una copia de esta guía en Español?

Llame gratis al 1 800 633 - 4227. Los usuarios de TTY

deberán llamar al 1 877 486 - 2048.