Medigap policies don't cover everything
A Medicare supplement (Medigap) insurance, sold by private companies, can help pay some of
the health care costs that Original Medicare doesn't cover, like copayments, coinsurance, and
Some Medigap policies also offer coverage for services that Original Medicare doesn't cover like
medical care when you travel outside the U.S. If you have Original Medicare and you buy a
Medigap policy, Medicare will pay its share of the Medicare-approved amount for covered health
care costs. Then your Medigap policy pays its share.
A Medigap policy is different from a Medicare Advantage Plan. Those plans are ways to get
Medicare benefits, while a Medigap policy only supplements your Original Medicare benefits.
Medigap policies generally don't cover long-term care, vision or dental care, hearing aids,
eyeglasses, or private-duty nursing.
Insurance plans that aren't Medigap
Some types of insurance aren't Medigap plans, they include:
- Medicare Advantage Plans (like an HMO, PPO, or Private Fee-for-Service Plan)
- Medicare Prescription Drug Plans
- Employer or union plans, including the Federal Employees Health Benefits Program (FEHBP)
- Veterans' benefits
- Long-term care insurance policies
- Indian Health Service, Tribal, and Urban Indian Health plans
Dropping your entire Medigap policy (not just the drug coverage)
If you decide to drop the entire Medigap policy, you need to be careful about the timing.
For example, you may want a completely different Medigap policy (not just your old Medigap
policy without the prescription drug coverage), or you might decide to switch to a Medicare
Advantage Plan that offers prescription drug coverage.
If you drop your entire Medigap policy and the drug coverage wasn't creditable or you go more
than 63 days before your new Medicare coverage begins, you have to pay a late enrollment
penalty for your Medicare Prescription Drug Plan, if you choose to join one.
How do Medicare Advantage Plans work?
Medicare Advantage Plans, sometimes called "Part C" or "MA Plans," are offered by private companies approved by Medicare.
If you join a Medicare Advantage Plan, you still have Medicare. You'll get your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage from the Medicare Advantage Plan and not Original Medicare.
Medicare Advantage Plans cover all Medicare services. Medicare Advantage Plans may also offer extra coverage.
Medicare pays a fixed amount for your care each month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare.
However, each Medicare Advantage Plan can charge different out-of-pocket costs. Each plan can also have different rules for how you get services, like:
These rules can change each year.
- Whether you need a referral to see a specialist
- If you must go to doctors, facilities, or suppliers that belong to the plan for non-emergency or non-urgent care
Medicare Cost Plans
Some types of Medicare health plans that provide health care coverage aren't Medicare Advantage Plans but are still part of Medicare.
Some of these plans provide Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage, while most others provide only Part B coverage. Some also provide Medicare prescription drug coverage (Part D).
These plans have some of the same rules as Medicare Advantage Plans. However, each type of plan has special rules and exceptions.
Medicare Cost Plans are a type of Medicare health plan available in certain areas of the country.
Here are important facts about Medicare Cost Plans:
- You can join even if you only have Part B.
- If you have Part A and Part B and go to a non-network provider, the services are covered under Original Medicare. You would pay the Part A and Part B coinsurance and deductible.
- You can join anytime the plan is accepting new members.
- You can leave anytime and return to Original Medicare.
- You can either get your Medicare prescription drug coverage from the plan (if offered), or you can join a Medicare Prescription Drug Plan (Part D).
Another type of Medicare Cost Plan only provides coverage for Part B services. These plans never include Part D. Part A services are covered through Original Medicare. These plans are either sponsored by employer or union group health plans or offered by companies that don't provide Part A services.
Medicare Advantage Plans Cover
Medicare Advantage Plans must cover all the services that Original Medicare covers. However, if you’re in a Medicare Advantage Plan, Original Medicare will still cover the cost for hospice care, some new Medicare benefits, and some costs for clinical research studies.
In all types of Medicare Advantage Plans, you're always covered for emergency and urgently needed care.
The plan can choose not to cover the costs of services that aren't medically necessary under Medicare. If you're not sure whether a service is covered, check with your provider before you get the service.
Most Medicare Advantage Plans offer extra coverage, like vision, hearing, dental, and/or health, and wellness programs. Most include Medicare prescription drug coverage (Part D).
In addition to your Part B premium, you usually pay a monthly premium for the Medicare Advantage Plan.
If you need a service that the plan says isn't medically necessary, you may have to pay all the costs of the service. But, you have the right to appeal the decision.
You can also ask the plan for a written advance coverage decision to make sure a service is medically necessary and will be covered. If the plan won't pay for a service you think you need, you'll have to pay all the costs if you didn't ask for an advance coverage decision.
What you pay in a Medicare Advantage Plan
Your out-of-pocket costs in a Medicare Advantage Plan (Part C) depend on:
- Whether the plan charges a monthly premium.
- Whether the plan pays any of your monthly Medicare Part B (Medical Insurance) premium.
- Whether the plan has a yearly deductible or any additional deductibles.
- How much you pay for each visit or service (copayment or coinsurance). For example, the plan may charge a copayment, like $10 or $20 every time you see a doctor. These amounts can be different than those under Original Medicare.
- The type of health care services you need and how often you get them.
- Whether you go to a doctor or supplier who accepts assignment (if you're in a PPO, PFFS, or MSA plan and you go out-of-network).
- Whether you follow the plan's rules, like using network providers.
- Whether you need extra benefits and if the plan charges for it.
- The plan's yearly limit on your out-of-pocket costs for all medical services.
- Whether you have Medicaid or get help from your state.
Get more cost details from your plan
If you're in a Medicare plan, review the "Evidence of Coverage" (EOC) and "Annual Notice of Change" (ANOC) your plan sends you each fall. The EOC gives you details about what the plan covers, how much you pay, and more. The ANOC includes any changes in coverage, costs, or service area that will be effective in January.