to health insurance for people with medicare4 2000 guide part 1 - medigap basics what is medicare?...

2000To Health Insurance for

People with Medicare

Guide

HEALTH CARE FINANCING ADMINISTRATION

n Buying a Medigap Policy

n Using a Medigap Policy

n Other Kinds of Health Insurance

Get the basics on pages 3-21.

A Guide For:

The Federal Medicare Agency

2000 Guide

TABLE OF CONTENTS

Introduction

How To Use This Guide ......................................................................................1

Part 1 - Medigap Basics

A Quick Look At Medicare ....................................................................4

Buying a Medigap Policy........................................................................9

Using a Medigap Policy........................................................................18

Other Kinds of Health Insurance..........................................................19

Summary of Medigap Basics................................................................21

Part 2 - Beyond the Basics

Buying a Medigap Policy......................................................................23

Using a Medigap Policy........................................................................62

Other Kinds of Health Insurance..........................................................67

Watch Out for Illegal Insurance Practices..........................................................83

Discrimination....................................................................................................84

Who to Call for Medicare or Medigap Information ..........................................85

Charts of Standardized Medigap Plans in Massachusetts, Minnesota,

and Wisconsin ......................................................................................94

Medicare Part A and Medicare Part B Coverage Charts ..................................97

Definitions Of Important Words ......................................................................100

Index (An alphabetical list of Medicare and Medigap topics) ........................104

Tell us what you think! We welcomeyour comments on the 2000 Guide ToHealth Insurance for People withMedicare although we may not be ableto respond to you directly.

Send your comments to:Health Care Financing AdministrationGuide To Health Insurance Comments7500 Security BoulevardBaltimore, MD 21244-1850

What’s new in 2000?n Medicare Part A & Part B Rates, see pages 97 and 98.

n Medicare Part B Preventive Services, see page 99. New in 2000, Medicarecovers Prostate Cancer Screening.

n Medigap Compare: A new way to compare Medigap policies on the Internet atwww.medicare.gov, see page 13.

n Nursing Home Compare: A new way to get information on nursing homes inyour area on the Internet at www.medicare.gov, see page 82.

1

Why do I need this guide?

Medicare is a federal health insurance program forpeople 65 years of age or older, and certain youngerpeople with disabilities or End-Stage Renal Disease(permanent kidney failure). It pays for much of yourhealth care, but not all of it. You have to pay somecosts yourself, unless you buy more insurance. Thereare three ways you can get more insurance:

n Medigap policies (from a private company orgroup)

n Employer or union coverage

n Other kinds of insurance

This booklet was written to explain Medigap andother insurance policies.

What is the purpose of this Guide?

The purpose of this Guide is to give you basic anddetailed information about Medigap policies. You willnot find information about the cost of any Medigappolicy in this Guide because costs will be differentdepending on where you live and which insurancecompany you buy the policy from. You may want totalk to family and friends, and insurance counselorsabout the information in this Guide and otherinsurance matters. Whether you need a Medigappolicy is a decision only you can make. If you wantinformation on the cost of a Medigap policy, call aninsurance company that sells Medigap policies inyour state. You can find out which companies sellMedigap policies in your state by calling your StateInsurance Department (see pages 86-87). Or, you canuse a computer to look on the Internet atwww.medicare.gov and click on “Medigap Compare.”

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INTRODUCTION

How To Use ThisGuide

2 2000 Guide

INTRODUCTION

Do I need a Medigap policy?

Medigap policies only help pay health care costs ifyou have the Original Medicare Plan.

You do not need to buy a Medigap policy if you arein a:

n Medicare managed care plan

n Private Fee-for-Service plan

n Medicare Medical Savings Account Plan*

n Religious Fraternal Benefit Plan*

In fact, it may be illegal for anyone to sell you aMedigap policy if they know you are in one of thesehealth plans.

If you have Medicaid, it is illegal for an insurancecompany to sell you a Medigap policy (except incertain situations), see page 79.

How should I use this Guide?

Read over “A Quick Look At Medicare” in Part 1.This will help you understand what Medicare doesand does not cover.

Use the chart on page 10 to help get an idea of thebenefits that Medigap policies cover. These benefitsare described in more detail on pages 24-27 in Part 2.

Use Part 2 to get more information about Medigapinsurance and other kinds of insurance.

How To Use ThisGuide (continued)

* At the time thisGuide was printed,no private insurancecompanies wereoffering these typesof plans. Call1-800-MEDICARE(1-800-633-4227,TTY/TDD: 1-877-486-2048 for thehearing and speechimpaired) to get themost currentinformation aboutthese types of plans.

3

Do I have to buy more insurance?

The choice to buy more insurance is yours. If youhave the Original Medicare Plan, you don’t have tobuy any additional insurance. But remember, evenwith a Medigap policy there are still costs that theOriginal Medicare Plan doesn’t cover. Moreinsurance is the best way to be sure that you cancover your other medical costs.

A Quick Look At Medicare ................Pages 4-8

Buying a Medigap Policy ....................Pages 9-17

Using a Medigap Policy ......................Page 18

Other Kinds of Health Insurance ........Pages 19-20

Summary of Medigap Basics ............ Page 21

Remember, Part 2 has more details on each of thesetopics.

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INTRODUCTION

Part 1 - MedigapBasics

How To Use ThisGuide (continued)

4 2000 Guide

PART 1 - MEDIGAP BASICS

What is Medicare?

Medicare is a health insurance program for:

n People 65 years of age and older.n Some disabled people under 65 years of age.n People with End-Stage Renal Disease (permanent

kidney failure requiring dialysis or a kidneytransplant).

There are two parts of Medicare:

Helps Pay For: Care in hospitals, some skillednursing facilities, hospice, and some home healthcare (see chart on page 97).

Cost: For most people, Part A is premium-free. Thismeans most people do not have to pay a monthlypayment (premium) for Part A because they (or aspouse) paid Medicare taxes while they wereworking.

Helps Pay For: Doctors, outpatient hospital care, andsome other medical services that Part A does notcover, such as the services of physical andoccupational therapists, and some home healthservices (see charts on pages 98-99).

Cost: You pay the Medicare Part B premium of$45.50 per month in 2000. Premiums can changeyearly. In some cases, this amount may be higher ifyou did not choose Part B when you first becameeligible for Medicare.

How do I get Part B?

You are automatically eligible for Part B if you areeligible for premium-free Part A. You are also eligibleif you are a United States citizen or permanentresident age 65 or older.

A Quick Look AtMedicare

Part A -Hospital Insurance

Part B - Medical Insurance

Terms in red aredefined on pages100-103.

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Just before you turn 65 years old, you have to decidewhether or not to take Part B. You should keep inmind that the cost of Part B may go up 10% for each12-month period that you could have had Part B butdid not take it, except in special cases (see “SpecialEnrollment Period”). You will have to pay this extra10% for the rest of your life. If you choose to getPart B, the monthly premium is taken out of yourSocial Security, Railroad Retirement, or Civil ServiceRetirement payment. If you don’t get any of thesepayments, you are billed by Medicare every 3months.

If you didn’t take Part B when you were first eligible,you can sign up during 2 enrollment periods. The twoenrollment periods are:

The General Enrollment Period is from January 1through March 31 of each year. You can sign up forPart A or Part B at your local Social SecurityAdministration office. Your Part B coverage will starton July 1 of that year.

If you didn’t take Part B when you were first eligiblebecause you or your spouse were working and hadgroup health plan coverage through your or yourspouse’s employer or union, you can sign up for PartB during a Special Enrollment Period.

You can sign up:

1. Anytime you are still covered by the employer orunion group health plan through your or yourspouse’s current or active employment, or

2. Within 8 months of the date when the employeror union group health plan coverage ends, orwhen the employment ends (whichever is first).

If you are disabled and working (or you havecoverage from a working family member), the

A Quick Look AtMedicare (continued)

General EnrollmentPeriod

Special EnrollmentPeriod

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Special Enrollment Period rules also apply. Most people who sign up for Part B during a SpecialEnrollment Period do not pay higher premiums.However, if you are eligible, but do not sign up forPart B during the Special Enrollment Period, the costof Part B may go up.

Call the Social Security Administration at 1-800-772-1213 (TTY: 1-800-325-0778) for more informationabout signing up for Medicare Parts A and B.

What are my Medicare health plan choices?

Depending on where you live, you may have threechoices: the Original Medicare Plan, a Medicaremanaged care plan, or a Private Fee-for-Service plan.

The Original Medicare Plan is available everywherein the United States. It is the way most people gettheir Medicare Part A and Medicare Part B healthcare. You may go to any doctor, specialist, or hospitalthat accepts Medicare. You pay your share on a pay-per-visit basis, and Medicare pays its share. Somethings are not covered, like most prescription drugs,cosmetic surgery, and routine physical exams.

Note: Medigap policies only help pay health carecosts if you have the Original Medicare Plan.

These are health plans available in many areas of thecountry. In most plans, you can only go to doctors,specialists, or hospitals on the plan's list. Plans mustcover all Medicare Part A and Medicare Part B healthcare benefits. Some plans cover extras, likeprescription drugs. Your costs may be lower than inthe Original Medicare Plan.

Note: Medigap policies don’t help pay health carecosts if you are in a Medicare managed care plan.

A Quick Look AtMedicare(continued)

The Original MedicarePlan (also known asfee-for-service)

Medicare ManagedCare Plans (like anHMO)

7

This is a new health care choice that will becomeavailable in some areas of the country in 2000.

A Private Fee-for-Service plan is a Medicare healthplan offered by a private insurance company. It is notthe same as the Original Medicare Plan which isoffered by the federal government. In a Private Fee-for-Service plan, Medicare pays a set amount ofmoney every month to the private company toprovide health care coverage to people with Medicareon a pay-per-visit arrangement. The insurancecompany, rather than the Medicare program, decideshow much you pay for the services you get.

For more information about this type of plan, call1-800-MEDICARE (1-800-633-4227, TTY/TDD1-877-486-2048 for the hearing and speech impaired)and ask for a free copy of Your Guide to Private Fee-for-Service Plans or use a computer to look on theInternet at www.medicare.gov.

If I am in the Original Medicare Plan, why wouldI buy a Medigap policy?

If you are in the Original Medicare Plan, a Medigappolicy may help you:

n Lower your out-of-pocket costs.

n Get more health insurance coverage.

You may want to buy a Medigap policy becauseMedicare does not pay for all of your health care.There are “gaps” or costs that you must pay inOriginal Medicare Plan coverage. The chart on page8 explains these gaps and gives examples.

You don’t need a Medigap policy if you are in aMedicare health plan other than the OriginalMedicare Plan.

2000 Guide


Private Fee-for-ServicePlans

A Quick Look AtMedicare(continued)

Note: Medigap policiesdon’t help pay healthcare costs if you are in aPrivate Fee-for-Serviceplan.

8 2000 Guide


Examples of Gaps

1. What you payfor Medicarecoveredservices

2. What iscovered inpart byMedicare

3. What is notcovered byMedicare

n Part A deductible for each benefitperiod

n Part B deductible of $100 per yearn 20% coinsurance for most Part B

covered services

n Home health care that does not meetcertain required conditions

n Costs for skilled nursing facility carefor days 21-100 in the benefit period(see page 97).

n First three pints of blood each year

n Outpatient prescription drugs n Eyeglassesn Hearing aidsn Routine physical examsn Emergency care outside the U.S.n Custodial caren Orthopedic shoesn Cosmetic surgeryn Dental caren Denturesn Routine foot care

What you have to pay to cover the gaps shown on the chart will depend on:

n Whether your doctor or supplier accepts “assignment” or takes Medicare’sapproved amount as payment in full (see page 100).

n How often you need health care.

n What type of health care you need.

n Whether you buy a Medigap policy.

n What Medigap policy you buy.

n Whether you have other health insurance coverage.

Gaps in the Original Medicare Plan

Why there’s a Gap

The law requiresyou to pay forpart of someMedicarecoverage

Medicare onlypays for part ofsome services

Medicaredoesn’t coversome medicalcosts

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Remember, terms inred are defined onpages 100-103.

What do Medigap policies cover?

Each standardized Medigap policy must cover basic(core) benefits (see the chart on page 10). Medigappolicies pay most, if not all, of the Original MedicarePlan coinsurance amounts. These policies may alsocover the Original Medicare Plan deductibles. Someof the policies cover extra benefits to fill more of thegaps in your coverage, like prescription drugs. If youlive in Massachusetts, Minnesota, or Wisconsin, seepages 94-96.

Buying a MedigapPolicy What is a Medigap policy and how does it work?

A Medigap policy is sold by private insurancecompanies to fill the "gaps" in Original MedicarePlan coverage. The front of the Medigap policy mustclearly identify it as "Medicare SupplementInsurance." In all but three states (Minnesota,Massachusetts, and Wisconsin), there are 10standardized Medigap plans called "A" through "J."Each plan has a different set of standard benefits.

Medicare SELECT is a type of Medigap insurancepolicy. If you buy a Medicare SELECT policy, youare buying one of the 10 standardized Medigapplans A through J (see page 23).

When you buy a Medigap policy you pay a premiumto the insurance company. As long as you pay yourpremium, policies bought after 1990 are automaticallyrenewed each year. This means that your coveragecontinues year after year as long as you pay yourpremium.You still must pay your monthly MedicarePart B premium.

The chart on page 10lists the benefits in the10 standardizedMedigap plans.

“The thing aboutMedigap is you cantake as much or aslittle coverage as youwant. When I had kneesurgery, my Medigappolicy paid much of thecosts that Medicare didnot pay for.”

MarkProvidence, Rhode Island

If you live inMassachusetts,Minnesota, orWisconsin, seepages 94-96.

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Do any Medigap policies cover prescription drugs?

Yes. Plans H and I offer the “basic” prescription drugbenefit. Plan J offers the “extended” prescription drugbenefit (see chart below).

BasicPrescriptionDrug Benefit

What is a “high deductible option” and how does itaffect my costs?

Insurance companies may offer a “high deductibleoption” on Plans F and J. If you choose this option,you must pay a $1,530 deductible for the year 2000before the plan pays anything. This is an increase forall high deductible plans that were bought before2000. This amount can go up each year.

High deductible option policies often cost less but, ifyou get sick, your out-of-pocket costs will be higherand you may not be able to change plans.

In addition to the $1,530 deductible that you mustpay for the high deductible option on plans F and J,you must also pay deductibles for prescription drugs($250 per year for Plan J) and foreign travelemergency ($250 per year for Plans F and J).

ExtendedPrescriptionDrug Benefit

$250 peryeardeductible

$250 peryeardeductible

50% of prescription drugcosts up to a maximumof $1,250 per year. (Formore information, seepage 26.)

50% of prescription drugcosts up to a maximum of$3,000 per year. (Formore information, seepages 26 and 27.)

After youpay...

The plan pays...

Plans H and I

Plan J

Buying a MedigapPolicy (continued)

12 2000 Guide



“Before I bought myfirst policy, I looked atdifferent insurancecompanies andcompared what theypay for and how muchit was going to cost meto join. That way, I wasable to see thedifference betweenwhat I pay now forcertain medical costsand what I would paywith a Medigappolicy.”

AbigailWilmington, NorthCarolina

What is not covered by Medigap policies?

Medigap policies do not cover:

n Long-term care

n Vision or dental care

n Hearing aids

n Private-duty nursing

n Unlimited prescription drugs

What should I think about before buying aMedigap policy?

n How much am I spending on health care?

n What are my health care dollars spent on?

n Which Medigap benefits do I need?

n How much can I afford to spend on premiums?

n What will my future health care costs be?Remember, you may need more health care as youget older.

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How can I get information on Medigap policies inmy state?

You can get information about Medigap policies inyour state by calling:

n Your State Insurance Department to find out whatMedigap polices are available in your state andwhich companies sell them (see pages 86-87); or

n Your State Health Insurance Assistance Programto get free counseling to help you decide whichpolicy is best for you (see pages 88-89).

You can also use a computer to find information onand compare Medigap policies offered in your state.Look on the Internet at www.medicare.gov and clickon "Medigap Compare." This website hasinformation on:

n Which Medigap policies are sold in your state.

n How to shop for a Medigap policy.

n What the policies must cover.

n How insurance companies decide what to chargeyou for a Medigap policy premium.

n Your Medigap rights and protections.

If you don’t have a computer, your local library orsenior center may be able to help you look at thisinformation.

New in 2000!


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Remember, termsin red are definedon pages 100-103.

When is the best time to buy a Medigap policy?

The best time to buy a Medigap policy is during yourMedigap open enrollment period.

Your Medigap open enrollment period lasts for 6months. It begins on the first day of the month in whichyou are both:

n Age 65 or over; and

n Enrolled in Medicare Part B.

During this period, an insurance company cannot denyyou insurance coverage, place conditions on a policy(like making you wait for coverage to start), or changethe price of a policy because of past or present healthproblems (see the “open enrollment” Example on page36).

If you buy a policy during your Medigap openenrollment period, the insurance company must shortenthe waiting period for pre-existing conditions by theamount of previous health coverage (creditable coverage)you have (see page 38).

If you are disabled or have End-Stage Renal Disease, seepage 39.

Should I start my Medigap open enrollment period ifI am age 65 or over and still working?

You may want to wait to enroll in Medicare Part B if youhave health coverage through an employer or unionbased on your or your spouse’s current or activeemployment. Your Medigap open enrollment periodwon’t start until after you sign up for Medicare Part B.Remember, once you’re age 65 or older and enrolled inMedicare Part B, the Medigap open enrollment periodstarts and cannot be changed.


15

How do I shop for a Medigap policy?

Quick Shopping Tips

n First, review the 10 standardized Medigap plansand choose the type of plan that has the benefitsyou want.

n Shop carefully. Call different insurance companiesabout the plan you want and compare cost andservice before you buy.

n Do not buy more than one Medigap policy at atime.

n Do not let a salesperson rush you into buying apolicy.

n Do not pay cash. Pay by check, money order, orbank draft made payable to the insurance company,not to the agent or anyone else.

Caution: Before you shop for a Medigap policy, lookat more detailed shopping information on pages 27-35.

What are Medigap protections?

Medigap protections are special rights you have tobuy a Medigap policy in addition to your Medigapopen enrollment period. You have these rights only incertain situations (see pages 16-17). Medigapprotections are important because if you do not buya Medigap policy during your open enrollmentperiod, and you don’t have these protections, aninsurance company may be able to refuse to sell youa policy, or may charge you more for a policy. Also,if you drop your Medigap policy, you may not beable to get it back unless you have these protections.

2000 Guide


“I checked all theinsurance companies inmy state...that paid thedeductible and alsohad prescription drugcoverage, because Itake a lot ofprescriptions.”

KristinaRichmond, Virginia


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What situations give me the right to buy aMedigap policy after my Medigap openenrollment period ends?

There are certain situations involving health coveragechanges where you may have the right to buy aMedigap policy after your Medigap open enrollmentperiod ends. These are also called “guaranteed issue”rights because insurance companies are required bylaw to issue you a policy. For example:

n Your Medicare managed care plan or Private Fee-for-Service plan is leaving the Medicare programor stops giving care in your area (see Situation #1on pages 43-47); or

n You move outside your Medicare health plan’sservice area (see Situation #2 on pages 47-50); or

n You leave the Medicare health plan because itfailed to meet its contract obligations to you (seeSituation #2 on pages 47-50); or

n You are in an employer group health plan thatsupplemented or paid some of the costs not paidfor by Medicare, and the plan ends your coverage(see Situation #2 on pages 47-50); or

n Your health coverage (like a Medicare managedcare plan, Private Fee-for-Service plan, MedicareSELECT policy, Programs of All-Inclusive Care forthe Elderly (PACE), or Medicare managed caredemonstration project) ends through no fault ofyour own. For example, the company goesbankrupt (see Situation #2 on pages 47-50); or

n You dropped your Medigap policy to join aMedicare managed care plan, or Private Fee-for-Service plan, or buy a Medicare SELECT policyfor the first time, and then leave that plan or policy


For more informationon PACE, see pages 19and 76.

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within one year after joining (see Situation #3 onpages 51-54); or

n You joined a Medicare health plan (like aMedicare managed care plan or Private Fee-for-Service plan) when you first became eligible forMedicare at age 65, and within one year ofjoining, you decided to leave the Medicare healthplan (see Situation #4 on pages 55-57).

In these situations, the Medigap insurance companycan’t deny you insurance, place conditions on apolicy, or charge you more for a policy because ofpast or current health problems. If you think any ofthese situations applies to you, call your State HealthInsurance Assistance Program (see pages 88-89) tomake sure that you qualify. If you are deniedMedigap coverage, you should call your StateInsurance Department (see pages 86-87).

Note: If you are under age 65 and disabled orhave End-Stage Renal Disease, you may have theright to buy certain Medigap policies that aresold to people under age 65 (see pages 39-40).For more information, call your State HealthInsurance Assistance Program (see pages 88-89).


If you live inMassachusetts,Minnesota, orWisconsin, you havethe right to buy aMedigap policy thatis similar to thestandardized policiesyou can buy in otherstates. For moreinformation, callyour State InsuranceDepartment (seepages 86-87).

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How do my bills get paid if I have a Medigappolicy?

Information on how your bills are paid should comewith your Medigap policy. Your insurance companycan also tell you how your claims are filed.

Generally, when you get health care covered by bothMedicare and your Medigap policy, you will not haveto file a separate claim to the Medigap insurancecompany. The Medicare Carrier that handlesMedicare claims for your area will send your claimsto the Medigap insurance company. To find out moreabout Medigap claims, see page 62.

Will Medicare and Medigap pay if I sign a privatecontract with my doctor?

A private contract is an agreement between you and adoctor who has decided not to give services throughthe Medicare program. By signing a private contract,you agree to pay whatever the doctor charges you andthere is no limit on what can be charged. Medicareand Medigap will not pay for any health care serviceyou get from that doctor. (For more detailedinformation about private contracts, see page 63.) Youmay want to talk with someone in your State HealthInsurance Assistance Program before signing a privatecontract with your doctor (see pages 88-89).

Using a MedigapPolicy

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What other kinds of health insurance orprograms, besides Medigap, will pay for some ofmy health care costs not covered by Medicare?

There are several kinds of health coverage, besidesMedigap, that pay for some of your health care costsnot covered by Medicare. They include:

n Employee or retiree coverage from an employer orunion: Call your benefit administrator to find outif you have or can get health care coverage basedon your or your spouse's past or currentemployment. Since this kind of health insurancecoverage is not a Medigap policy, the rules thatapply to Medigap policies do not apply.

n COBRA Coverage (Consolidated Omnibus BudgetReconciliation Act of 1985): This law requires anemployer to let you and your dependents staycovered under the employer's group health planfor a certain length of time after losing your job,having your work hours reduced, or after yourspouse's death or a divorce. However, you mayhave to pay both your share and the employer'sshare of the premium. For more information onCOBRA, see pages 70-72.

n The PACE Program (Programs of All-InclusiveCare for the Elderly): This program combines bothinpatient and outpatient medical and long-termcare services for eligible persons. To be eligible,you must be at least 55 years old, live in theservice area of a PACE program, and be certifiedas eligible for nursing home care by theappropriate state agency. The goal of PACE is tokeep you independent, and living in yourcommunity as long as possible, and to providequality care at low cost. For more information onPACE, see page 76.

Other Kinds ofHealth Insurance

Caution: If you dropyour employer orunion group healthcoverage, you may notbe able to get it back.For more information,call your benefitadministrator.

Note: When you haveretiree coverage from anemployer or union, theyhave control over thisinsurance. They maychange the benefits orpremiums, and can alsocancel the insurance ifthey choose.

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n Federally Qualified Health Centers (FQHCs):These are special health centers, like a communityhealth center, tribal health clinic, migrant healthservice, and health center for the homeless, thatcan give you routine health care at a lower cost.For more information on FQHCs, see page 77.

n Medicaid: This is a joint federal and state programthat helps pay medical costs for some people withlow incomes and limited resources. Medicaidprograms vary from state to state, but most healthcare costs are covered if you qualify for bothMedicare and Medicaid. If you cannot afford to payyour Medicare premiums and other health care costs,you may be able to get help from your state. Formore information on Medicaid, see pages 78-79.

n Hospital Indemnity Insurance: This kind ofinsurance pays a certain cash amount for each dayyou are in the hospital up to a certain number ofdays. It is not designed to fill gaps in yourMedicare coverage. For more information onhospital indemnity insurance, see page 80.

n Specified Disease Insurance: This kind ofinsurance pays benefits for only a single disease,such as cancer, or for a group of diseases. It is notdesigned to fill gaps in your Medicare coverage.For more information on specified diseaseinsurance, see page 80.

n Long-Term Care Insurance: This kind of insurancepolicy may cover medical and non-medical carelike care to help you with your daily needs, such asbathing, dressing, using the bathroom, and eating.Generally, Medicare does not pay for long-termcare. This type of insurance may help fill somegaps in the coverage that you and/or your spousemay need in the future. For more information onlong-term care insurance, see pages 80-82.

Other Kinds ofHealth Insurance(continued)

212000 Guide


Note: These arenot Medigap

policies.

Medicare

Depending on where you live, you may have choicesin how you get your health care:

n The Original Medicare Plan

n Medicare managed care plans

n Private Fee-for-Service plans - New in 2000

Medicare does not pay for all your health care.Medigap policies are designed to fill gaps in theOriginal Medicare Plan coverage.

Medigap Policies

n Up to 10 standardized Medigap plans may beavailable in your state (except in Massachusetts,Minnesota, and Wisconsin, see pages 94-96).

n Medigap policies only help pay health care costs ifyou have the Original Medicare Plan.

n Medigap policies (including Medicare SELECT)are sold by private insurance companies to help fillthe gaps in the Original Medicare Plan.

n You choose the policy you want and pay apremium to the insurance company.

Using a Medigap Policy

n In most cases, your Medicare Carrier sends yourclaims to the Medigap insurance company.

Other Kinds of Health Insurance

There are other kinds of health care programs orinsurance to help pay health care costs, like:

Summary ofMedigap Basics

n Employer or Retiree Health Coveragen COBRA n PACE n FQHCn Medicaid n Hospital Indemnity Insurancen Specified Disease Insurancen Long-Term Care Insurance

Whether you need aMedigap policy is adecision that only youcan make. Depending onyour health care needsand finances, you maywant to continue youremployee or retireehealth coverage, or joina Medicare managedcare plan, or a PrivateFee-for-Service plan(available in 2000 insome areas). You mayalso want to think aboutyour long-term careneeds (see pages 80-82).

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PART 2 - BEYOND THE BASICS


Part 2 goes beyond the basics. It gives more detailedinformation about what you learned in Part 1.

Part 2 - Beyond theBasics

Buying a Medigap Policy ..................Pages 23-61

Your Medigap Policy Choices ............Pages 23-24What Medigap Policies Cover ............Pages 24-27Shopping for a Medigap Policy ..........Pages 27-35Medigap Policies for People Age 65 and Older ................................Pages 36-39Medigap Policies for PeopleUnder Age 65 ......................................Pages 39-40Medigap Protections ............................Pages 41-61

Using a Medigap Policy ....................Pages 62-66

How Your Bills Get Paid......................Page 62Private Contracts..................................Page 63-64Switching Medigap Policies ................Pages 64-66

Other Kinds of HealthInsurance ..........................................Pages 67-82

Group Health Coverage ......................Pages 67-69More on Employee Coverage ..............Pages 69-72Who Pays First ....................................Pages 72-75Other Health Insurance Options ..........Pages 76-79Other Private Health Insurance Options................................Page 80Long-Term Care Insurance..................Pages 80-82

Watch Out for Illegal Insurance Practices............................Page 83

Discrimination....................................Page 84

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What are my Medigap policy choices?

In all but three states (Massachusetts, Minnesota,and Wisconsin), you can buy any one of up to 10standardized Medigap policies that are sold in yourstate. Plan A is the “basic” benefit package and isincluded in all the other plans. Insurance companiesmust give you the benefits offered under eachpolicy.

Federal law lets states allow an insurer to add “newand innovative benefits” to the benefits in astandardized policy. Check with your insurancecompany to find out if these benefits are available.

What is Medicare SELECT?

Medicare SELECT is a type of Medigap insurancepolicy. If you buy a Medicare SELECT policy, youare buying one of the 10 standardized Medigapplans A through J. With a Medicare SELECT policy,you need to use specific hospitals and doctors to getfull insurance benefits (except in an emergency).For this reason, Medicare SELECT policiesgenerally have lower premiums.

If you do not use a Medicare SELECT provider fornon-emergency services, you will have to pay whatMedicare doesn’t pay. Medicare will pay its share ofapproved charges no matter what provider youchoose. Medicare SELECT might not be offered inyour state.

Buying a MedigapPolicy

Is there any other important information I need toknow?

There are many situations when your health coveragechanges (like losing your Medicare managed careplan or employer coverage) that can affect what

For more information,call your State HealthInsurance AssistanceProgram (see pages 88-89).

Your Medigap PolicyChoices

If you live inMassachusetts,Minnesota, orWisconsin, seepages 94-96.

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What are the basic (core) benefits in allstandardized Medigap plans?

n Coverage for the Part A coinsurance amount ($194per day in 2000) for days 61-90 of a hospital stayin each Medicare benefit period.

n Coverage for the Part A coinsurance amount ($388per day in 2000) for days 91-150 of a hospital staywhile using Medicare’s 60 lifetime reserve days(which you may only use once).

n After you use up all Medicare hospital benefits,coverage for 100% of the Medicare Part A eligiblehospital expenses. You have this coverage for up to365 more days of inpatient hospital care duringyour lifetime. After you use up your Medigaphospital benefits, you may have to pay the full costof hospital expenses.

n Coverage under Medicare Part A and Part B forthe reasonable cost of the first 3 pints of blood orequivalent quantities of packed red blood cells percalendar year unless this blood is replaced.

n Coverage for the coinsurance amount for Part Bservices (generally 20% of Medicare-approvedamount) after you meet the $100 annualdeductible.

For a higher Medigap premium, you can buy extrabenefits (see pages 25-27).

What MedigapPolicies Cover

Medigap policies you can buy and when. For moreinformation on your rights to buy a Medigap policyin these situations, see pages 42-61.


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Before you make any decisions about your healthcare coverage, think about your personal needs.Then, decide if the extra benefits offered are worththe extra premium costs.

Medigap Plans B through J cover the Medicarehospital deductible, which is $776 in 2000. Keep inmind that the additional cost that you pay inpremiums for this benefit is generally less than thecost of paying the hospital deductible. Each time youhave to stay in the hospital you will have to pay thedeductible if it’s the beginning of a new benefitperiod.

Plans C through J cover the skilled nursing facilitycoinsurance, which is $97 a day in 2000. Medicarepays all of the covered costs for the first 20 days ofcare in a skilled nursing facility. If you are in anursing facility for more than 20 days, Plans Cthrough J will pay the $97 a day coinsurance for days21 through 100.

Plans C, F, and J cover the Medicare Part Bdeductible, which is $100 per year in 2000.

Plans C through J cover foreign travel emergencies.This benefit pays for emergency care outside theUnited States beginning the first 60 days of each trip.After you meet the $250 deductible, this benefit pays80% of the cost of your care for up to $50,000 inyour lifetime. If you travel, this benefit could saveyou money for emergency care.

Medigap ExtraBenefits

Medicare HospitalDeductiblePlans B, C, D, E, F, G,H, I, and J

Skilled NursingFacility CoinsurancePlans C, D, E, F, G, H,I, and J

Medicare Part BAnnual DeductiblePlans C, F, and J

Foreign TravelEmergencyPlans C, D, E, F, G, H,I, and J

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Plans D, G, I, and J cover the cost of at-home help withactivities of daily living (like bathing and dressing) inaddition to Medicare-covered home health visits. Youcan get this benefit if you are already getting Medicare-covered home health care services. It also covers homehealth care for up to 8 weeks after skilled care is nolonger needed. However, it will not pay more than $40each visit and $1,600 each year.

Plans F, G, I, and J cover Medicare Part B excesscharges when your doctor charges more than Medicarewill pay. These policies pay the difference between yourdoctor’s charge and Medicare’s approved amount. PlansF, I, and J pay all of the excess charges. Plan G pays80% of the excess charges. Under federal law, doctorswho don’t accept “assignment” (take Medicare’sapproved amount as payment in full) may charge up to15% more than the Medicare-approved amount (somestates have even stricter limits). For example, ifMedicare approves $100, your doctor can charge asmuch as $115. Plan F, I, or J would cover the $15difference. Plan G would pay you $12 (80% of $15).

Plans E and J cover preventive care, which is limited to$120 each year. The preventive care benefit helps payfor routine yearly check-ups, serum cholesterolscreening, hearing test, diabetes screening, and thyroidfunction test.

Plans H, I, and J offer some prescription drug coverage.This benefit has a $250 yearly deductible and pays 50%of drug costs that Medicare doesn’t cover. It will onlypay up to $1,250 a year under Plans H and I, and up to$3,000 a year under Plan J. You may think about thisbenefit if you have high prescription drug costs.Because it covers half your drug costs after the yearlydeductible, to get the full benefit under Plans H and I,you should have at least $2,750 in drug costs in a year(you pay $1,250 plus $250; plan pays $1,250). To getthe full benefit under Plan J, you should have at least

Medigap ExtraBenefits(continued)

At-Home RecoveryPlans D, G, I, and J

Medicare Part B ExcessChargePlans F, G, I, and J

Preventive CarePlans E and J

Prescription DrugsPlans H, I, and J

Assignment can saveyou money. Call1-800-MEDICARE(1-800-633-4227)and ask for a freebrochure.

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Shopping for aMedigap Policy

What should I keep in mind as I shop for aMedigap policy?

As you shop for a Medigap policy, keep in mind thateach company’s benefits are alike, so they arecompeting on service, reliability, and price. Comparepremiums and make sure that the insurance companyis honest and reliable before buying. Insurer ratingservices look at the financial health of insurancecompanies. Different rating services use differentrating scales. Be sure to find out how the ratingservice labels its highest ratings and the meaning ofthe ratings for the companies you are considering.You can get ratings from some insurer ratingservices for free at most public libraries.Your StateInsurance Department can also give you informationabout the insurance companies (see pages 86-87).You can also use a computer to look on the Internetat www.medicare.gov. Click on “Medigap Compare.”

Federal law lets states allow an insurer to add “newand innovative benefits” to the benefits in astandardized policy. Check with your insurancecompany to find out if these benefits are available.

$6,250 in drug costs in a year (you pay $3000 plus$250; plan pays $3,000). Note: In some states, youmay not be able to get policies with a prescriptiondrug benefit unless you enroll during your openenrollment period.

Insurance companies may offer a high deductibleoption on Plans F and J. For more information on thisoption, see page 11.

For more information on Medigap policies, see thechart on page 10 or use a computer to look on theInternet at www.medicare.gov. Click on “MedigapCompare.”

Medigap ExtraBenefits(continued)

“When I was lookingfor my Medigap policy,I looked at whatdifferent policies cover,their prices, whetherthey coveredprescriptiondrugs...Once I foundthe company I wanted,I called the StateInsurance Departmentto make sure it was areliable company.”

Janice, Washington, D.C.

More Information

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What do I need to know about Medigap policypremiums?

There can be big differences in the premiums thatinsurance companies charge for exactly the samecoverage. When you compare premiums, be sure youare comparing the same Medigap policies.

Insurance companies have three different ways ofpricing policies based on your age:

n No-age-rated (also called community-rated)policies

These policies charge everyone the same rate nomatter how old they are.

Example:Sally pays the same premium at each age.

Premium at Age 65Premium at Age 75Premium at Age 85

$60$60$60

Shopping for aMedigap Policy(continued)


$70$70$70

n Issue-age-rated policies

The premium for these policies is based on yourage when you first buy the policy, and the costdoes not go up automatically as you get older.

Example:Sally pays the same premium depending on how oldshe is when she buys the policy.

Buy Policy at Age 65

Remember, allpremiums may changeand go up each yearbecause of inflationand rising health carecosts.

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--$95$95



----

$130



$50$85

$120

n Attained-age-rated policies

The premiums for these policies are based on yourage each year. These policies are generallycheaper at age 65, but their costs go upautomatically as you get older.

Example:Sally pays higher premiums as she gets older.

Caution: In general, attained-age-rated policies costless when you are 65 than issue-age-rated or no-age-rated policies. However, between the ages of 70 and75, attained-age-rated policies usually cost more thanother types of policies.

Remember, allpremiums may changeand go up each yearbecause of inflationand rising health carecosts.

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What other factors may affect my premium whenI buy a Medigap policy?

Other factors that may affect your premium whenyou buy a Medigap policy are:

n Whether you are male or female. Some companiesoffer discounts for females.

n Whether you smoke or not. Some companies offerdiscounts for non-smokers.

n Whether you are married or not. Some companiesoffer discounts for married couples.

What is underwriting? Can it affect the cost of myMedigap policy?

Medical underwriting is the process that a companyuses to review your health and decide whether toaccept your application for insurance. You usuallymust answer medical questions on an application.You need to fill out this application carefully (seepage 34). Some companies may want to review yourmedical records before they sell you a policy. Thecompany may use this information to add a waitingperiod for pre-existing conditions if your state lawallows. The company may also use this informationto decide how much to charge you for a Medigappolicy.

The company may not deny you coverage or chargeyou more for a policy if you are in your Medigapopen enrollment period or when you have the right tobuy a Medigap policy.

Insurance companies may “medically underwrite”any Medigap policy at times other than openenrollment or when you have a right to buy aMedigap policy (see pages 41-61).


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Whether you need a Medigap policy is a decisionthat only you can make. Depending on your healthcare needs and finances, you may want to continueyour employee or retiree health coverage, or join aMedicare managed care plan or a Private Fee-for-Service plan (available in 2000 in some areas). Youmay also want to think about your long-term careneeds (see page 80).

If you decide to buy a Medigap policy, shopcarefully. Look for a policy that you can afford andthat gives you the coverage you need most. Read thefollowing tips to help you shop for a Medigap policy.

The benefits in each of the standardized Medigappolicies are the same no matter which insurancecompany sells it. Review the plans and choose thebenefits that you need most.


Although each of the standardized Medigap policiesis the same no matter which insurance company sellsit, the costs may be very different. Companies usedifferent ways to price Medigap policies. Companiesalso differ in customer service. Call differentinsurance companies and compare cost and servicebefore you buy.

It is illegal for an insurance company to sell you asecond Medigap policy unless you tell them inwriting that you are going to cancel the first Medigappolicy when the second Medigap policy goes intoeffect. Call 1-800-MEDICARE (1-800-633-4227,TTY/TDD: 1-877-486-2048 for the hearing andspeech impaired) to report anyone who tries to sellyou a Medigap policy when you already have one.

□ Review the plansu

□ Shop carefullybefore you buy

u

□ Don’t buy more thanone Medigap policyat a time

u

Shopping Tips

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You should only switch policies to get differentbenefits, better service, or a better price. However, donot keep a policy that does not meet your needsbecause you have had it for a long time. If you decideto buy a new Medigap policy, the company mustcount the time you had the same benefits under thefirst policy towards the pre-existing condition waitingperiod. However, you may have a waiting period forpre-existing conditions for new benefits that you didnot have under your first policy. You must also sign astatement that you plan to cancel the first policy. Donot cancel the first policy until you are sure that youwant to keep the new policy. You have 30 days todecide if you want to keep the new policy. This iscalled your free look period.

You should get your policy within 30 days. If you donot, call the company and ask them to put in writingwhy the policy was delayed. If 60 days go by withoutan answer, call your State Insurance Department (seepages 86-87).

Before you buy a Medigap policy, you should findout whether it has a waiting period before it fullycovers your pre-existing conditions. If you have ahealth problem that was diagnosed or treated duringthe 6 months immediately before the Medigap policystarts, the policy might not cover your costs rightaway for care related to that health problem. Medigappolicies must cover pre-existing conditions after thepolicy has been in effect for 6 months. Someinsurance companies may have shorter waitingperiods before covering a pre-existing condition.Other insurance companies may not have any waitingperiod. If you buy a policy during your Medigapopen enrollment period, the insurance company mustshorten the waiting period for pre-existing conditionsby the amount of previous health coverage you have.This is called creditable coverage (see page 38).


□ Check for pre-existing conditionexclusions

u

□ Be careful ofswitching from oneMedigap policy toanother

u

□ Make sure you getyour policy within 30days

u

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An insurance company must meet certain standardsin order to sell policies in your state. You shouldcheck with your State Insurance Department to makesure that the insurance company you are doingbusiness with is licensed in your state. This is foryour protection. Insurance agents must also belicensed by your state and the state may require themto carry proof that they are licensed. The proof willshow their name and the name of the companies theyrepresent. Do not buy a policy from any insuranceagent that cannot prove that he or she is licensed. A business card is not a license.

It is illegal for an insurance company or agent topressure you into buying a Medigap policy, or lie toyou or mislead you to get you to switch from onecompany or policy to another. False advertising isalso illegal. Another type of illegal advertisinginvolves mailing cards to people who may want tobuy insurance. If you fill out and return the cardenclosed in the mailing, the card may be sold to aninsurance agent who will try to sell you a policy.

State Insurance Departments approve Medigappolicies sold by private insurance companies. Thismeans that the company and Medigap policy meetrequirements of state law. Do not believe statementsthat Medigap insurance is a government-sponsoredprogram (like the Original Medicare Plan). It isillegal for anyone to tell you that they are from thegovernment and try to sell you a Medigap policy. Ifthis happens to you, report that person to your StateInsurance Department (see pages 86-87). It is alsoillegal for a company or agent to claim that aMedigap policy has been approved for sale in anystate in which it has not been.


□ Watch out for illegalmarketing practices

u

□ Neither the state norfederal governmentsells or servicesMedigap policies

u

□ Find out if theinsurance companyis licensed

u

34 2000 Guide


Do not be pressured into buying a Medigap policy.Good sales people will not rush you. Keep in mind,that if you are within your 6-month Medigap openenrollment period (see page 36) or in a situationwhere you have a guaranteed right to buy a Medigappolicy, there are time limits you must follow (seepages 41-61). Buying the Medigap policy of yourchoice may be harder after the Medigap openenrollment or special protection period ends. Thiswill be especially true if you have a pre-existinghealth condition. If you are not sure whether aMedigap policy is what you need, ask the salespersonto explain it to you with a friend or family memberpresent.

Do not believe an insurance agent who says yourmedical history on an application is not important.Some companies ask for detailed medicalinformation. You must answer the medical questionseven if you are applying during your Medigap openenrollment period (see page 36) or you are in asituation where you have the right to buy a Medigappolicy (see pages 41-61). During these two times, thecompany cannot use your answers to turn you downor use this information to decide how much to chargeyou for a Medigap policy. However, if you leave outany of the medical information they ask for, thecompany could refuse to cover you for a period oftime for any medical condition you did not report.The company also could deny a claim or cancel yourMedigap policy if you send in a bill for care of ahealth problem you did not report.


□ Start looking earlyso you won’t berushed

u

□ If you decide tobuy, fill out theapplicationcarefully

u

Write down the agents’ and/or companies’ names,addresses, and telephone numbers or ask for abusiness card with this information.

□ Keep agents’ and/orcompanies’ names,addresses, andtelephone numbers

u

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You must be given a clearly worded summary of aMedigap policy. Read it carefully .

Pay by check, money order, or bank draft payable tothe insurance company, not the agent or anyone else.Get a receipt with the insurance company’s name,address, and telephone number for your records.

It is illegal for anyone to sell you a policy and call ita Medigap policy if it does not match thestandardized Medigap policies sold in your state. Adoctor may offer you a “retainer agreement” that sayshe/she can provide certain non-Medicare-coveredservices and not charge you the Medicarecoinsurance and deductible amounts. This type ofagreement may be illegal. If a doctor refuses to seeyou as a Medicare patient unless you pay him or hera yearly fee and sign a “retainer agreement,” youshould call 1-800-MEDICARE (1-800-633-4227,TTY/TDD: 1-877-486-2048 for the hearing andspeech impaired).


□ Look for an outlineof coverage

u

□ Do not pay cashu

□ Beware of non-standardized plans

u

36



Medigap Policies forPeople Age 65 andOlder

When do most people buy a Medigap policy?

Most people buy a Medigap policy during theirMedigap open enrollment period. Your Medigap openenrollment period lasts for six months after the firstday of the month in which you are both age 65 orolder and enrolled in Medicare Part B. Once the sixmonth Medigap open enrollment period starts, itcannot be changed. During this time, you have theright to buy the Medigap policy of your choice andthe insurance company cannot deny you insurancecoverage, place conditions on a policy (like makingyou wait for coverage to start), or change the price ofa policy because of past or present health problems.If you buy a policy during your Medigap openenrollment period, the insurance company mustshorten the waiting period for pre-existing conditionsby the amount of previous health coverage you have.This is called creditable coverage (see page 38).

Mr. Smith is 68 and has heart disease. He has justenrolled in Medicare Part B and his coverage startson March 1, 2000. Mr. Smith has until September1, 2000 to buy his Medigap policy without his heartdisease affecting the cost or type of policy he canchoose. After September 1, 2000, Mr. Smith willnot have this guarantee.

Example (OpenEnrollment)

How can I tell if I am in my Medigap openenrollment period?

Your Medicare card shows the dates that your Part Aand/or Part B coverage started. If you are age 65 orolder, you can figure out whether you are in yourMedigap open enrollment period by adding 6 monthsto the date that your Part B coverage starts. If thatdate is in the future, you are still in your Medigapopen enrollment period. If that date is in the past,you have missed your Medigap open enrollmentperiod.

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Should I enroll in Medicare Part B and start myMedigap open enrollment period if I am age 65 orover and still working?

If you enroll in Medicare Part B to supplement youremployer or union coverage, you will start yourMedigap open enrollment period when it may be oflittle use to you. You may want to wait to enroll inMedicare Part B if you have health coverage throughan employer or union based on your or your spouse’scurrent or active employment (see page 5 “SpecialEnrollment Period”). Carefully consider youroptions. Once you are age 65 or older and enrolledin Part B, the 6-month Medigap open enrollmentperiod starts and cannot be changed.

Medigap Policies forPeople Age 65 andOlder (continued)

Mrs. Poole just turned 65. She is still working andhas health coverage through her employer. Shedecides to enroll in Medicare Part B. Her coveragewill begin on May 1, 2000. Mrs. Poole decides shedoesn’t need to buy a Medigap policy because heremployer group health plan covers the samebenefits as a Medigap policy. However, once she isenrolled in Part B, her Medigap 6-month openenrollment period will start. Therefore, Mrs. Poolewill have until November 1, 2000 to buy theMedigap policy of her choice without conditions orprice changes even though she doesn’t need it.

Example

“My wife had aninsurance policythrough her employerand I was on herpolicy. When sheretired, she changed tomy policy. Then, whenI retired, we decided toget Medicare Part Band buy a Medigappolicy.”

Larry, Boston, Massachusetts

Should I wait to get Medicare Part B and start myMedigap open enrollment period if I am in goodhealth?

If you are over age 65 and still working, you maywant to wait to take Part B until you can make thebest use of your Medigap insurance open enrollmentperiod. However, the cost of Part B may go up 10%for each 12-month period that you could have hadPart B but did not take it, except in special cases (seepage 5, “Special Enrollment Period”). An insurance

38



What is creditable coverage?

Creditable coverage is any previous health coverageyou had under:

n a group health plan (like an employer plan);

n a health insurance policy;

n Medicare Part A or Part B;

n Medicaid;

n a medical program of the Indian Health Service ortribal organization;

n a State health benefits risk pool;

n TRICARE (the health care program for militarydependents and retirees);

n the Federal Employees Health Benefit Plan;

n a public health plan; or

n a health plan under the Peace Corps Act.


Will my pre-existing conditions be covered if I buya Medigap policy?

If you buy a Medigap policy during your Medigapopen enrollment period, the insurance company canrefuse to cover care for pre-existing conditions for upto 6 months. This only applies to conditions that werediagnosed or treated during the 6 monthsimmediately before the start of your Medigap policy.This 6-month period is called the pre-existingcondition waiting period. However, they cannotrefuse to cover pre-existing conditions if you have atleast 6 months of creditable coverage. Any newhealth problem would be covered immediately,regardless of whether you had creditable coverage.

company would probably accept your application, usemedical underwriting to decide if they will sell you apolicy, and charge you a reasonable premium.However, this is not guaranteed. Remember, yourhealth could change at any time!

2000 Guide

Note: Whether you canuse creditable coveragedepends on whether youhad any “breaks incoverage.” If there wasany time that you had nohealth coverage of anykind, and during thattime you were withoutcoverage for more than63 days, you can onlycount creditablecoverage that you hadafter that break incoverage.

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Is there a Medigap open enrollment period forpeople under age 65 who first get Medicare becauseof a disability or End-Stage Renal Disease (ESRD)?

Yes, but only when you turn age 65.

You may have Medicare Part B benefits before age 65due to a disability or ESRD (permanent kidney failuretreated with dialysis or a kidney transplant). In thiscase, you may not be able to buy a Medigap policyright away, but you will have the right to choose andbuy any Medigap policy when you turn age 65. It doesnot matter that you had Medicare Part B before youturned age 65.

For 6 months after you turn age 65 and are enrolled inMedicare Part B:

n You can buy any Medigap policy (including thosepolicies that pay for prescription drugs), and

n Insurance companies cannot refuse to sell you aMedigap policy due to a disability or other healthproblem.

Example (CreditableCoverage)

Mrs. Johnson is 68 and has heart disease. She hashad Medicare Part B since November 1, 2000.Before this date, she had no health insurance. OnMarch 1, 2001, Mrs. Johnson buys a Medigappolicy. Her insurance company may refuse to coverher pre-existing heart disease condition for 6months (the pre-existing condition waiting period).However, Mrs. Johnson can use her 4 months ofMedicare Part B coverage to shorten this 6 monthpre-existing condition waiting period. This waitingperiod will now be 2 months instead of 6 months.During these 2 months, after Medicare pays itsshare, Mrs. Johnson will have to pay the rest of thecosts for the care of her heart disease.

Medigap Policies forPeople Under Age 65

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Medigap Policies forPeople Under Age 65(continued)

n Connecticutn Delawaren Kansasn Louisianan Mainen Maryland

n Massachusettsn Michigann Minnesotan Missourin New Hampshiren New Jersey

n New Yorkn Oklahoman Oregonn Pennsylvanian Texasn Wisconsin

When you buy a policy during your Medigap openenrollment period, the insurance company mustshorten the waiting period for pre-existing conditionsby the amount of creditable coverage you have. Ifyou had Medicare for more than 6 months, you willnot have a pre-existing condition waiting periodbecause Medicare counts as creditable coverage.

Several states require Medigap insurance companies tooffer a limited Medigap open enrollment period forpeople with Medicare Part B who are under age 65. Atthe time of this printing, the following states requireinsurance companies to offer a Medigap open enrollmentperiod to people with Medicare under age 65:

Also, some insurance companies will sell Medigappolicies to people with Medicare under age 65.However, these policies may cost you more.Remember, if you live in a state that has a Medigapopen enrollment period for people under age 65, youwill still get another Medigap open enrollment periodwhen you turn age 65.

Also, if you join a Medicare health plan and yourcoverage ends, you may have the right to buy aMedigap policy (see Situations #1 and #2 on page42).

If you have questions, you should call your StateHealth Insurance Assistance Program (see pages 88-89).

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Introduction toMedigap Protections

n Arkansasn Delawaren Floridan Iowan Illinoisn Indianan Kansasn Mainen Massachusettsn North Carolinan New Hampshire

n New Mexicon Nevadan New Yorkn South Dakotan Texasn Virginian Vermontn Wisconsinn West Virginian Wyoming

What are Medigap protections?

Medigap protections are special rights you have tobuy a Medigap policy in addition to your Medigapopen enrollment period. These are also called“guaranteed issue” rights because insurancecompanies are required by law to issue you a policy.These protections are important because if you donot buy a Medigap policy during your Medigap openenrollment period, an insurance company might beable to refuse to sell you a policy, or you may becharged more for the policy. In addition, if you dropyour Medigap policy, you may not be able to get itback unless you have this protection.

The Medigap protections in this section are fromfederal law. Some states provide more Medigapprotections than federal law. At the time this Guidewas printed, these states reported that they offer moreMedigap protections than federal law requires:

Call your State Insurance Department (see pages 86-87) or State Health Insurance Assistance Program(see pages 88-89) to find out if your state offers moreMedigap protections than federal law.

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When do I have a right to Medigap protections?

There are a few types of situations involving healthcoverage changes where you may have a guaranteedissue right to buy a Medigap policy even when youare not in your Medigap open enrollment period. For example:

1. Your Medicare managed care plan or Private Fee-for-Service plan coverage ends because the plan isleaving the Medicare program or stops giving carein your area (see Situation #1 on pages 43-47), or

2. Your health coverage (like a Medicare managedcare plan or Private Fee-for-Service plan, employergroup health plan that supplemented or paid someof the costs not paid for by Medicare, MedicareSELECT policy or Program of All-Inclusive Carefor the Elderly (PACE), or Medicare managed caredemonstration project) ends through no fault ofyour own including your moving outside of theplan’s service area (see Situation #2 on pages 47-50), or

3. You dropped your Medigap policy to join aMedicare managed care plan or Private Fee-for-Service plan, or buy a Medicare SELECT policyfor the first time, and then leave the plan or policywithin one year after joining (see Situation #3 onpages 51-54), or

4. You joined a Medicare health plan (like aMedicare managed care plan with a Medicare +Choice contract or Private Fee-for-Service plan)when you first became eligible for Medicare atage 65 and within one year of joining, youdecided to leave the health plan (see Situation #4on pages 55-57).

Each situation will be discussed in detail on thefollowing pages.

Medigap Protections

If you live inMassachusetts,Minnesota, orWisconsin, you havethe right to buy aMedigap policy thatis similar to thestandardized policiesyou have a right tobuy in the otherstates. Call yourState InsuranceDepartment (seepages 86-87).

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Can I buy a Medigap policy if my Medicaremanaged care plan or Private Fee-for-Service planleaves the Medicare program or stops giving carein my area?

If your Medicare managed care plan or Private Fee-for-Service plan leaves the Medicare program orstops giving care in your area, you have the right tobuy Medigap plans A, B, C, or F that are sold in yourstate.

In some cases, you have the right to return to yourold Medigap policy (see Situation #3 on pages 51-54)or to buy any of the 10 standardized Medigappolicies sold in your state (see Situation #4 on pages55-57).

If you get a letter telling you that your Medicaremanaged care plan or Private Fee-for-Service plan isleaving the Medicare program or will no longer givecare in your area, you may have three choices:

1. Stay in your plan until the date your coverageends. You have 63 calendar days after your healthcoverage ends to apply for a Medigap policy.

2. Switch to another Medicare managed care planin your area. In some cases, you may have to waituntil the new plan is accepting new members tojoin.

3. Leave your plan (disenroll) as soon as you getyour letter. You have 63 calendar days from thedate on the letter from your Medicare managedcare plan or Private Fee-for-Service plan tellingyou that the plan will no longer be giving care inyour area, to apply for a Medigap policy.

Choice #3 only applies to Private Fee-for-Serviceplans or Medicare managed care plans with a“Medicare + Choice” contract (not a “cost contract”).

Medigap Protections(continued)

Situation #1

44 2000 Guide


Call your managed care plan to find out what kind ofcontract they have so you will know if you can leavethe plan as soon as you get your letter without losingyour Medigap protections.

You have the right to buy Medigap plans A, B, C, orF that are sold in your state. If you decide to leaveyour plan before your coverage ends, you must turnin a written request to your plan telling them youwant to leave (disenroll).Your coverage will end onthe last day of the month in which your plan getsyour written request to leave (see Example #1a).


Situation #1(continued)

In October 2000, Mrs. Walton receives a letterfrom her Medicare managed care plan (with aMedicare + Choice contract) telling her that theplan will be leaving the Medicare program onDecember 31, 2000. The letter is dated October 1,2000. She decides to get health care coverage fromthe Original Medicare Plan. She turns in herwritten request to leave her plan on October 12,2000. Her coverage will end October 31, 2000.Mrs. Walton has the right to buy Medigap plans A,B, C, or F that are sold in her state as long as sheapplies by December 2, 2000 (63 calendar daysfrom the date on the plan’s letter to her).

Example #1a

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As long as you apply for your new Medigap policyno later than 63 calendar days from the date on theletter from your plan or no later than 63 calendardays after your health coverage ends (see Example#1b), the insurance company:

n Cannot deny you insurance coverage or placeconditions on the policy (such as making you waitfor coverage to start);

n Must cover you for all pre-existing conditions;

n Cannot charge you more for a policy because ofpast or present health problems.

Important: When your health coverage ends, yourhealth plan will send you a letter telling you that yourcoverage is ending. Keep a copy of the letter (makesure that your name is on the letter) and the postmarkedenvelope to prove that you lost coverage from yourhealth plan. You should also keep a dated copy of yourMedigap policy application, and any insurance companydenial letters that are mailed to you to prove that youhave been denied your Medigap rights if this happens.

In October 2000, Mrs. Walton receives a letterfrom her Medicare managed care plan telling herthat it will be leaving the Medicare program onDecember 31, 2000. The letter is dated October 1,2000. She decides to stay in her plan until hercoverage ends on December 31, 2000. She willautomatically be enrolled in the Original MedicarePlan starting January 1, 2001. Mrs. Walton has theright to buy Medigap plans A, B, C, or F that aresold in her state as long as she applies by March 4,2001 (63 calendar days after her health coverageends).

Example #1b

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Does this protection cover me if I am under age 65and have Medicare because of a disability or End-Stage Renal Disease (ESRD)?

There is no federal law that requires insurancecompanies to have general Medigap open enrollmentperiods for people under age 65. However, if anyinsurance company in your state sells Medigap plansA, B, C, or F to people under age 65, eithervoluntarily or because it is required by state law, theymust sell you a policy if you are in situation #1, #2,or #3 listed on page 42. For more information, callyour State Health Insurance Assistance Program (seepages 88-89).



Summary of your Medigap Protections if yourMedicare managed care plan or Private Fee-for-Service plan leaves the Medicare program or willno longer be giving care in your area:

n You may have three choices about what to do, andwhen to do it (see page 43);

n You have the right to buy Medigap plans A, B, C,or F that are sold in your state as long as youapply no later than 63 calendar days from the dateon the letter from your plan or no later than 63calendar days after your health coverage ends;

n The insurance company cannot deny youinsurance coverage or place conditions on thepolicy (such as making you wait for coverage tostart);

n The insurance company must cover you for allpre-existing conditions;

n The insurance company cannot charge you morefor a policy because of past or present healthproblems;

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n If you are under age 65 and have Medicarebecause of a disability or ESRD, you must beallowed to buy Medigap plans A, B, C, or F thatare otherwise sold in your state to people underage 65 with Medicare.

Remember, if you wish to leave the plan as soon asyou get your letter without losing your Medigapprotections, you should first call your managed careplan to make sure it has a “Medicare + Choice”contract rather than a “cost contract.”

Situation # 2 Can I buy a Medigap policy if my health coverageends other than in the case where my Medicaremanaged care plan leaves the Medicare program?

If your health coverage (like a Medicare managedcare plan, Private Fee-for-Service plan, employergroup health plan that supplemented or paid some ofthe costs not paid for by Medicare, MedicareSELECT policy, or Programs of All-Inclusive Carefor the Elderly (PACE), or Medicare managed caredemonstration project) ends, in certain situations youhave the right to buy Medigap plans A, B, C, or Fthat are sold in your state. You must apply no laterthan 63 calendar days after your health coverageends.

The insurance company must sell you one of theseMedigap plans if:

n You move outside of the plan’s service area (the

For moreinformation onPACE, see page 76.

Another Option

Even if you do not meet the conditions for Medigapprotections, your insurance company may still allowyou to buy any Medigap policy, especially if you arein good health. For more information, call your StateHealth Insurance Assistance Program (see pages 88-89).



area where the plan accepts members and whereyou get services from the plan); or

n You leave the health plan because it failed to meetits contract obligations to you (for example, themarketing material was misleading or qualitystandards were not met); or

n You were in an employer group health plan thatsupplemented or paid some of the costs not paid forby Medicare, and the plan ends your coverage; or

n Your insurance company ends your MedicareSELECT policy and you’re not at fault (forexample, the company goes bankrupt); or

n Your PACE program stops participating inMedicare or stops giving care in your area.

As long as you apply for your new Medigap policy nolater than 63 calendar days after your health coverageends, the insurance company:

n Cannot deny you insurance coverage or placeconditions on the policy (like making you wait forcoverage to start);

n Must cover you for all pre-existing conditions;


You should not wait until your health coverage hasalmost ended before you apply for a Medigap policy.You can apply for a Medigap policy early (while youare still in your health plan) and choose to start yourMedigap coverage the day after your health plancoverage ends. This will prevent gaps in your healthcoverage (see Example #2 on page 49).

Caution: In most cases in Situation #2, you muststay in your health plan until the date your coverageends. If you leave the plan before that date, you maylose your right to buy Medigap plans A, B, C, or Fthat are sold in your state.

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Situation # 2 (continued)

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Situation # 2(continued)

Mrs. Jones was covered under an employer grouphealth plan that paid some of the costs not paidfor by Medicare. She got a letter in the mailtelling her that her health plan coverage was endingon April 5, 2000. Mrs. Jones wanted to buy aMedigap policy that would help pay her healthcare costs not covered by Medicare. Because herhealth care coverage was ending, Mrs. Jones hadthe right to buy Medigap plans A, B, C, or F thatwere sold in her state as long as she applied byJune 7, 2000 (63 calendar days after her healthcoverage ended). She had to stay in her employergroup health plan until the date her coverageended, or she would lose her right to buy one ofthese Medigap plans. Mrs. Jones applied for aMedigap policy on March 16, 2000 and chose tostart her Medigap coverage on April 6, 2000, theday after her health coverage ended. Thisprevented gaps in her health coverage.

Example #2

Important: When your health coverage ends, yourhealth plan will send you a letter telling you that yourcoverage is ending. Keep a copy of the letter (makesure that your name is on the letter) and the postmarkedenvelope to prove that you lost coverage from yourhealth plan. You should also keep a dated copy of yourMedigap policy application, and any insurance companydenial letters that are mailed to you to prove that youhave been denied your Medigap rights if this happens.

Does this protection cover me if I am under age 65and have Medicare because of a disability or End-Stage Renal Disease (ESRD)?

There is no federal law that requires insurancecompanies to have general Medigap open enrollmentperiods for people under age 65. However, if anyinsurance company in your state sells Medigap plans

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Summary of your Medigap Protections if yourhealth coverage ends (except in the case whereyour Medicare managed care plan or Private Fee-for-Service plan leaves the Medicare program, seepage 43):

n You have the right to buy Medigap plans A, B, C,or F that are sold in your state as long as youapply no later than 63 calendar days after yourhealth coverage ends;

n The insurance company cannot deny you insurancecoverage or place conditions on the policy (likemaking you wait for coverage to start);

n The insurance company must cover you for all pre-existing conditions;

n The insurance company cannot charge you morefor a policy because of past or present healthproblems;

n If you are under age 65 and have Medicarebecause of a disability or ESRD, you must beallowed to buy Medigap plans A, B, C, or F thatare otherwise sold in your state to people underage 65 with Medicare.

A, B, C, or F to people under age 65, eithervoluntarily or because it is required by state law,they must sell you a policy if you are in situations#1, #2, or #3 listed on page 42. For moreinformation, call your State Health InsuranceAssistance Program (see pages 88-89).

Another Option

Even if you do not meet these conditions forMedigap protections, your insurance company may

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Situation # 3 If I drop my Medigap policy to join a Medicaremanaged care plan or Private Fee-for-Serviceplan, or buy a Medicare SELECT policy, and thenleave the plan or policy, will I be able to get myMedigap policy back?

Maybe. If you dropped your Medigap policy to join aMedicare health plan (like a Medicare managed careplan or a Private Fee-for-Service plan) or buy aMedicare SELECT policy, and then leave the plan orpolicy, under certain conditions, you may be able toreturn to the Medigap policy you had before (if it isstill available).

You have this protection, if:

n This is the first time that you have ever beenenrolled in a Medicare health plan or MedicareSELECT policy; and

n You leave the Medicare health plan or MedicareSELECT policy within one year after joining.

You must apply for your former Medigap policy nolater than 63 calendar days after your Medicarehealth plan coverage ends (see Example #3 on page53). If your former Medigap policy is no longeravailable, see “What can I do if the Medigap policy Ihad is no longer available?” on page 52.

Remember, you should not wait until your Medicarehealth plan coverage has almost ended before youapply for a Medigap policy. You can apply for aMedigap policy early (while you are still in yourMedicare health plan) and choose to start yourMedigap coverage the day after your health plan

still allow you to buy any Medigap policy, especiallyif you are in good health. For more information, callyour State Health Insurance Assistance Program (seepages 88-89).

Important information about Medicare SELECTpolicies.

You may also have this same protection if youdropped a Medicare SELECT policy to join aMedicare health plan (like a Medicare managed careplan). This is because a Medicare SELECT policy isa type of Medigap policy.

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Important: If you bought a Medigap policy before1990, your policy is not a standardized Medigappolicy. It may have benefits that are different fromthe 10 standardized Medigap plans. Therefore, if youdropped it, you would not be able to get it backbecause that policy is no longer being sold.

What can I do if the Medigap policy I had is nolonger available?

If your former Medigap policy is no longer available,you have the right to buy Medigap plans A, B, C, or Ffrom any insurance company which sells these plansin your state. You must apply no later than 63 calendardays after your Medicare health plan coverage ends.As long as you apply for your new Medigap policy nolater than 63 calendar days after your health coverageends, the insurance company:


n Must cover you for all pre-existing conditions; and




coverage ends. This will prevent gaps in your healthcoverage (see Example #3 on page 53.)

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If you currently have a Medicare SELECT policy, youalso have the right to switch, at any time, to a regularMedigap policy that is sold by the same company (ifany are available). The Medigap policy you switch tomust have equal or less coverage than the MedicareSELECT policy you currently have.

Mr. Perkins joined a Medicare managed care planon December 1, 2000. He had never been in aMedicare managed care plan before. Before that,Mr. Perkins was in the Original Medicare Planand had a Plan J Medigap policy. Six monthslater, Mr. Perkins decided to leave the managedcare plan and return to the Original MedicarePlan. He put in his request in writing to leave hismanaged care plan on June 5, 2001. His managedcare plan coverage ended on June 30, 2001.Because this was the first time he had ever beenin a Medicare managed care plan, he had theoption of returning to his Plan J Medigap policyas long as he applied for it by September 1, 2001(63 calendar days after his health coverageended). Mr. Perkins found out that his Medigapinsurance company still sold Medigap policy PlanJ. He applied for it on June 10, 2001, and chose tostart his Medigap coverage on July 1, 2001, theday after his Medicare health plan coverageended. This prevented gaps in his health coverage.

Example #3

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Summary of your Medigap protections if youdropped your Medigap policy to join a Medicarehealth plan (like a Medicare managed care plan orPrivate Fee-for-Service plan), or buy a MedicareSELECT policy for the first time, then leave theplan or policy within one year after joining:

n You have the right to return to your formerMedigap policy (if it is still available from thesame insurance company). You must apply no laterthan 63 calendar days after your Medicare healthplan coverage ends;

n If your former policy is not available, you have theright to buy Medigap plans A, B, C, or F that aresold in your state as long as you apply no later than63 calendar days after your Medicare health plancoverage ends;

n The insurance company cannot deny you insurancecoverage or place conditions on the policy (likemaking you wait for coverage to start);


n The insurance company cannot charge you morefor a policy because of past or present healthproblems.

Another Option

Even if you do not meet these conditions forMedigap protections, your insurance company maystill allow you to buy any Medigap policy, especiallyif you are in good health. For more information, callyour State Health Insurance Assistance Program (seepages 88-89).



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Is there any other time when I have the right tobuy any of the 10 standardized Medigap policies,other than during my Medigap open enrollmentperiod?

Yes. You have the right to buy any Medigap policysold in your state if:

n You joined a Medicare health plan (like aMedicare managed care plan with a Medicare +Choice contract or a Private Fee-for-Service plan),when you first became eligible for Medicare atage 65*, and

n You leave the plan within one year after joining.

This only applies to Private Fee-for-Service plans orMedicare managed care plans with a Medicare +Choice contract. Call your managed care plan to findout if they have a Medicare + Choice contract.

You must apply for the Medigap policy no later than63 calendar days after your Medicare health plancoverage ends. As long as you apply for your newMedigap policy no later than 63 calendar days afteryour health coverage ends, the insurance company:


n Must cover you for all pre-existing conditions; and


You should not wait until your Medicare health plancoverage has almost ended before you apply for aMedigap policy. You can apply for a Medigap policyearly (while you are still in your Medicare healthplan) and choose to start your Medigap coverage theday after your Medicare health plan coverage ends.This will prevent gaps in your health coverage (seeExample #4 on page 56).

*You are eligible forMedicare on the firstday of the month inwhich you turn age 65.If your birthday is onthe first day of themonth, your Medicarecoverage starts on thefirst day of the monthbefore your birthday.


Situation # 4

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Note: If you are still in your 6-month Medigap openenrollment period after you leave your Medicarehealth plan, you may have more than 63 calendardays to buy a Medigap policy. For more information,call your State Health Insurance Assistance Program(see pages 88-89).

Mrs. Miner joined a Medicare managed care planon February 1, 2000, the first day of the month inwhich she turned 65. Six months later, shedecided to leave her plan. She turned in herwritten request to leave her plan on August 3,2000. Her managed care plan coverage ended onAugust 30, 2000. Since she did not choose to joinanother managed care plan, she wasautomatically enrolled in the Original MedicarePlan. Mrs. Miner had the right to buy anyMedigap policy, as long as she applied byNovember 2, 2000 (63 calendar days after herhealth coverage ended). Mrs. Miner applied forher Medigap policy on August 25, 2000, andchose to start her Medigap coverage onSeptember 1, 2000, the day after her Medicarehealth plan coverage ended. This prevented gapsin her health coverage.



Example #4

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Summary of Medigap protections when youjoined a Medicare health plan (like a Medicaremanaged care plan with a Medicare + Choicecontract or a Private Fee-for-Service plan) whenyou first became eligible for Medicare at age 65,and you leave the plan within one year afterjoining:

n You have the right to buy any Medigap policy soldin your state as long as you apply no later than 63calendar days after your Medicare health plancoverage ends;

n The insurance company cannot deny youinsurance coverage or place conditions on thepolicy (like making you wait for coverage to start);


n The insurance company cannot charge you morefor a policy because of past or present healthproblems.



Another Option

Even if you do not meet these conditions forMedigap protections, your insurance company maystill allow you to buy any Medigap policy, especiallyif you are in good health. For more information, callyour State Health Insurance Assistance Program (seepages 88-89).

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If you think any of the previous situations apply toyou, you may have the right to buy a Medigap policy.Call your State Health Insurance Assistance Program(see pages 88-89) to make sure that you qualify forthese Medigap protections. They can also help youfind the Medigap policy that is right for you.

Important: When your health coverage ends (seeSituation #1 on page 43 and Situation #2 on page 47),your health plan will send you a letter telling you thatyour coverage is ending. Keep a copy of the letter(make sure that your name is on the letter) and thepostmarked envelope to prove that you lost coveragefrom your health plan. You should also keep a datedcopy of your Medigap policy application, and anyinsurance company denial letters that are mailed toyou to prove that you have been denied your Medigaprights if this happens.

If you are denied Medigap coverage, call your StateInsurance Department (see pages 86-87).

Remember, to get these protections, you must apply nolater than 63 calendar days after your health coverageends.

General MedigapProtectionInformation

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The following chart is a summary of the situations, explained on the previous pages, that maygive you the right to buy a Medigap policy when your health coverage changes, and theprotections that apply for each situation. In order to get these Medigap protections, you mustmeet certain conditions. See the following chart for more details. If you live in Massachusetts,Minnesota, or Wisconsin see page 42 for your protections.

Note: There may be times when more than one of these situations apply to you. When thishappens, you may want to choose the protection that gives you the best choice of policies. Forexample, if both situations #1 and #4 apply to you, you may have the right to buy any Medigappolicy. This is because situation #4 offers you the best choice by allowing you to buy anyMedigap policy that is sold in your state. Situation #1 limits your choices to only Medigapplans A, B, C, or F that are sold in your state.

Summary of Medigap Protections Chart

1. Your Medicare managed care plan orPrivate Fee-for-Service plan coverageends because the plan is leaving theMedicare program or will no longer givecare in your area.

You may have three choices. (For more informationon these three choices, see page 43.)

You have the right to buy Medigap plans A, B, C,or F that are sold in your state as long as you applyno later than 63 calendar days from the date on theletter from your plan (for Medicare health planswith a Medicare + Choice contract) or no later than63 calendar days after your health coverage ends.

The insurance company cannot deny you insurancecoverage or place conditions on the policy (likemaking you wait for coverage to start). You must becovered for all pre-existing conditions. You can’t becharged more for a policy because of past orpresent health problems.

If you are under age 65 and have Medicare becauseof a disability or ESRD, you must be allowed tobuy Medigap plans A, B, C, or F that are sold inyour state to people under age 65 with Medicare.Remember, there is no federal law that requiresinsurance companies to have general Medigap openenrollment periods for people under age 65.

Your Health Coverage Situation Medigap Protections

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2. Your health coverage (like a Medicaremanaged care plan or Private Fee-for-Service plan, employer group health planthat supplemented or paid some of the costsnot paid for by Medicare, MedicareSELECT policy, Program of All-InclusiveCare for the Elderly (PACE), or a Medicaremanaged care demonstration project) endsthrough no fault of your own.

You have the right to buy Medigap plans A,B, C, or F that are sold in your state as longas you apply no later than 63 calendar daysafter your health coverage ends.

The insurance company cannot deny youinsurance coverage or place conditions on thepolicy (like making you wait for coverage tostart). You must be covered for all pre-existingconditions. You can’t be charged more for apolicy because of past or present healthproblems.

If you are under age 65 and have Medicarebecause of a disability or ESRD, you must beallowed to buy Medigap plans A, B, C, or Fthat are sold in your state to people under age65 with Medicare.

Caution: In most cases, you must stay inyour health plan until the date your coverageends. If you leave the plan before this date,you may lose your right to buy Medigapplans A, B, C, or F.

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3.You dropped your Medigap policy tojoin a Medicare managed care plan orPrivate Fee-for-Service plan, or buy aMedicare SELECT policy, then leavethe plan or policy, and:

n This is the first time that you have everbeen enrolled in a Medicare healthplan or Medicare SELECT policy; and

n You leave the Medicare health plan orMedicare SELECT policy within oneyear after joining.

You must be allowed to return to your formerMedigap policy if it is still available from the sameinsurance company. You must apply no later than 63calendar days after your health coverage ends. If itis not available, you have the right to buy Medigapplans A, B, C, or F that are sold in your state aslong as you apply no later than 63 calendar daysafter your Medicare health plan coverage ends.

The insurance company cannot deny you insurancecoverage or place conditions on the policy (likemaking you wait for coverage to start). You must becovered for all pre-existing conditions. You can’t becharged more for a policy because of past or presenthealth problems.

Caution: If you bought a Medigap policy before1990, your policy is probably not a standardizedMedigap policy. It may have benefits that aredifferent from the 10 standardized Medigap plans.Therefore, if you dropped it, you would not be able toget it back because that policy is no longer beingsold.

4. You joined a Medicare health plan (likea Medicare managed care plan with aMedicare + Choice contract, or aPrivate Fee-for-Service plan) when youfirst became eligible for Medicare atage 65, and you leave the plan withinone year after joining.

You must be allowed to buy any Medigap policy soldin your state as long as you apply no later than 63calendar days after your Medicare health plancoverage ends.

The insurance company cannot deny you insurancecoverage or place conditions on the policy (likemaking you wait for coverage to start). You must becovered for all pre-existing conditions. You can’t becharged more for a policy because of past or presenthealth problems.

Note: If you are still in your Medigap openenrollment period after you leave your Medicarehealth plan, you may have more than 63 calendardays to buy a Medigap policy.

All rights to buy Medigap policies under these protections include Medicare SELECT policiessince they are a type of Medigap policy.

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Using a MedigapPolicy

How Your Bills GetPaid

Does the Medigap insurance company pay my doctordirectly?

The insurance company will pay your doctor or providerdirectly when:

n Your doctor or supplier has signed an agreement withMedicare to accept assignment of all Medicare claimsfor all people with Medicare;

n Your policy is a Medigap policy; and

n You tell your doctor’s office to put on the Medicareclaim form that you want Medigap insurance benefitspaid to the doctor or supplier. Your doctor will put yourMedigap policy number and company on the Medicareclaim form. You will need to sign the claim form.

When these conditions are met, the Medicare Carrierwill process the claim and send it to the Medigapinsurance company. The carrier will send you anExplanation of Medicare Benefits (EOMB) orMedicare Summary Notice (MSN). Your Medigapinsurance company will pay your doctor or providerdirectly and then send you a notice. If you don’t getthis notice, you may ask your Medigap insurancecompany for it.

In most cases, Medicare claims are sent directly to theinsurance company, even if the doctor does not acceptassignment (also called a participation agreement).

What happens if the Medigap insurance companydoes not pay my doctor directly?

If the Medigap insurance company does not pay yourdoctor directly (when the above three conditions aremet), you should report this to your State InsuranceDepartment (see pages 86-87). For more informationon Medigap claim filing by the carrier, call yourMedicare Carrier (see pages 92-93).

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If I sign a private contract with my doctor, willMedicare and Medigap pay?

No. A private contract is an agreement between you anda doctor who has decided not to give services throughthe Medicare program. The private contract only appliesto the services given by the doctor who asked you tosign it. This means that Medicare and Medigap will notpay for the services you get from the doctor with whomyou have a private contract. You cannot be asked to signa private contract in an emergency or for urgentlyneeded care. Note: You still have the right to see otherMedicare doctors for services.

What happens if I sign a private contract with mydoctor?

If you sign a private contract with your doctor:

n No Medicare payment will be made for the servicesyou get from this doctor.

n Your Medigap policy, if you have one, will not payanything for this service. (Call your insurancecompany before you get the service.)

n You will have to pay whatever this doctor or providercharges you (the limiting charge will not apply).

n Medicare managed care plans or Private Fee-for-Service plans will not pay for these services.

n No claim should be submitted, and Medicare will notpay if one is.

n Many other insurance plans will not pay for theservice either.

Can I pay on my own for services that are notcovered by Medicare?

Yes. You may choose to pay on your own for services theOriginal Medicare Plan doesn’t cover. In this case, yourdoctor does not have to stop giving services throughMedicare or ask you to sign a private contract. You are

Private Contracts

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Switching MedigapPolicies

Private Contracts(continued)

A Medigap policy will not pay any coinsurance ordeductible amounts on the cost of services that wouldgenerally be covered by Medicare, but are denied bya Medicare Carrier or Fiscal Intermediary becausethey are not medically necessary for a particularpatient. However, some of the 10 standardizedMedigap policies contain certain benefits thatprovide payment for limited categories of servicesthat are never covered by Medicare. For example, theforeign travel emergency benefit in plans C throughJ; the outpatient prescription drug benefit in Medigapplans H, I, and J; the at-home recovery benefit inplans D, G, I, and J; and the preventive care benefitin plans E and J all pay for limited categories of non-Medicare-covered services.

Can my Medigap insurance company drop me?

In most cases, no. Medigap policies sold after 1990are required to be guaranteed renewable. This meansthat your insurance company must let you renew yourMedigap policy unless you do not pay the premiums,you lie, or commit fraud under the policy. There isonly one situation where you may lose a Medigapguaranteed renewable policy: if the insurancecompany goes bankrupt. If this happens, you havethe right to buy Medigap plans A, B, C, or F that aresold in your state.

Insurance companies may refuse to renew olderMedigap policies that were not sold as guaranteedrenewable. To do this, an insurance company mustdecide to cancel all policies of this type sold in yourstate. If this happens, you have the right to buyMedigap plans A, B, C, or F that are sold in yourstate (see Example on page 65).

always free to get non-Medicare-covered services onyour own if you choose to pay for the serviceyourself.

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In 1987, Mr. Jones bought a Medigap policy fromCompany A. The Medigap policy Mr. Jonesbought was not guaranteed renewable. CompanyA is no longer offering this type of Medigappolicy and wants to cancel all policy contracts ofthis type. Therefore, Mr. Jones may switch toanother Medigap policy. His choices includeMedigap policies A, B, C, or F that are sold in hisstate.

Do I have to switch my older Medigap policy forone of the newer standardized Medigap plans?

No, you do not have to switch your policy.

What should I do before switching my Medigappolicy?

Before switching policies, compare benefits andpremiums. Some of the older Medigap policies mayoffer better coverage, especially for prescriptiondrugs and long-term care. On the other hand, olderMedigap policies may have bigger premium increasesthan newer standardized Medigap policies. OlderMedigap policies cannot be sold to people who arenow buying Medigap insurance.

If I decide to switch my Medigap policy, and thenI change my mind, can I go back to my olderMedigap policy?

No. If you do switch Medigap policies, you will notbe able to go back to your Medigap policy if it wassold to you before 1990.

Example

Switching MedigapPolicies (continued)


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Do I need more than one Medigap policy?

No. It is illegal for insurance companies to sell you asecond policy. If you already have a Medigap policyand you want to buy another one, you must sign astatement saying that you plan to cancel your firstMedigap policy. Do not cancel your first Medigappolicy until the second one is in place, the pre-existing condition waiting period is over, and youdecide to keep the second Medigap policy. You have30 days to decide if you want to keep the new policy.This is called your free look period.

Switching MedigapPolicies (continued)

Do I have to have my Medigap policy for a certainlength of time before I can switch to a differentMedigap policy?

No. However, if you had a Medigap policy for atleast 6 months and you decide to switch, yoursecond Medigap policy generally must cover you forall pre-existing conditions. If you had a Medigappolicy for less than 6 months, the new policy mustgive you credit for the time you were covered underthe older policy. If there is a benefit in the secondMedigap policy that was not in your first policy, thecompany can make you wait up to 6 months beforecovering that benefit.

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What kinds of group health coverage are there?

There are several kinds of coverage that might becalled “group” health coverage, such as coverageoffered under:

n Employers or unions: This type of group healthcoverage is for current employees or retirees.Generally, employer plans have better rates thanyou can get if you buy a policy yourself, andemployers may pay part of the cost.

n Organizations or associations: This type of grouphealth coverage is for members of an organizationor association. Just because you are buyingthrough a group does not always mean that youare getting a lower rate. This type of coverage cancost as much as, or more than, the same coverageyou get with a policy you buy yourself. Be sureyou understand the benefits included and how thepremiums are decided, then compare prices.

What happens if I have employer or unioncoverage when I turn age 65?

When you reach age 65 you will need to make adecision about Part B (see page 37). You may stillhave health coverage through your or your spouse’scurrent or active employer or union membership. Ifyou do, be sure to read the information in thesections “Special Enrollment Period” (see page 5),“More on Employee Coverage” (see pages 69-72),and “Who Pays First” (see pages 72-75). Also, findout if your employer coverage can be continued afteryou retire. Check the price and benefits, includingbenefits for your spouse. Make sure you know whateffect your continued coverage as a retiree will haveon his or her insurance protections.

Other Kinds ofHealth Insurance

Group HealthCoverage

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What happens if I drop employer-based coverage?

If you drop your employer-based group healthcoverage, you probably won’t be able to get it back.For more information, call your benefitadministrator.

How does retiree coverage work?

Retiree coverage that is not a Medigap policy doesnot have to follow the rules for Medigap policies.However, under some circumstances, retiree coveragemust follow the rules of the Department of Labor.These plans might not fill the gaps in Medicare.They might not pay your medical costs during anyperiod in which you were eligible for Medicare butdid not sign up for it.

While retiree coverage may not offer the samebenefits as a Medigap policy, it may offer otherbenefits such as prescription drug coverage androutine dental care. Keep in mind that the retireecoverage provided by your employer or union mayhave limits on how much it will pay. It may alsoprovide “stop loss” coverage, or a limit on your out-of-pocket spending after you have already paid acertain amount of out-of-pocket costs.

If you are not sure how your plan works withMedicare, get a copy of your plan’s benefits booklet,or look at the summary plan description provided byyour employer or union. You can also call yourbenefit administrator and ask how the plan payswhen you have Medicare.

Note: When you haveretiree coverage from anemployer or union, theyhave control over thisinsurance. They maychange the benefits orthe premiums and canalso cancel the insuranceif they choose.

Group HealthCoverage (continued)

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What if I buy a Medigap policy while I haveretiree coverage?

Although it is generally unwise to buy moreinsurance than you need, you may buy a Medigappolicy even if it has some of the same benefits asyour retiree coverage under a group health plan. Yourretiree coverage may have a coordination of benefitsclause, sometimes called a “carve out.” If it does, itwill not pay benefits the Medigap policy pays. TheMedigap policy must pay full benefits even if theretiree coverage also pays for the same service. Youmay want to call your benefit administrator or yourState Health Insurance Assistance Program (see pages88-89) before buying a Medigap policy that has thesame benefits as your retiree coverage.

More on EmployeeCoverage

What health benefits must my employer provide ifI am age 65 or older and still working?

Employers with 20 or more employees must offer thesame benefits, including health benefits under thesame conditions, to current or active employees age65 and over as they offer to younger employees. Ifthey offer coverage to spouses, they must offer thesame coverage to spouses age 65 and over that theyoffer to spouses under age 65. If your employerand/or employer group health coverage does notfollow this rule, you should call the Health CareFinancing Administration (see page 90).

Note: Sometimes, employee health coverage endsautomatically at the end of a calendar year evenbefore you get a notice from your employer that yourcoverage has ended. This could start the 63 calendarday period for Medigap protections before you evenfind out you are entitled to them (see pages 47-50).Check with your employer to make sure youunderstand how your coverage works and how youcan protect yourself.

Group HealthCoverage (continued)

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What happens if I or my spouse stop working,stop group health coverage, and already haveMedicare?

You should:

n Call your Medicare Carrier (see pages 92-93) orwrite a letter telling them that your or yourspouse’s employment situation has changed.

n Give the carrier the name and address of theemployer plan, your policy number with the grouphealth plan, the date coverage stopped, and why.

n When you get health care services, tell the doctoror hospital that Medicare now pays first andshould be billed first. Give the date your grouphealth plan coverage stopped.

Note: The Health Insurance Portability andAccountability Act (HIPAA) of 1996 requires youremployer to send you a Certificate of CreditableCoverage when your group health coverage ends. Allthe information you need to give to the MedicareCarrier will be on this certificate. If for some reasonyour employer does not send you a Certificate ofCreditable Coverage, you should ask for one. Thesecertificates are free.

More on EmployeeCoverage (continued)

What is COBRA?

COBRA (The Consolidated Omnibus BudgetReconciliation Act of 1985) is a law that requiresemployers with 20 or more employees to letemployees and their dependents keep their grouphealth coverage for a time after they leave their grouphealth plan under certain conditions. This is called“continuation coverage.” You may have this right ifyou lose your job or have your working hoursreduced, or if you are covered under your spouse's

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plan and your spouse dies or you get divorced.COBRA generally lets you and your dependents keepthe group coverage for 18 months (or up to 29 or 36months in some cases), but you may have to pay bothyour share and the employer's share of the premium.Some state's laws require employers with less than 20employees to let you keep your group healthcoverage for a time, but you should check with yourState Insurance Department to make sure (see pages86-87). In most situations that give you COBRArights, other than a divorce, you should get a noticefrom your benefit administrator. If you don't get anotice, or if you get divorced, you should call yourbenefit administrator as soon as possible.

If you already have continuation coverage underCOBRA when you enroll in Medicare, your COBRAmay end. This is because the employer has the optionof canceling the continuation coverage at this time.The length of time your spouse may get coverageunder COBRA may change when you enroll inMedicare. For more information about group healthcoverage under COBRA, call your State InsuranceDepartment (see pages 86-87).

However, if you elect COBRA coverage after youenroll in Medicare, you can keep your continuationcoverage. When your group health coverage ends,you and your dependents can get coverage underCOBRA. If you only have Medicare Part A whenyour group health plan coverage ends (based oncurrent or active employment), you can enroll inMedicare Part B during a special enrollment periodwithout having to pay a Part B premium penalty. Youneed to enroll in Part B either at the same time youenroll in Part A or during a special enrollment periodafter your group health plan coverage, based oncurrent or active employment, ends. Remember, thiswill also start your Medigap open enrollment period


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(see page 37). However, if you only have MedicarePart A, sign-up for COBRA coverage and wait untilthe COBRA coverage ends to enroll in Medicare PartB, you will have to pay a Part B premium penalty.You do not get a Part B special enrollment periodwhen COBRA coverage ends. State law may giveyou the right to continue your coverage underCOBRA beyond the point COBRA coverage wouldordinarily end. Your rights will depend on what isallowed under the state law.


Who Pays First Does Medicare or my group health plan pay first?

If you are age 65 or over and covered by a grouphealth plan because of current or active employmentor the current or active employment of a spouse ofany age, Medicare is the secondary payer if theemployer has 20 or more employees and covers anyof the same services as Medicare. This means thatthe group health plan is the primary payer. It paysfirst on your hospital and medical bills. Medicarewill review what your group health plan paid forMedicare-covered health care services, and pay anyadditional costs up to the Medicare-approved amount.You will have to pay the costs of services thatMedicare or the group health plan does not cover.

If you do not take the group health plan coverage,Medicare will be the primary payer. Medicare willpay its share for any Medicare-covered health careservice you get (see pages 97-99 for a list ofMedicare-covered services). Your employer can offeryou a plan that will pay for services not covered byMedicare such as hearing aids, routine dental care,prescription drugs, and routine physical check-ups.However, the employer cannot offer you a plan thatpays supplemental benefits for Medicare-coveredservices or pays for these benefits in any other way.

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Remember, when you enroll in Medicare Part B, youstart your 6-month Medigap open enrollment period(see page 37). To help decide whether to keep yourgroup health plan coverage, talk with your benefitadministrator, your State Insurance Department (seepages 86-87), or your State Health InsuranceAssistance Program (see pages 88-89).

Who pays first if I’m a disabled Medicarebeneficiary under age 65?

Medicare pays first if you are under age 65, haveMedicare because of a disability, and your grouphealth plan coverage is through an employer withfewer than 100 employees. If the employer has 100employees or more, the health plan is called a largegroup health plan (LGHP). If you are covered by aLGHP because of your current employment or thecurrent employment of a family member, Medicarepays second. Sometimes employers with fewer than100 employees join other employers in a LGHP. If atleast one employer in the LGHP has 100 employeesor more, then Medicare always pays second. SomeLGHPs let others join the plan such as a self-employed person, a business associate of anemployer, or a family member of one of thesepeople. A LGHP cannot treat any of their planmembers differently because they are disabled andhave Medicare.

Who Pays First(continued)

Who pays first if I have Medicare because of End-Stage Renal Disease (ESRD), and have grouphealth coverage?

If you are eligible to enroll in Medicare because ofESRD (permanent kidney failure), your group healthplan will pay first on your hospital and medical billsfor 30 months whether or not you are enrolled in

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Who Pays First(continued)

Medicare and have a Medicare card. During this time,Medicare is the secondary payer. The group healthplan pays first during this period no matter how manyemployees work for the employer, or whether you or afamily member are currently employed. At the end ofthe 30 months, Medicare becomes the primary payer.This only applies to those with ESRD, whether youhave your own group health coverage or you arecovered as a family member.

For more information on ESRD, you can get a freecopy of Medicare Coverage of Kidney Dialysis andKidney Transplant Services by calling 1-800-MEDICARE (1-800-633-4227, TTY/TDD: 1-877-486-2048 for the hearing and speech impaired). Youcan also see and print a copy of this booklet by usinga computer to look on the Internet atwww.medicare.gov.

If you don’t have a computer, your local library orsenior center may be able to help you look at thisinformation.

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If you... Condition Pays first Pays second

Are age 65 or older and coveredby a group health plan becauseyou are working or are coveredby a group health plan of aworking spouse of any age

Are disabled and covered by alarge group health plan (LGHP)because you are working orbecause of a family member whois working

Have End-Stage Renal Disease(permanent kidney failure) andgroup health plan coverage(including a retirement plan)

Have an employer retiree planand are age 65 or older or aredisabled

Know Who Pays If You Have Other Health Insurance

n The employer hasfewer than 20employees

n The employer hasfewer than 100employees

n First 30 monthsof eligibility orentitlement toMedicare

n Medicare n Group healthplan

n Medicare n Group healthplan

n Group healthplan

n Medicare

Chart modified and used with permission from the Medicare Rights Center, Inc.

If you have Medicare and group health plan coverage be sure to tell your doctor and otherproviders so your bills can be sent to the appropriate payer to avoid delays.

n The employer has20 or moreemployees

n Group healthplan

n Medicare

n At least oneemployer coveredby the plan has100 or moreemployees

n Large grouphealth plan

n Medicare

n After 30 months n Medicare n Grouphealth plan

n Eligible forMedicare

n Medicare n Retireecoverage

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What is the PACE program?

The Programs of All-Inclusive Care for the Elderly(PACE) is a program that combines both inpatientand outpatient medical and long-term care services.To be eligible, you must be at least 55 years old, livein the service area of the PACE program, and becertified as eligible for nursing home care by theappropriate state agency. The goal of PACE is to keepyou independent and living in your community aslong as possible and to offer quality care at low cost.

Services include primary care, social work, therapyto help you get better, medical services for specialproblems, medical services that support routinetreatment, and long-term care services (such astransportation, meals, and personal care). Theservices are given in the PACE center, at home, andin other inpatient settings such as a hospital.

A team of health care providers looks at your needs,makes a plan of care, and gives you services for thetotal care that you need. This health care teamincludes, but is not limited to, doctors, nurses,therapists, and social workers. If you need nursinghome care, PACE will give you this service andcheck your health condition on a regular basis.

PACE sites get payments directly from Medicare andMedicaid for services that all eligible enrollees get.However, PACE sites are only in certain communities.To find a PACE site near you, or for moreinformation, call your state, county, or local medicalassistance office - not a federal office. You can alsouse a computer to look on the Internet under theNursing Home section of www.medicare.gov forPACE locations and telephone numbers.

Remember, PACE does not work with Medigappolicies.

Other HealthInsurance Options

New in 2000:

If you are over age 65and in a PACE programthat leaves the Medicareprogram or stops givingcare in your area, youhave the right to buyMedigap plans A, B, C,or F that are sold inyour state. You mustapply no later than 63calendar days after yourhealth coverage ends(see pages 47-50).

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What is a Federally Qualified Health Center?

Another possible way to lower your health care costsis to go to a Federally Qualified Health Center(FQHC). At a FQHC, you can get routine care.When you use a FQHC, Medicare pays for somehealth services like preventive care that are notusually covered. FQHCs include community healthcenters, tribal health clinics, migrant health services,and health centers for the homeless. Anyone withMedicare may go to a FQHC for health careservices. They are usually in inner-city and ruralareas. FQHC services that are available to peoplewith Medicare include:

n Routine physical exams.

n Screening and diagnostic tests for vision andhearing problems, and other health problems.

n Flu shots and other similar shots.

When you get these services at a FQHC, you do nothave to pay the $100 yearly Part B deductible. If youget other services like X-rays, you will have to paythe usual Part B yearly deductible of $100.Sometimes you will not have to pay the 20 percentcoinsurance for Part B services.

To find the FQHC nearest to you, call 1-800-MEDICARE (1-800-633-4227, TTY/TDD 1-877-486-2048 for the hearing and speech impaired). Askfor the telephone number of the Primary CareAssociation in your state.

Can I get help paying health care costs for youngchildren in my care who don’t have insurance?

If you have young children under age 19 in your carewho don’t have insurance, you may be able to gethelp to pay for their health care costs under yourState Children’s Health Insurance Program.

Health Insurance ForChildren under Age 19

A new State Children’sHealth Insurance Programis now available. Call1-877-KIDS-NOW(1-877-543-7669) or lookon the Internet atwww.insurekidsnow.gov formore details.

Other HealthInsurance Options(continued)

78 2000 Guide


How can Medicaid help Medicare beneficiaries?

Medicaid is a joint federal and state program thathelps pay medical costs for some people with lowincomes and limited resources. Medicaid programsvary from state to state. Most of your health carecosts are covered if you qualify for both Medicareand Medicaid. People on Medicaid may also getcoverage for nursing home care and outpatientprescription drugs which are not covered byMedicare.

States also have programs that pay some or all ofMedicare’s premiums and may also pay Medicaredeductibles and coinsurance for certain people whohave Medicare and a low income. To qualify forthese programs, you must:

n Have Medicare Part A (hospital insurance). Ifyou’re not sure if you have Part A, look on yourred, white, and blue Medicare card or call theSocial Security Administration at 1-800-772-1213.

n Have a monthly income of less than $1,238 for anindividual or $1,661 for a couple. These incomelimits are slightly higher in Hawaii and Alaska.(These income limits will change slightly in2001.)

n Have savings of $4,000 or less for an individual or$6,000 or less for a couple. Savings includemoney in a checking or savings account, stocks,or bonds.

If you want more information on these programs,call 1-800-MEDICARE (1-800-633-4227,TTY/TDD: 1-877-486-2048 for the hearing andspeech impaired) and ask for information on“Savings for Medicare Beneficiaries.”


Some of these programsmay not be available inGuam, Puerto Rico, theVirgin Islands, the NorthernMariana Islands, andAmerican Samoa.

Call your nearestmedical assistanceoffice if you think youqualify.

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What should I do if I have a Medigap policy andthen go on Medicaid?

If you have a Medigap policy and go on Medicaid,you have the right to suspend the Medigap policyrather than dropping it while you are on Medicaid.However, in some cases, it may not be a good idea tosuspend your Medigap policy. Call your state medicalassistance office to help you with this decision.

If you do suspend your policy, while it is suspended,you do not pay premiums and it will not paybenefits. You can only suspend a Medigap policy forup to 2 years. At the end of the suspension, you canstart it up again without new medical underwriting orpre-existing condition waiting periods. Call yourinsurance company to find out how to suspend apolicy.

Can an insurance company sell me a Medigappolicy if I already have Medicaid?

If you have Medicaid, an insurance company can sellyou a Medigap policy only in certain situations (seechart below).

If...

Medicaid pays yourMedigap premium

Medicaid pays yourMedicare premiums,deductibles, andcoinsurance

Medicaid pays all or partof your Medicare Part Bpremium

Then you can buy...

Any Medigap policy

Medigap plans H, I, or J

Any Medigap policy


In any other situation, it is illegal for an insurancecompany to sell you a Medigap policy if you haveMedicaid.

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Other Private HealthInsurance Options

The following types of policies are generally limitedin scope and are not substitutes for Medigapinsurance or comprehensive health coverage. Benefitsunder these policies are not designed to fill gaps inyour Medicare coverage.

What is hospital indemnity insurance?

n Hospital indemnity insurance pays a fixed cashamount for each day you are in the hospital up to acertain number of days. Some policies may haveadded benefits such as surgical benefits or skillednursing home confinement benefits. Some policieshave a maximum number of days or a maximumpayment amount.

What is specified disease insurance?

n Specified disease insurance, which is onlyavailable in some states, pays benefits for only onedisease, such as cancer, or for a group of specifieddiseases. The value of this coverage depends onthe chance you will get the specific disease ordiseases covered. Benefits are usually limited to afixed amount for each type of treatment.Remember, Medicare and any Medigap policy youhave will very likely cover costs from anyspecified diseases you may have.

What is long-term care?

Long-term care is different from traditional medicalcare. Someone with a long physical illness, or adisability, or a memory or thought problem (such asAlzheimer’s disease) often needs long-term care. Long-term care is made up of many different services to helppeople with chronic conditions overcome limitationsthat keep them from being independent. Long-termcare may include help with activities of daily living,

Long-Term Care Insurance

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Long-Term Care Insurance(continued)

What is long-term care insurance?

Long-term care insurance is one way you may pay forlong-term care. This type of insurance will pay forsome or all of your long-term care. Long-term careinsurance is a relatively new type of insurance. It wasintroduced in the 1980s as nursing home insurance. Ithas changed a lot and now often covers much morethan nursing home care.

If you are shopping for long-term care insurance, findout which types of long-term care services thedifferent policies cover. For more information aboutlong-term care insurance, get a copy of A Shopper’sGuide to Long-Term Care Insurance from either yourState Insurance Department (see pages 86-87) or theNational Association of Insurance Commissioners,120 W. 12th Street, Suite 1100, Kansas City, MO64105-1925. You may also get a copy of Your Guideto Choosing a Nursing Home from the Health CareFinancing Administration by calling 1-800-MEDICARE (1-800-633-4227, TTY/TDD: 1-877-486-2048 for the hearing and speech impaired).

home health care, respite care, adult day care, care in anursing home, and care in an assisted living facility.Long-term care may also include case managementservices, which will evaluate your needs and coordinateand monitor the delivery of long-term care services.

Does Medicare cover long-term care?

No. Generally, Medicare only covers medicallynecessary care under Part A (Hospital Insurance) andPart B (Medical Insurance). You must meet certainconditions for Medicare to cover skilled nursingfacility, home health, and hospice care (see pages 97-99).

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Who sells long-term care insurance?

Private insurance companies sell long-term careinsurance policies. You can buy them from aninsurance agent or through the mail. Or, you canbuy a group policy through an employer or throughmembership in an association. You can also getlong-term care benefits through a life insurancepolicy. Insurance companies must be licensed inyour state to sell long-term care insurance. Becertain that you are dealing with a company thatyou know. If you decide to buy long-term careinsurance, be sure that the company and the agent,if one is involved, is licensed in your state. If youare not sure, call your State Insurance Department(see pages 86-87).

How can I find out about nursing homes in myarea?

You can now get important information about thenursing homes in your area by using a computer tolook on the Internet at www.medicare.gov. Click on“Nursing Home Compare” to see where nursinghomes are located in your area, how big they are,what types of residents they have, and whether ornot the nursing home accepts Medicare or Medicaid.With “Nursing Home Compare,” you can also seenursing home inspection reports that can tell you ifany problems were found during the inspection. Ifyou don’t have a computer, your local library orsenior center may be able to help you look at thisinformation.

Long-Term Care Insurance(continued)

New in 2000!

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Watch Out forIllegal InsurancePractices

It is illegal for anyone to:

n Sell you a second Medigap policy when they knowthat you already have one, unless you tell theinsurance company in writing that you plan tocancel your existing Medigap policy.

n Sell you a Medigap policy if they know you haveMedicaid except in certain situations (see page79).

n Sell you a Medigap policy if they know you areenrolled in a Medicare managed care plan with aMedicare + Choice contract or Private Fee-for-Service plan.

n Claim that a Medigap policy is part of theMedicare program or any other federal program.

n Use the mail to advertise Medigap policies that arenot approved for sale in your state.

n Misuse the names, letters, symbols, or emblems ofthe U.S. Department of Health and HumanServices (DHHS), Social Security Administration(SSA), Health Care Financing Administration(HCFA), or any of their various programs likeMedicare.

You should report any suspected violations of thelaws on marketing insurance policies to your StateInsurance Department (see pages 86-87).

If you believe that a federal law has been violated,you may call 1-800-MEDICARE (1-800-633-4227,TTY/TDD: 1-877-486-2048 for the hearing andspeech impaired). In most cases, however, your StateInsurance Department can help you with insurance-related problems (see pages 86-87).

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DiscriminationEvery facility or agency that participates in theMedicare program must comply with the law. It’sillegal to discriminate on the basis of race, color,sex, national origin, disability, or age. If you believethat you have been discriminated against based onany of these categories, contact the Department ofHealth and Human Services, Office of Civil Rightsat 1-800-368-1019 (TTY/TDD: 1-800-537-7697 forthe hearing and speech impaired).

852000 Guide

Who to Call for Medicare or Medigap Information

For the most recent contact information,visit the Important Contacts section of this website.

If you are in a Medicare health plan like a managed care plan or a Private Fee-for-Service plan,you should call your plan with questions about bills, health services, and appeals.

CALL... IF YOU HAVE QUESTIONS ABOUT...

State InsuranceDepartment

State HealthInsuranceAssistanceProgram

Health CareFinancingAdministrationRegional Offices

State Agencieson Aging

Medicare Carrier

Medigap policies sold in your area and insurance-related problems.

Buying a Medigap policy or long-term careinsurance, dealing with payment denials orappeals, Medicare rights and protections, yourcare or treatment, choosing a Medicare healthplan, or Medicare bills.

Local seminars and health fairs on Medicarehealth plan choices, or to report a complaintdirectly to the Health Care FinancingAdministration.

Services for older persons.

Medicare Part B coverage, bills, and medicalservices, or how to recognize Medicare fraud andabuse.

2000 Guide86

Basic Benefits

Part A: InpatientHospital Deductible

Part A: Skilled NursingFacility Coinsurance

Part B: Deductible

Foreign TravelEmergency

Inpatient Days in MentalHealth 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 Smear tests andmammograms. Check your plan for other state-mandated benefits.)

MASSACHUSETTS STANDARDIZED MEDIGAP PLANS

Basic Benefits - Included in all plans:

n Hospitalization: Part A coinsurance plus coverage for 365 additional days during yourlifetime after Medicare benefits end

n Medical Expenses: Part B coinsurance (generally 20% of Medicare-approvedexpenses)

n Blood: First 3 pints of blood each year

Medigap Benefits Core Supplement 1 Supplement 2

60 days percalendar year

120 days perbenefit year

120 days perbenefit year

3 3 3

3 3 3

3

33

3 3

3 3

3 3

3

3

3

For more information on these policies, call your State Insurance Department (see pages 86-87) or look on the Internet at www.medicare.gov and click on “Medigap Compare.”

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Who To Contact

Basic Benefits

Part A: InpatientHospital Deductible

Part A: Skilled-NursingFacility Coinsurance

Part B: Deductible

Foreign TravelEmergency

Outpatient Mental Health

Usual and Customary Fees

Preventive Care

Prescription Drugs

At-home Recovery

Physical Therapy

Coverage while in a Foreign Country

MINNESOTA STANDARDIZED MEDIGAP PLANS


n Hospitalization: Part A coinsurance

n Medical Expenses: Part B coinsurance (generally 20% of Medicare-approved expenses)


Medigap Benefits Basic Extended Basic

50% 50%

3 3

3 3

80%

3

3

3

3

3

3

For more information on these policies, call your State Insurance Department(see pages 86-87) or look on the Internet at www.medicare.gov and click on“Medigap Compare.”

3

80%

3

80%

80%

20% 20%

80%

OptionalRiders

n Part A:InpatientHospitalDeductible

n Part A:Deductible

n Usual andCustomaryFees

n PreventiveCare

n PrescriptionDrugs

n At-homerecovery

Insurancecompanies areallowed to offersix additionalriders that can beadded to a Basicplan. You maychoose any oneor all of theriders to design aMedigap planthat meets yourneeds.

2000 Guide88

Optional Riders

n Medicare Part ADeductible Rider

n Additional HomeHealth Care Rider(365 visitsincluding those paidby Medicare)

n Medicare Part BDeductible Rider

n Medicare Part BExcess ChargesRider

n OutpatientPrescription DrugRider

n Foreign TravelRider

Insurance companies areallowed to offeradditional riders to aMedigap plan.


n Hospitalization: Part A coinsurance

n Medical Expenses: Part B coinsurance (generally 20% of Medicare-approved expenses)


WISCONSIN STANDARDIZED MEDIGAP PLANS

3

3

For more information on these policies, call your StateInsurance Department (see pages 86-87) or look on the Internetat www.medicare.gov and click on “Medigap Compare.”

Medigap Benefits Basic Plan

175 days per lifetime inaddition to Medicare

3

3

3

3

3

40 visits in addition tothose paid by Medicare

Basic Benefits

Part A: Skilled-NursingFacility Coinsurance

Inpatient Mental Health Coverage

Home Health Care

Part B: Coinsurance

Outpatient Mental Health

Prescription Drugs

3

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MEDICARE PART A COVERAGE CHART

Medicare Part A (Hospital Insurance)Covers:

What You Pay in 2000* in the OriginalMedicare Plan

Hospital Stays: Semiprivate room, meals, general

nursing and other hospital services and supplies.This does not include private duty nursing, atelevision or telephone in your room, or a private

room, unless medically necessary. Inpatient mentalhealth care coverage in a psychiatric facility islimited to 190 days in a lifetime.

For each benefit period you pay:• A total of $776 for a hospital stay of 1-60 days.• $194 per day for days 61-90 of a hospital stay.

• $388 per day for days 91-150 of a hospital stay.(See Lifetime Reserve Days on page 102)

• All costs for each day beyond 150 days.

Skilled Nursing Facility (SNF) Care**: Semiprivate room, meals, skilled nursing and

rehabilitative services, and other services andsupplies (after a 3-day hospital stay).

For each benefit period you pay:• Nothing for the first 20 days.

• Up to $97 per day for days 21-100.• All costs beyond the 100th day in the benefit

period.

If you have questions about SNF care and conditionsof coverage, call your Fiscal Intermediary.***

Home Health Care**: Part-time skilled nursingcare, physical therapy, occupational therapy, speech-

language therapy, home health aide services, durablemedical equipment (such as wheelchairs, hospitalbeds, oxygen, and walkers) and supplies, and other

services.

You pay:• Nothing for home health care services.• 20% of approved amount for durable medical

equipment.

If you have questions about home health care andconditions of coverage, call your Regional HomeHealth Intermediary.***

Hospice Care**: Medical and support servicesfrom a Medicare-approved hospice, drugs for

symptom control and pain relief, short-term respitecare, care in a hospice facility, hospital, or nursinghome when necessary, and other services not

otherwise covered by Medicare. Home care is alsocovered.

You pay:• A copayment of up to $5 for outpatient prescription

drugs and 5% of the Medicare payment amount forinpatient respite care (short-term care given to a

hospice patient by another care giver, so that theusual care giver can rest). The amount you pay forrespite care can change each year.

If you have questions about hospice care andconditions of coverage, call your Regional HomeHealth Intermediary.***

Blood: Given at a hospital or skilled nursing facility

during a covered stay.

You pay:• For the first 3 pints of blood if you do not replace it.

* New Part A and B amounts will be available by January 1, 2001.

** You must meet certain conditions in order for Medicare to cover these services.*** Call 1-800-633-4227 to get the telephone number for the Fiscal Intermediary or Regional Home Health

Intermediary in your state.

If you have general questions about Medicare Part A, call your Fiscal Intermediary.

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MEDICARE PART B COVERAGE CHART

Medicare Part B (Medical Insurance)Covers:

What You Pay in 2000* in the OriginalMedicare Plan

Medical and Other Services: Doctors' services(except for routine physical exams), outpatientmedical and surgical services and supplies,

diagnostic tests, ambulatory surgery center facilityfees for approved procedures, and durable medicalequipment (such as wheelchairs, hospital beds,

oxygen, and walkers).

Also covers outpatient physical and occupationaltherapy including speech-language therapy.

Outpatient mental health services.

You pay:• $100 deductible (pay once per calendar year).• 20% of approved amount after the deductible, except in

the outpatient setting.

• 20% for all outpatient physical, occupational, and

speech therapy services.

• 50% for most outpatient mental health. See note below.

Clinical Laboratory Service: Blood tests,

urinalysis, and more.

You pay:• Nothing for Medicare-approved services.

Home Health Care**: Part-time skilled care, home health aide services, durable medical

equipment when supplied by a home health agencywhile getting Medicare covered home health care,and other supplies and services.

You pay:• Nothing for services.• 20% of approved amount for durable medical

equipment.

Outpatient Hospital Services: Services for thediagnosis or treatment of an illness or injury.

You pay:• 20% of the charged amount (after the deductible).

During the year 2000, this will change to a setcopayment amount.

Blood: Pints of blood needed as an outpatient, or as

part of a Part B covered service.

You pay: • For the first 3 pints of blood, then 20% of the

approved amount for additional pints of blood (afterthe deductible) if you do not replace it.

* New Part A and B amounts will be available by January 1, 2001.

**You must meet certain conditions in order for Medicare to cover these services.

Note: Actual amounts you must pay are higher if the doctor does not accept assignment (see page 100). If

you have general questions about your Medicare Part B coverage, call your Medicare Carrier (see pages92-93).

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MEDICARE PART B PREVENTIVE SERVICES CHART

Medicare Part B Covered Preventive Services

Who is covered... What you pay...

Bone Mass Measurements:Varies with your health status.

Certain people with

Medicare who are atrisk for losing bonemass.

20% of the Medicare-approved

amount after the yearly Part Bdeductible.

Colorectal Cancer Screening: • Fecal Occult Blood Test - Once every 12 months.• Flexible Sigmoidoscopy - Once every four years.

• Colonoscopy - Once every two years if you arehigh risk for cancer of the colon.

• Barium Enema - Doctor can substitute for

sigmoidoscopy or colonoscopy.

All people with

Medicare age 50 andolder. However, thereis no age limit for

having acolonoscopy.

No coinsurance and no Part Bdeductible for the fecal occult

blood test. For all other tests,20% of the Medicare-approvedamount after the yearly Part B

deductible.

Diabetes Monitoring:Includes coverage for glucose monitors, teststrips, lancets, and self-management training.

All people with

Medicare who havediabetes (insulinusers and non-users).

20% of the Medicare-approved

amount after the yearly Part Bdeductible.

Pap Smear and Pelvic Examination: (Includes a clinical breast exam) Once every three years. Once every 12 months if

you are high risk for cervical or vaginal cancer,or if you are of childbearing age and have had anabnormal Pap Smear in the preceding three

years.

All women with

Medicare.

No coinsurance and no Part B

deductible for the Pap Smear(clinical laboratory charge). Fordoctor services and all other

exams, 20% of the Medicare-approved amount with no Part Bdeductible.

Prostate Cancer Screening:• Digital Rectal Examination - Once every 12

months.• Prostate Specific Antigen (PSA) Test -

Once every 12 months.

All men withMedicare age 50 andolder.

Generally, 20% of the Medicare-

approved amount after the yearlyPart B deductible.No coinsurance and no Part B

deductible for the PSA Test.

Shots (Vaccinations):• Flu Shot - Once every 12 months.

• Pneumonia Shot - One may be all you everneed, ask your doctor.

• Hepatitis B Shot - If you are at medium to high

risk for hepatitis.

All people withMedicare.

No coinsurance and no Part Bdeductible for flu and

pneumonia shots if the doctoraccepts assignment (see page100). For Hepatitis B shots, 20%

of the Medicare-approvedamount after the Part Bdeductible.

Mammogram Screening:Once every 12 months.

All women with

Medicare age 40 andolder.

20% of the Medicare-approvedamount with no Part B

deductible.

92 2000 Guide

DEFINITIONS OF IMPORTANT WORDS

* ACTIVITIES OF DAILY LIVING(ADL): Activities you usually do during anormal day. Although definitions differ,ADL’s are usually viewed as everydayactivities such as walking, getting in and outof bed, dressing, bathing, eating, and usingthe bathroom.

ASSIGNMENT: In the Original MedicarePlan, a process in which a doctor orsupplier agrees to accept the amountMedicare approves as full payment. Youmust pay any coinsurance amount.

BASIC (CORE) BENEFITS: Benefitsprovided in Medigap Plan A. They are alsoincluded in all the other Medigap plans.

BENEFIT PERIOD: The way that Medicaremeasures your use of hospital and skillednursing facility services. A benefit periodstarts the day you go to a hospital or skillednursing facility. The benefit period endswhen you haven’t received hospital orskilled nursing care for 60 days in a row. Ifyou go into the hospital after 60 days, a newbenefit period begins. You must pay theinpatient hospital deductible for eachbenefit period. There is no limit to thenumber of benefit periods you can have.

BENEFITS: The money or servicesprovided by an insurance policy. In a healthplan, benefits are the health care you get.

COINSURANCE: The percent of theMedicare-approved amount that you have topay after you pay the deductible for Part Aand/or Part B. In the Original MedicarePlan, the coinsurance payment is apercentage of the approved amount for theservice (like 20%).

* CONSOLIDATED OMNIBUS BUDGETRECONCILIATION ACT (COBRA) OF1985: COBRA is a law that requiresemployers with 20 or more employees tolet employees and their dependents keeptheir group health plan coverage for aperiod of time after they leave their grouphealth plan under certain conditions. Youmay have to pay both your share and theemployer’s share of the premium.

COORDINATION OF BENEFITSCLAUSE: A written statement that tellswhich health plan or insurance policy paysfirst if two health plans or insurancepolicies cover the same benefits. If one ofthe plans is Medicare, federal law maydecide who pays first.

COPAYMENT: In some Medicare healthplans, the amount you pay for each medicalservice, like a doctor visit. A copayment isusually a set amount you pay for a service.For example, this could be $5 or $10 for adoctor visit. Copayments may also be usedfor hospital outpatient services in theOriginal Medicare Plan later this year.

* This definition, whole or in part, was used with permission from Walter Feldesman, Esq.,Dictionary of Eldercare Terminology, 2000.

932000 Guide


CREDITABLE COVERAGE: Any previoushealth coverage that can be used to shortenthe pre-existing condition waiting period. (Seepre-existing conditions.)

CUSTODIAL CARE: Personal care, such asbathing, cooking, and shopping. This isusually not covered by Medicare.

DEDUCTIBLE (MEDICARE): The amountyou must pay for health care before Medicarebegins to pay, either each benefit period forPart A, or each year for Part B. These amountscan change every year. (see Benefit Period;Part A; Part B)

DURABLE MEDICAL EQUIPMENT(DME): Medical equipment that is ordered bya doctor for use in the home. These itemsmust be reusable, such as walkers,wheelchairs, or hospital beds. DME is paidfor under Medicare Part B, and you pay 20%coinsurance in the Original Medicare Plan.

* END-STAGE RENAL DISEASE (ESRD):Kidney failure that is severe enough to requirelifetime dialysis or a kidney transplant. ESRDpatients are eligible for Social Securitypayments if found to be disabled.

* EXCESS CHARGE (MEDIGAP): Thedifference between a doctor’s or other healthcare provider’s actual charge (which may belimited by Medicare or the state) and theMedicare-approved payment amount.

FISCAL INTERMEDIARY: A privatecompany that has a contract with Medicare topay Part A and some Part B bills. (Also called“Intermediary.”)

GAPS: The costs or services that are notcovered under the Original Medicare Plan.Also called Medicare gaps.

GUARANTEED ISSUE SITUATIONS:Certain situations involving health coveragechanges where you may have the right to buya Medigap policy in addition to your Medigapopen enrollment period.

GUARANTEED RENEWABLE: A Medigappolicy that your insurance company mustallow you to automatically renew or continue,unless you do not pay your premiums.

HEALTH CARE FINANCINGADMINISTRATION (HCFA):The federal agency that runs the Medicareprogram. In addition, HCFA works with theStates to run the Medicaid and StateChildren’s Health Insurance Program. HCFAworks to make sure that the beneficiaries inthese programs are able to get high qualityhealth care.

HOME HEALTH CARE: Skilled nursing careand certain other health care you get in yourhome for the treatment of an illness or injury.(See Activities of Daily Living.)

* This definition, whole or in part, was used with permission from Walter Feldesman, Esq.,Dictionary of Eldercare Terminology, 2000.

94 2000 Guide


LIFETIME RESERVE DAYS: Sixty days thatMedicare will pay for when you are in ahospital for more than 90 days. These 60reserve days can be used only once duringyour lifetime. For each lifetime reserve day,Medicare pays all covered costs except for adaily coinsurance ($388 in 2000).

LIMITING CHARGE: The highest amount ofmoney you can be charged for a coveredservice by doctors and other health careproviders who don’t accept assignment. Thelimit is 15% over Medicare’s approvedamount. The limiting charge only applies tocertain services and does not apply tosupplies and equipment.

LONG-TERM CARE: Custodial care givenat home or in a nursing home for people withchronic disabilities and lengthy illnesses.Long-term care is not covered by Medicare.

MEDICAID: A joint federal and stateprogram that helps with medical costs forsome people with low incomes and limitedresources. Medicaid programs vary from stateto state, but most health care costs arecovered if you qualify for both Medicare andMedicaid.

MEDICAL UNDERWRITING: The processthat an insurance company uses to decidewhether or not to take your application forinsurance, whether or not to add a waitingperiod for pre-existing conditions (if yourstate law allows it), and how much to chargeyou for that insurance.

MEDICARE: A federal health insuranceprogram for: people 65 years of age or older,certain younger people with disabilities, andpeople with End-Stage Renal Disease(permanent kidney failure requiring dialysisor a kidney transplant, sometimes calledESRD).

MEDICARE CARRIER: A private companythat contracts with Medicare to pay Part Bbills. (Also called “Carrier.”)

MEDICARE COVERAGE: Made up of twoparts: Hospital Insurance (Part A) andMedical Insurance (Part B).

MEDICARE PART A (HOSPITALINSURANCE): Hospital insurance that paysfor inpatient hospital stays, care in a skillednursing facility, home health care, andhospice care.

MEDICARE PART B (MEDICALINSURANCE): Medical insurance that helpspay for doctors’ services, outpatient hospitalcare, and other medical services that are notcovered by Part A.

MEDICARE SELECT: A type of Medigappolicy that may require you to use doctorsand hospitals within its network to be eligiblefor full benefits.

MEDIGAP: A Medicare supplemental healthinsurance policy sold by private insurancecompanies to fill “gaps” in Original MedicarePlan coverage. Except in Minnesota,Massachusetts, and Wisconsin, there are 10standardized policies labeled Plan A throughPlan J. Medigap policies only work with theOriginal Medicare Plan. (See Gaps.)

952000 Guide


OPEN ENROLLMENT PERIOD(MEDIGAP): A one-time only, six monthperiod after you enroll in Medicare Part Band are age 65 or older, when you can buyany Medigap policy you want. You cannotbe denied coverage or charged more dueto your health history during this time.

ORIGINAL MEDICARE PLAN: A pay-per-visit health plan that lets you go toany doctor, hospital, or other health careprovider who accepts Medicare. You mustpay the deductible. Medicare pays itsshare of the Medicare-approved amount,and you pay your share (coinsurance). TheOriginal Medicare Plan has two parts: PartA (Hospital Insurance) and Part B(Medical Insurance).

OUT-OF-POCKET COSTS: Health carecosts that you must pay on your own,because they are not covered by Medicareor other insurance.

PRE-EXISTING CONDITION(MEDIGAP): A health problem for whichyou got medical treatment or advicewithin 6 months before the date that anew insurance policy starts.

PREMIUM: The periodic payment toMedicare, an insurance company, orhealth care plan for health care coverage.

PREVENTIVE CARE: Care to keep youhealthy or to prevent illness, such ascolorectal cancer screening, yearlymammograms, and flu shots.

PRIMARY PAYER: The insurancecompany that pays first on a claim formedical care. This could be Medicare oranother insurance company.

MEDIGAP PROTECTIONS: Your rightsto buy a Medigap policy in certainsituations after your Medigap openenrollment period.

PROVIDER: A hospital, health careprofessional, or health care facility.

SECONDARY PAYER: The insurancecompany that pays second on a claim formedical care. This could be Medicare,Medicaid, or other health insurancedepending on the situation.

SKILLED NURSING FACILITY (SNF):A facility that provides skilled nursing orrehabilitation services to help you recoverafter a hospital stay.

WAITING PERIOD: The time betweenwhen you sign up with a Medigapinsurance company or Medicare healthplan and when the coverage starts.

96 2000 Guide

INDEX

Activities of Daily Living (ADL) ....................26, 80, 100Assignment..............8, 26, 62, 98, 100At-home Recovery ....................10, 26Attained-Age-Rated Policies ..........29Basic Core Benefits ....10, 23, 24, 100Benefit Period................8, 24, 97, 100Blood ....................................24, 97-98Claims........................................18, 62Coinsurance ....................8, 9, 99, 100Consolidated Omnibus Budget ReconciliationAct of 1985 (COBRA) ....................19, 70-72, 100Coordination of Benefits Clause........................69, 100Copayment ..............................97, 100Creditable Coverage....32, 38, 39, 101Custodial Care ..........................8, 101Deductible ................8, 10-11, 25, 101Department of Labor ......................68Durable Medical Equipment ........................ 97, 98, 101Employee Coverage..............19, 69-72Employer Group Health Plan ..........................16, 67-70End-Stage Renal Disease (ESRD) ......4, 17, 39, 59, 101Excess Charges..................10, 26, 101Explanation Of Medicare Benefits............................................62Federally Qualified Health Center ............................20, 77Fiscal Intermediary..................97, 101Foreign Travel Emergency ..10, 11, 25Free Look Period ......................32, 66Gaps ................................7-9, 20, 101

General Enrollment Period (Part B) ..................................5Group Health Coverage..............67-69Guaranteed Issue Rights ..........16, 101Guaranteed Renewable............64, 101Health Care FinancingAdministration (HCFA) ....81, 90, 101Home Health Care... 8, 26, 97-98, 101Hospice Care ..................................97Hospital Indemnity Insurance....................................20, 80Issue-Age-Rated Policies ..........28-29Large Group Health Plan ................73Lifetime Reserve Days ......24, 97, 102Limiting Charge ......................63, 102Long-Term Care Insurance ..............................20, 80-82Medicaid ..........................2, 20, 78-79Medical Underwriting ............30, 102Medicare Carrier ........18, 62, 98, 102Medicare Managed Care Plan ........................6, 16, 17, 42Medicare Medical Savings Account Plan ....................................2Medicare Part A (Hospital Insurance) ............4-6, 97, 102Medicare Part B (Medical Insurance)........4-6, 98-99, 102Medicare SELECT........9, 16, 23, 102Medicare Summary Notice..............62Medicare Supplemental Insurance ....9Medigap

over age 65............................36-39under age 65..........................39-40

Medigap Benefits Chart ..................10For Massachusetts ....................94For Minnesota............................95For Wisconsin ............................96

2000 Guide

INDEX

Medigap Compare ................1, 13, 27Medigap Protections ......15, 41-61, 69Mental Health Care ..................97, 98National Association of Insurance Commissioners ..................81No-Age-Rated Policies........................28Nursing Home Compare ....................82Occupational Therapy ..............4, 97, 98Open Enrollment Period(Medigap) ........14-16, 36-41, 73, 103Original Medicare Plan......2-9, 21, 53 Out-of-Pocket Costs ..........11, 68, 103PACE............16, 19, 42, 47-48, 60, 76Part A (Hospital Insurance) ......4, 6, 8, 10, 36Part B(Medical Insurance) ......4-6, 8, 10, 14Participation Agreement ..................62Physical Therapy ............4, 95, 97, 98Pre-Existing Condition ..14, 30, 32, 38-40, 46, 103Premium ..4-6, 25, 28-30, 65, 79, 103Prescription Drugs ......6, 9-12, 26, 72Preventive Care ........26, 77, 94-96, 99Primary Payer ....................72-73, 103Private Contract....................18, 63-64Private Fee-for-Service Plan ......2, 6-7Provider ............................23, 62, 103Railroad Retirement Board................5Regional Home Health

Intermediary ....................................97Religious Fraternal Benefit Plan ......................................2Retainer Agreement ........................35Retiree Coverage......19, 31, 68-69, 75Riders ........................................94-96Secondary Payer ................72-75, 103Skilled Nursing Facility Care ..4, 8, 10, 25, 80-81, 103Social Security Administration......5, 6Special Enrollment Period (Part B) ..................5-6, 67, 71Specified Disease Insurance......20, 80Standardized Medigap Plans..9-10, 23

For Massachusetts ....................94For Minnesota............................95For Wisconsin............................96

State Agencies on Aging ................91State Children’s Health Insurance Program ................................77State Health Insurance Assistance Program......13, 17, 23, 40, 47State Insurance Department ..10, 13, 17, 27, 32, 41-42State Medical Assistance Office ............................79TRICARE ........................................38Union Coverage ............19, 37, 67, 68Waiting Period ..................14, 32, 103www.medicare.gov ..........1, 13, 27, 76

U.S. DEPARTMENT OFHEALTH AND HUMAN SERVICESHealth Care Financing Administration7500 Security BoulevardBaltimore, Maryland 21244-1850

Official BusinessPenalty for Private Use, $300

Publication No. HCFA - 02110Revised March 2000

To get this 2000 Guide to Health Insurance forPeople with Medicare on audio-tape, in large type,or in braille, call 1-800-MEDICARE (1-800-633-4227, TTY/TDD: 1-877-486-2048 for the hearingand speech impaired).

¿Necesita usted una copia en Español o en audio-cassette del manual de La Guía de Seguro deSalud para personas con Medicare? (Llame al1-800-638-6833.)

Developed jointly by the Health Care Financing Administration of the U. S. Department of Health and Human Services and the National Association of Insurance Commissioners

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