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Medicare FAQs - Original Medicare and Medigap

1. What is Original Medicare?

Original Medicare includes Part A and Part B coverage. People who have Original Medicare and do not want to replace it with a Medicare Advantage plan can add prescription drug coverage with a Part D plan. Participants also can choose to buy a Medigap (Medicare supplement insurance) policy to help fill the gaps in Part A and Part B coverage.

2. What is Medigap?

The term Medigap, also known as Medicare supplement insurance, refers to insurance policies sold by private insurance companies to fill the "gaps" in Original Medicare coverage. An example of a gap would be the 20 percent coinsurance amount due on a Medicare Part B claim for a medical visit.

3. Who is eligible for Medigap?

If you have Medicare, you are also eligible for Medigap (though your Medigap options may be limited if you are under 65 and qualify for Medicare based on a permanent disability). You can only use a Medigap plan if you have Original Medicare. If you choose to use a Medicare Advantage plan instead, it is illegal for someone to sell you a Medigap policy.

4. When can I enroll in a Medigap plan?

Medigap coverage can be purchased at any time. However, if it is not purchased when you are eligible for the guaranteed issue right or during a special enrollment period, an insurance company can use medical underwriting, which means the company can decide whether or not to accept your application and set different terms, such as waiting periods and premiums.

5. When is the initial enrollment period for Medigap coverage?

For most, the initial enrollment Medigap period is the six-month period that begins on the first day of the month in which you turn age 65 or older AND enroll in Part B. For those under 65, the ability to purchase a Medigap policy varies by state.

6. What is medical underwriting?

Medical underwriting is the insurance company's ability to decide, based on pre-existing conditions, whether or not to accept your application, add a waiting period for coverage of pre-existing conditions, and/or how much to charge for insurance coverage.

7. What is a pre-existing condition?

A pre-existing condition is a health problem that you had before the new insurance policy starts. When applying the pre-existing condition clause, the insurance company can make you wait for coverage for any health problem. This period is called a waiting period and usually lasts six months. However, during this time, Original Medicare will cover this condition.

8. What if I apply for coverage during a time other than during my guaranteed issue or special enrollment period?

If you are applying for coverage outside a guaranteed issue or special enrollment period, you may be denied coverage or have to wait before a pre-existing condition is covered.

9. What are the guaranteed issue rights, or Medigap protections, for individuals interested in Medigap plans?

There are certain guaranteed issue rights, or Medigap protections, for individuals interested in Medigap plans. For example, you may purchase a Medigap policy when outside the guaranteed issue period if you are in a Medicare Advantage plan and are leaving the service area and you are going back to Original Medicare; if your employer group, retiree or COBRA coverage that supplements what Medicare pays is ending; if you move out of the Medicare SELECT (supplement insurance) plan's area; if the Medigap insurance company goes bankrupt; or you can demonstrate that the Medicare Advantage plan or Medigap plan you are currently in misled you.

10. What do I do if I want a Part D plan along with my Medigap coverage?

Your Medigap plan works to fill the gaps in Medicare and a Part D plan covers your prescription medications. They do not work together and most people have both.

11. Are there standardized Medigap plans?

Yes. There are standardized Medigap plans. They are identified by letters ranging from A through N.

12. Do any of the Medigap plans offer prescription drug coverage?

Yes. H, I and J policies purchased prior to January 2006 (the start of the Medicare prescription drug benefit, also called Part D) offer drug coverage. However, H, I and J plans purchased after January 1, 2006, do not offer drug coverage because those same drugs may be covered under Medicare Part D. If you have the old H, I or J plan and are considering a change, you should carefully evaluate your options to ensure that the coverage you choose is right for you.