Medicare Supplement Insurance is also called Medigap insurance. As the name suggests, it exists as supplemental coverage to Original Medicare (Medicare Part A and B) in Texas. Medigap supplements Original Medicare by paying the healthcare costs that Original Medicare does not cover. These out-of-pocket costs include deductibles, copayments, and coinsurance. Medicare-approved private insurance companies sell Medicare supplement plans. Enrollees pay monthly premiums directly to the insurance carrier.
Medigap is available only to Original Medicare enrollees. Medigap cannot be used with Medicare Advantage Plans.
Medicare supplement insurance, also called Medigap, is health coverage purchased as an add-on to cover gaps in Original Medicare by paying out-of-pocket costs. These out-of-pocket costs include deductibles, coinsurance, and copayments. Medigap is available to Original Medicare enrollees only. Private insurance companies licensed by Medicare sell Medigap plans in Texas.
Other things to note about Medigap in Texas include:
Although private companies sell Medigap and Medicare Advantage plans, there are significant differences. Medigap insurance is supplemental and fills gaps by paying out-of-pocket expenditures connected with Original Medicare. Medicare Advantage plans replace Original Medicare and often give additional coverage. You can pick between the two, but you cannot have a Medigap policy and a Medicare Advantage plan.
If you are under a Medicare Advantage plan, you have to use the medical professionals in the plan’s network to get coverage. Medigap enrollees can use any medical professional that accepts Medicare. Furthermore, Medicare Advantage enrollees usually need a referral from their primary care doctor to see a specialist. However, if you have a Medigap plan, you do not need any referral from your primary care doctor to see a specialist.
Many Medicare Advantage plans include prescription drug coverage, while with Medigap, you have to purchase separate prescription drug coverage (Part D).
Medigap and Medicare Supplement Insurance are the same thing, just used interchangeably to describe health coverage that supplements the gaps in Original Medicare.
The purpose of Medigap is to provide extra health coverage to cover the out-of-pocket costs that Original Medicare does not cover. These costs include deductibles, coinsurance, and copayments. Some plans also cover medical costs when you travel outside the U.S. Medigap coverage does not include services relating to long-term care, dental care, vision care, hearing aids, eyeglasses, and private-duty nursing. The majority of Medigap plans also do not provide prescription coverage.
It is only available to Original Medicare enrollees, not Medicare Advantage enrollees.
Medigap insurance covers all or part of the expenses that Original Medicare enrollees would normally have to pay out of pocket. Because while Original Medicare (Medicare Parts A and B) provides comprehensive health coverage, there are still out-of-pocket expenses that beneficiaries have to handle. Medigap policies cover these out-of-pocket costs. It does not provide care that is not covered by Medicare and must be paid entirely by the enrollee. Thus, since Original Medicare does not cover or offer routine dental, hearing, and vision services, Medigap does not cover the costs of such services.
Medigap covers out-of-pocket costs like deductibles, coinsurance, and copayments that apply to Medicare Parts A and B. Medicare Part A deductible is $1,556 for every benefit period, and Part B deductible is $233. After paying deductibles, Medicare Part B covers 80% of the Medicare-approved cost, and the beneficiary will pay the remaining 20%. Part A also has a coinsurance that begins to accrue after 60 days in the hospital. There is a coinsurance charge under Part A for skilled nursing facility stays of more than 20 days ($185.50 per day for days 21 through 100 in 2021). Part A and Part B have no limit on how much an enrollee can spend on out-of-pocket expenses.
Essentially, Medicare beneficiaries are protected from the deductibles and coinsurance charges mentioned by Medigap plans, which fill the “gap” in Medicare.
Apart from these out-of-pocket costs, Medigap plans can cover your healthcare costs when you travel outside of the U.S.
There are ten plan types available in Texas, with each plan labeled after a letter that corresponds with a certain level of basic benefits. These plans are standardized; they all provide the same basic benefits. Some plans offer additional benefits. So, a policyholder can decide which one meets their needs. Insurance providers can only sell Medigap standardized policies identified by the approved letters to enrollees.
The ten Medigap plans available to Texas residents are plans A, B, C, D, F (it has a high-deductible option), G (it has a high-deductible option), K, L, M, and N. Plans E, H, I, and J are no longer available to new subscribers. The existing plans provide the following benefits:
The additional benefits provided by some of these plans are below:
Generally, if you are an Original Medicare enrollee, you may consider using Medigap to handle your out-of-pocket costs. However, not every Original Medicare enrollee needs a Medigap policy. Persons with additional health coverage can use their health plans to cover the gaps in coverage of Original Medicare. You might not need a Medigap plan if:
To help you determine if you need Medigap, speak with a knowledgeable health insurance agent who has access to multiple Medicare insurers.
In 2020, over 4.2 million of Texas residents were covered by Medicare insurance, with over 2.5 million covered by Original Medicare. Original Medicare in Texas (Medicare Parts A and B) is not a blanket insurance plan. This means that it does not cover everything that an enrollee might need in the form of services and costs. Particularly, you will still have to cover a part of the cost of services through deductibles, coinsurance, and copayments. These costs seem basic on paper, but they could accumulate to a heavy medical bill when you experience a serious illness or get injured. This is where Medicare supplement insurance becomes useful. Depending on the type of plan, it covers the payment of these out-of-pocket costs fully or in part.
If you are an Original Medicare enrollee or you qualify for Medicare coverage, you should speak to a licensed health insurance agent in Texas to know if you need Medigap insurance.
Trying to decide how much Medigap, or any other health insurance, you need in Texas depends on your income and how much coverage you need. Most Medigap plans have similar benefits, but their premium costs differ based on the insurance provider. Thus, when searching for a plan, ensure that you compare insurance companies providing the same plan type.
Generally, Medigap Plan F is considered the most comprehensive and popular plan. It costs between $117 to $903, depending on your age, sex, health status, and when you buy. There is also a high deductible option with premiums ranging from $34 to $367 depending on your age, sex, health status, and when you buy. However, it is not available to persons that qualified for Medicare coverage after January 1, 2020.
The second most comprehensive plan is Medigap Plan G. Premium costs for a Plan G policy range from $96-$924, depending on your age, sex, health status, and when you buy. It also has a high deductible option, ranging from $29-$180 depending on your age, sex, health status, and when you buy.
Medicare provides enrollees with a portal that can be used to compare Medigap costs by providing your zip code. It would be best to discuss your insurance options with a knowledgeable state-licensed health insurance agent. They can help you decide how much insurance coverage you need based on your situation.
To qualify for Medigap, you must first be an Original Medicare enrollee. An Original Medicare enrollee can buy a Medigap plan from any Medicare-approved insurance company in Texas within the enrollment period. There are ten standardized plans. They all provide the same basic benefits, while some provide additional benefits. These benefits cover many out-of-pocket costs from services and treatment received under Original Medicare, like copayments, coinsurance, and deductibles.
If you are enrolled under Original Medicare and purchase a Medigap policy, Medicare will first pay a portion of the Medicare-approved amounts for covered medical expenses. After that, your Medigap policy will cover the rest, in line with the benefits of your Medigap plan.
You pay monthly premiums for Medigap plans directly to your insurance provider and pay your monthly Part B premium to Medicare.
Some Medigap policies cover services that Original Medicare does not, like medical care when traveling outside the U.S. However, Medigap does not cover services like long-term care, vision or dental services, hearing aids, eyeglasses, or private-duty nursing.
Medigap mostly covers out-of-pocket costs that you are required to cover as an Original Medicare enrollee. These costs, like deductibles, coinsurance, and copayments, come from receiving inpatient and outpatient services under Original Medicare.
Some Medigap plans provide additional services like medical coverage when their beneficiaries travel outside the U.S.
Medigap plans only cover the individual named under the policy. There are no plans that cover couples or households. Discuss your coverage needs with a knowledgeable health insurance agent licensed in Texas.
Medigap works best as an add-on to Original Medicare to handle the coverage gaps by paying out-of-pocket costs like copayments, coinsurance, and deductibles. In addition, some Medigap plans available on the Texas market provide emergency medical benefits during foreign travel for beneficiaries.
Most beneficiaries of Original Medicare tend to get a Medigap plan to help cover their out-of-pocket costs. Because Original Medicare has annual limits on out-of-pocket costs, the insured purchase supplemental insurance (Medigap) to handle their copays, coinsurance, deductibles, and even costs related to insurance while traveling outside the U.S.
Medigap insurance provides individual coverage. That is, it covers the individual under the plan only. A married couple cannot be under the same Medigap plan. They have to buy separate Medigap plans if they need Medigap coverage.
Most Medigap plans cover out-of-pocket costs arising from Original Medicare services in different ways. They cover at least some part, if not all, of:
In addition, some Medigap policies include coverage for:
An assignment is a contract between doctors and other healthcare professionals and Medicare. It means that a healthcare professional agrees or is required by law to accept the Medicare-approved amount as full payment for services provided to a Medicare enrollee. If a healthcare professional accepts an assignment:
An inventory of doctors, hospitals, and suppliers who deal with Medicare can be found on the Medicare website. Also, the Physician Compare directory displays which doctors received Medicare claim assignments.
Some healthcare professionals do not accept assignments. They are called “non-participating.” These professionals can choose to charge more than the Medicare-approved price. This means increased costs for Medicare beneficiaries when they receive treatments or services from these non-participating professionals. When a beneficiary encounters this, they may have to pay the entire cost charged at the time of the service. Then, submit a claim to Medicare for any Medicare-covered service to reimburse them.
Note that while a non-participating provider can charge more than the Medicare-approved amount, they cannot charge more than the limiting charge.
No. Since 2006, Medigap plans have stopped providing prescription drug coverage. If you want prescription drug coverage (Part D), you have to join a stand-alone prescription drug plan or buy a Medicare Advantage plan that offers prescription drug coverage.
Medigap does not cover the following:
Generally, all Medicare beneficiaries have three major coverage options:
Original Medicare enrollees mostly use Medigap to cover the out-of-pocket costs when they receive services or supplies under their Original Medicare coverage. These out-of-pocket costs include deductibles, copayments, and coinsurance.
With approximately 2.5 million Texas residents using Original Medicare in 2020, based on nationwide usage of 30%, around 750,000 of them used Medigap as a supplemental coverage. This was a significant boost compared with just five years earlier, when just 25% of Americans used it. As the baby boomer population ages, this trend is expected to grow, possibly surpassing 40% by 2030.
If you have questions on whether you need Medigap insurance, it is always best to consult with a knowledgeable and state-licensed health insurance agent who deals with Medicare coverage, has access to multiple insurers, and can discuss all Medicare insurance options. An experienced agent can assess your specific Medicare insurance needs, suggest the possible options, and explain to you in what way each option benefits you. Here’s is a quick FAQ:
You do not need a Medigap plan if you have a Medicare Advantage Plan. It is unlawful for someone to sell a Medigap plan to you if you have a Medicare Advantage Plan unless you want to move back to Original Medicare.
You cannot have Medigap insurance if you have Medicaid. Federal law prohibits the sale of Medigap plans to dual-eligible persons. These are persons that have Medicare and Medicaid coverage. The only exceptions are when:
It depends. A Medicare Advantage beneficiary does not need Medigap. If you are enrolled under Original Medicare, your need for Medigap is based on whether you already have additional coverage or not. If you have additional coverage, you may not need Medigap because your additional coverage will fill the gaps in your Original Medicare coverage. This additional coverage could be from Medicaid, or it may be employer-sponsored. However, if you do not have additional health coverage, you need Medigap to supplement your Original Medicare coverage.
You can use Medigap to fill the “gaps” of your Original Medicare. Because although Original Medicare will cover most of the cost of services and supplies, you will be responsible for the rest of the cost. These costs come in the form of deductibles, copays, and coinsurance, which are generally called out-of-pocket costs. If you buy a Medigap plan, it will handle most of your out-of-pocket costs. Private insurance carriers sell Medigap policies. There are ten different types of standardized Medigap plans. The cost of Medigap coverage varies depending on the type of plan, where you live, and who sells the plan. Medigap insurers determine premiums based on age, sex, health status, and when the plan is bought.
Once you enroll, your Medigap coverage begins on the first day of the month after you signed up.
If you intend to buy a Medigap plan, you should buy it during any of the enrollment periods. Because you will be able to get a Medigap policy at the same price a person in good health pays. Buying a Medigap policy outside this window can lead to uncertainty about whether you will be able to get coverage. And even if you get coverage, it may cost more.
Basically, Medigap insurance is available for every Original Medicare beneficiary in Texas. However, if you have an additional health insurance plan, you may not need Medigap because your additional health coverage may cover your Original Medicare coverage gaps. This additional health coverage could be from a former or current job or Medicaid.
If you are an Original Medicare enrollee or you intend to sign up for Original Medicare, you should speak to a licensed health insurance agent in Texas. They can advise you on whether you can get Medigap insurance.
You qualify for Medigap if you sign up for Original Medicare in Texas.
It is not every Original Medicare enrollee that needs Medigap Insurance. Only those that do not have extra health coverage to fill in the gaps of their Original Medicare coverage need Medigap. If you do not have Medicare Advantage but have Original Medicare, without any supplemental insurance to help take care of deductibles, copays, and other expenses - you most likely need Medigap.
In 2020, there were over 4.2 million Medicare enrollees in Texas, with over 2.5 million Original Medicare enrollees. Since Original Medicare does not have a limit on out-of-pocket costs, most enrollees get some form of supplemental coverage in the form of employer-sponsored insurance or Medicaid. For those that do not have either, they get Medigap plans. These supplemental coverage plans save Original Medicare enrollees from the likelihood of incurring high medical expenses. Texans that do not have supplemental coverage are more likely to incur excessive medical costs or forgo medical care owing to financial constraints.
You should get Medigap if you are an Original Medicare enrollee and need a plan to cover your out-of-pocket costs.
There are no particular direct alternatives to Medicare Supplement insurance. However, there is an alternative to Original Medicare (the comprehensive health plan that Medigap supplements). The alternative is Medicare Advantage, which offers the same services as Original Medicare, and it can include the benefits of Medigap and prescription drug coverage (Part D). In 2020, 41% of Texans who qualified for Medicare coverage chose Medicare Advantage over Original Medicare with or without the accompanying supplemental Medigap policy.
Let’s first look at the benefits of Medigap insurance below:
Although it is a government health program, Medicare in Texas is not free. Enrollees still pay premiums and other out-of-pocket costs. Getting a Medigap plan to cover the out-of-pocket costs can save you a lot of money on healthcare costs in the long run. Many people consider the peace of mind and financial security that comes with a Medigap plan to be well worth the investment.
Also, Medigap plans are accepted anywhere Medicare Assignment is accepted. This is approximately 96% of the healthcare providers and institutions in the United States. Consequently, you will be able to keep your current providers and identify professionals around your area easily.
Generally, you should consider your healthcare requirements and your financial circumstances. While many people can benefit from a Medicare Supplement plan, others may find that a Medicare Advantage plan is more appropriate. A licensed and knowledgeable health insurance agent in Texas should be able to guide you in picking which one is better for you.
If you have Original Medicare coverage and do not have Medigap, you will have to cover your out-of-pocket costs yourself. Unless you have additional coverage that will cover such costs. If you have Medicare Advantage, you do not need (and cannot use) Medigap.
It is always better to be safe than sorry when it comes to your health. Having only Medicare may not be sufficient to protect you from expensive medical bills. Medicare covers only a part of your medical expenses. As a result, you will be responsible for the balance of the cost, and any unpaid deductibles or copayments. The best solution is to purchase a separate plan that will cover your medical expenses. This is what Medigap covers.
To find the best Medigap coverage for you, speak to a licensed health insurance agent in Texas.
If your Medigap insurance lapses, you lose coverage. Your Medigap insurance will lapse when you fail to pay your payments after receiving sufficient notice and the grace period. In Texas, the Medigap grace period is normally three months. In the absence of lapsed Medigap coverage, you will be liable for all the charges that Original Medicare does not cover.
To answer your Medicare questions, speak with a knowledgeable Texas-licensed health insurance agent who has access to multiple insurers and plans.