* A licensed sales agent may call or e-mail as a result of completing the information to discuss Medicare Advantage, Prescription Drug Plans or Medicare Supplement Insurance.
Here at Ashford Insurance, we represent several of the major carriers for Texas Medicare Supplement plans (aka Medigap policies) and Medicare Part D drug plans. We will help you find the plan that suits your health care needs, and your financial budget as well.
Our goal at Ashford Insurance is to ensure you understand your options in the Medicare marketplace. We know that this can be a very tedious endeavor and every individual is different; having access to major carriers is the only way to determine what level of coverage will best suit your needs.
Medicare supplement insurance guide
Medicare is a federal health insurance program that pays most of the health care costs for people who are 65 or older. It will also pay for health care for some people under age 65 who have disabilities.
You can buy Medicare supplement insurance to help pay some of your out-of-pocket costs that Medicare won’t pay. Because it helps cover some of the “gaps” in Medicare coverage, Medicare supplement insurance is often called Medigap insurance.
Do you need a Medicare supplement?
Not everyone needs a Medicare supplement policy. If you have other health coverage, the gaps might already be covered. You probably don’t need Medicare supplement insurance if:
If you have other health insurance, ask your insurance company or agent how it works with Medicare.
Original Medicare has two parts. Part A covers hospital services and Part B covers other types of medical expenses. You may go to any doctor or hospital that accepts Medicare. Medicare supplement policies only work with original Medicare.
Medicare Part A (hospital coverage) pays for:
Medicare Part B (medical coverage) pays for
Medicare Part D (prescription drug coverage) pays for generic and brand-name prescription drugs. You can get prescription drug coverage by joining a stand-alone prescription drug plan or by buying a Medicare Advantage plan that includes drug coverage. If you have group health insurance, your health plan might already cover prescriptions. Ask your plan’s sponsor whether the plan has prescription drug coverage that is comparable to Medicare Part D.
Insurance companies approved by Medicare offer Part D coverage.
The Centers for Medicare and Medicaid Services (CMS) publishes the Medicare & You handbook that describes Medicare coverages and health plan options. CMS mails the handbook to Medicare beneficiaries each year. You can also get a book by calling 800-MEDICARE (800-633-4227).
Services Medicare doesn’t cover
What you pay with original Medicare
For Medicare parts A and B, you will usually pay monthly premiums, and deductibles, copays, and coinsurance. You also pay the full cost of any services that Medicare doesn’t cover.
Ask if your doctor ‘accepts assignment’
“Assignment” is an agreement between doctors and other health care providers and Medicare. Doctors who “accept assignment” charge only what Medicare will pay them for a service. You must pay any deductibles, coinsurance, and copayments that you owe.
Doctors who don’t accept assignment may charge more than the Medicare-approved amount. You are responsible for the higher charges. You also might have to pay the full cost of the service at the doctor’s office, and then wait to be reimbursed by Medicare.
Use your Medicare Summary Notice to review the charges. You get a Medicare Summary Notice each quarter. If you were overcharged and weren’t reimbursed, follow the instructions on the notice to report the overcharge to Medicare. The notice will also show you any deadlines to complain or appeal charges and denied services. If you are in original Medicare, you can also look at your Medicare claims online at MyMedicare.gov.
Medicare has a directory of doctors, hospitals, and suppliers that work with Medicare. The Physician Compare directory also shows which providers accepted assignment on Medicare claims.
Medicare Advantage plans
You might have the option to join a Medicare Advantage plan, also called Medicare Part C. To be eligible, you must have both Medicare parts A and B and live in an area that has a plan.
The federal government contracts with insurance companies and managed care plans to offer Medicare Advantage in certain areas. Medicare pays the plan a set amount each month for the plan to provide Medicare Parts A and B services to its members. You pay your monthly Medicare Part B premium and any premium the Medicare Advantage plan charges. You also must pay any copayments, deductibles, and coinsurance the plan requires.
If you are in a Medicare Advantage plan, you won’t get a Medicare Summary Notice. You’ll instead get monthly statements from your plan and you might be able to view your claims on the plan’s website.
Medicare Advantage options vary by ZIP code and county. The options available in Texas include:
Medicare Advantage plans usually have more benefits than original Medicare. For instance, some Medicare Advantage plans cover dental and vision services. However, Medicare Advantage might not be the best option for some people. Your choice of doctors and hospitals in a Medicare Advantage plan are limited. If you have other insurance, such as a group retirement plan, ask your group plan if it works with a Medicare Advantage plan or with original Medicare.
Because Medicare negotiates contracts with Medicare Advantage plans each year, the plans available and the benefits they provide can change each year. If your plan discontinues services, you will have to find a new plan in your area or return to original Medicare. To learn what plans are available in your area, call Medicare or visit the Medicare Plan Finder.
If your Medicare Advantage plan leaves your area, or if you move out of the plan’s service area, you may have the right to join another Medicare Advantage plan. You may also have the right to buy Medicare supplement plans A, B, C, F (including Plan F with a high deductible), K, or L, regardless of your medical history or condition.
If your Medicare Advantage plan ends, it must give you written notice of your options and tell you how long you have to buy a Medicare supplement policy. The written notice is your proof to the Medicare supplement company of your right to buy Medicare supplement. If you’re under age 65 and on Medicare, this right in Texas is limited to Medicare supplement Plan A.
Medicare’s open enrollment period for Medicare Advantage and prescription drug plans is October 15 to December 7.
Medicare will mail you a Medicare & You handbook each year before open enrollment. The handbook has a list of Medicare Advantage and prescription drug plans. Use the handbook to review whether there are any changes and costs in your Medicare Advantage or prescription drug plan.
The Texas State Health Insurance Assistance Program (SHIP) can help you compare plans and costs in your area. Call SHIP at 800-252-9240.
The Medicare open enrollment period doesn’t apply to Medicare supplement plans.
Medicare supplement insurance
Medicare supplement insurance fills in the gaps between what original Medicare pays and what you must pay out-of-pocket for deductibles, coinsurance, and copayments.
Medicare supplement policies only pay for services that Medicare says are medically necessary, and payments are generally based on the Medicare-approved charge. Some plans offer benefits that Medicare doesn’t offer, such as emergency care outside the United States.
Medicare supplement policies are sold by private insurance companies that are licensed by TDI. But Medicare supplement benefits are set by the federal government.
It’s best to buy Medicare supplement insurance during your six-month open enrollment period. Your open enrollment period begins when you enroll in Medicare Part B at age 65 or older. During this time, companies can’t refuse to sell you a policy because of your health history or condition. If you wait until after your open enrollment period, you might not be able to buy a policy if you have a preexisting condition.
Note: Your Medicare supplement policy is renewed automatically each year to ensure you have continuous coverage. If you drop your Medicare supplement policy, you may not be able to get it back, or you might not be able to buy a new policy.
Medicare Select is a type of Medicare supplement policy that usually requires you to use doctors and hospitals in the plan’s network for your routine care. If you use out-of-network hospitals — other than in an emergency — you’ll have to pay more of the cost.
If you move out of the plan’s service area, you have the right to buy a Medicare supplement policy that offers the same or fewer benefits as your current policy. You must buy the plan from the same company that provides your Select coverage. If you’ve had your Medicare Select policy for more than six months, you won’t have to answer medical questions.
The 10 standard Medicare supplement insurance plans
There are 10 Medicare supplement insurance plans. Each plan is labeled with a letter of the alphabet and has a different combination of benefits. Plan F has a high-deductible option. Plans K, L, M, and N have a different cost-sharing component.
Every company must offer Plan A. If they offer other plans, they must offer Plan C or Plan F.
The 10 Medicare supplement plans (plans A, B, C, D, F, G, K, L, M, and N) provide these benefits:
This chart summarizes the benefits provided by each plan: Standard Medicare Supplement Insurance Plans.
Keeping your coverage if you move
If you are moving to another county or state, make sure your Medicare plan will still be in effect after you move.
If you have original Medicare, federal rules usually allow you to keep your Medicare supplement policy. There are exceptions to this if you have a Medicare Select plan or if you have a plan that includes added benefits, such as vision coverage or discounts that were available only where you bought the plan.
If you have a Medicare Advantage plan, ask the plan whether it’s available in your new ZIP code. If the plan isn’t available, you’ll have to get a new one. You can switch to another Medicare Advantage plan in your new area or to original Medicare.
Alternatives to Medicare supplement insurance
Before buying a Medicare supplement policy, find out whether there are other options for paying your Medicare out-of-pocket costs. The following plans and programs might help you pay costs.
Employee group plans
If you stay at your job after you become eligible for Medicare and you still have health insurance through your job, you probably don’t need Medicare supplement insurance. The same is true if you have health coverage through a spouse’s employer health plan.
Some employers offer their retirees coverage through a group Medicare supplement policy or a Medicare Advantage plan. Because health plans work differently, ask your employer’s benefits coordinator how well the plan covers the gaps in Medicare coverage. Then make a decision about Medicare supplement insurance.
COBRA coverage from an employer plan
Federal and state law allows people who leave their jobs to continue their employer-sponsored health coverage for a period of time. Be aware of the following:
Talk to your employer about COBRA and Medicare eligibility.
Medicaid is a state and federal program that pays for health coverage for people with low incomes. If you qualify for Medicaid, the state will pay your Medicare premiums and out-of-pocket costs. Medicaid will also pay for some services not covered by Medicare. If you have Medicaid, you don’t need Medicare supplement insurance.
Medicare savings programs
Medicaid-sponsored Medicare savings programs pay Medicare premiums, deductibles, and coinsurance for people who qualify. These programs allow people to use their savings to cover other expenses or to buy more coverage.
The Medicare savings programs are:
The federal QMB program pays the Medicare Part B premium and covers all Medicare deductibles and copayments. You don’t need Medicare supplement insurance if you are in the QMB program.
The other Medicare savings programs pay either the Medicare Part A or Part B premiums. You might need a Medicare supplement policy to help cover your other expenses.
Open enrollment for people age 65 and older
The open enrollment period for Medicare supplement plans is a six-month period during which you may buy any Medicare supplement plan offered in Texas. During this period, companies must sell you a policy, even if you have health problems. The open enrollment period begins when you enroll in Medicare Part B. You must have both Medicare parts A and B to buy a Medicare supplement policy.
You can use your open enrollment rights more than once during this six-month period. For instance, you may change your mind about a policy you bought, cancel it, and buy any other Medicare supplement policy.
Although a company must sell you a policy during your open enrollment period, it may require a waiting period of up to six months before it starts covering your preexisting conditions.
Preexisting conditions are conditions for which you received treatment or medical advice from a doctor within the previous six months.
Open enrollment for Texans with disabilities
People under age 65 who get Medicare because of disabilities have a six-month open enrollment period beginning the day they enroll in Medicare Part B. This open enrollment right only applies to Medicare supplement Plan A.
Note: People who have Medicare because of disabilities have another open enrollment period during the first six months after turning 65.
Guaranteed issue right
You may have the right to buy a Medicare supplement policy outside of your open enrollment period if you lose certain types of health coverage. This is called “guaranteed issue”.
For people over age 65, the guaranteed issue right applies to Medicare supplement plans A, B, C, F (including Plan F with a high deductible), K, and L.
Texans under age 65 with disabilities who enroll in Medicare Part B have guaranteed issue rights, but only for Medicare supplement Plan A.
People who lose Medicaid because of a change in their financial situation also have a guaranteed issue right to buy a Medicare supplement policy.
The guaranteed issue right is good for 63 days from the date coverage ends or from the date of notice that coverage will end, whichever is later. Companies may not place any restrictions, such as preexisting condition waiting periods or exclusions, on these policies. You must provide the company with proof that you lost coverage. Usually, people do this with a letter from the company notifying them that their coverage will end.
For more information about your guaranteed issue right, read Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare.
30-day ‘free look’
You can return your Medicare supplement policy within 30 days and get your money back with no questions asked. Keep a record of the date you received the policy. Read the policy when you get it. If you return the policy to the company, use certified mail with a return receipt to prove that it was returned within the 30-day time limit.
The 30-day “free look” period doesn’t apply to Medicare Advantage. If you drop Medicare supplement to join a Medicare Advantage plan, you may not be able to get your Medicare supplement policy back.
Renewing your policy
All Medicare supplement policies are “guaranteed renewable.” This means that a company may not cancel your policy or refuse to renew it unless you made intentionally false statements on your application or you didn’t pay your premium.
An insurance company may raise your premium once a year. If you have an attained-age policy, a company may also raise your premium on your birthday.
Suspending a policy
If you become eligible for Medicaid, you may ask that your Medicare supplement benefits and premiums be suspended for up to two years. You must notify your company within 90 days of becoming eligible. If you lose your Medicaid eligibility, the policy will automatically be reinstated.
If you lose Medicaid eligibility within two years and want to reinstate your Medicare supplement policy, you must contact your company within 90 days of losing eligibility. After two years, you’ll have to reapply with the company if you want to reinstate your policy.
Doctors who take Medicare must submit Medicare claims to the Medicare claims contractor for you. If you get a bill, review your Medicare Summary Notice and what your company paid to see if you owe anything.
Medicare supplement policies pay only for services that Medicare considers medically necessary. If Medicare denies a claim, you have the right to appeal the decision. The appeals process and deadline to request an appeal are described in your summary notice.
Texas law requires insurance companies to pay claims promptly. If your Medicare supplement company refuses to pay a claim for a Medicare-approved charge or delays payment of your claims, you, your doctor, or your hospital may file a complaint with TDI.
Agents and companies are breaking the law if they do any of these things:
If you believe that an agent or company has engaged in unfair and illegal practices, file a complaint with TDI.
Agencies that can help
Medicare (Medicare eligibility and benefits questions or information about Medicare Advantage plan options)
Texas Health and Human Services (talk to the Area Agencies on Aging to learn about your Medicare options)
Texas Legal Services Center (information about your rights and public assistance benefits)
Texas Health and Human Services Office of the Ombudsman (information about Medicaid or Medicare savings programs)
Question? Call us at 817-952-3153.
Sarah began working in the healthcare industry in 2001, where she worked for many years with elderly Alzheimer and Dementia patients. From there she worked as a Group Benefits Administrator with a local healthcare company in the Human Resource Department for a period of 10 years. Since then, she has decided to work in the Medicare insurance industry full time and has joined the family business, Ashford Insurance, as a Medicare Insurance Agent.
Need help? Call us for an appointment at (817) 952-3153
* A licensed sales agent may call or e-mail as a result of completing the information to discuss Medicare Advantage, Prescription Drug Plans or Medicare Supplement Insurance.