eHealth Medicare contains information about and access to insurance plans for people who are eligible for Medicare. It is operated by eHealthInsurance Services, Inc., a licensed health insurance agency certified to sell Medicare products.
This is not a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE or consult www.medicare.gov (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
What is Medigap?
Need help paying your Medicare deductibles, copayments and coinsurance? A Medigap insurance policy (also called Medigap supplemental insurance or Medicare supplemental plans) helps pay the "gap" between what Original Medicare (Medicare Parts A and B) pays for your health care and what you pay out of your own pocket.
Medicare Supplement in 2012
What Med Supp Plans Cover
Med Supp Benefits
A
B
C
D
F*
G
K
L
M
N
Source: CMS.gov
Medicare Part A Coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up
Medicare Part B Coinsurance or Copayment
50%
75%
***
Blood (First 3 Pints)
50%
75%
Part A Hospice Care Coinsurance or Copayment
50%
75%
Skilled Nursing Facility Care Coinsurance
50%
75%
Medicare Part A Deductible
50%
75%
50%
Medicare Part B Deductible
Medicare Part B Excess Charges
Foreign Travel Emergency(Up to Plan Limits)
Out-of-Pocket Limit**
$4,660
$2,330
* Plan F also offers a high-deductible plan. If you choose this option, this means you must pay for Medicare-covered costs up to the deductible amount of $2,070 in 2012 before your Medigap plan pays anything.
** After you meet your out-of-pocket yearly limit and your yearly Part B deductible ($140 in 2012), the Medigap plan pays 100% of covered services for the rest of the calendar year.
*** Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that don't result in an inpatient admission.
Plans D and G effective on or after June1, 2010, have different benefits than D or G Plans bought before June1, 2010.
Plans E, H, I, J will no longer be available to buy. If you already have or you buy Plan E, H, I, or J before June 1, 2010, you can keep that plan. Contact your plan for more information.
Medicare Advantage vs. Medigap comparison chart
Comparison
Medicare Advantage
Medicare Supplement
Source: Oregon.gov DCBS SHIBA
Eligibility
Must have Parts A and B, and live in service area. Takes all applicants except those with End Stage Renal Disease (some exceptions).
Must have Parts A and B. Usually companies may deny, but must accept all applicants, all ages, during Medigap Open Enrollment and Guaranteed Issue periods.
All plan members pay same premium regardless of age,gender, or health. Cost sharing (copays) must be paid for most medical services. Many plans have an out-of-pocket annual maximum.
Premium varies with gender and health and goes up with age. Companies may underwrite (add to premium). Generally, no copay costs at time of service. No out-ofpocket maximum.
Provider choice and availability (Always ask your providers what insurance they accept!)
HMOs and PPOs maintain provider network; they must have available providers in order to accept new members. PFFS has no provider network; it may be hard to find providers who accept it in some areas. HMO: Generally covers in-network only. Referrals may be required for specialist visits. PPO: Covers out of network, but then costs may be higher. No referrals required.
No network: Go to any provider that accepts Medicare. No referrals required for specialist visits.
May be hard to find providers accepting Original Medicare in some areas.
May be used for treatments at major medical facilities, such as Mayo Clinics, OHSU, etc.
Prescription drug coverage (Make sure your choice covers your Rx!)
If you want Rx coverage, you must enroll in the included Rx coverage if choosing an HMO or PPO. (VA-eligible excepted.)
With PFFS, you may choose either the plan's Rx coverage, if offered, or a stand-alone PDP.
Not included. If you want Rx coverage, you may enroll in any stand-alone (PDP) plan available.
Renewable?
No, benefits may change yearly. However, you usually remain in a plan unless you disenroll at election times.
Yes, guaranteed renewable as long as you pay the premium and the application was correct. Benefits never change. No election season for Medigaps.
Extras?
Some plans include routine dental, vision, or physicals. Some offer additional alternative medicine package.
Covers only same as Original Medicare. No routine dental, vision, or physicals; no alternative medicine.
Whom it may be best for
Network plans may be good for people who otherwise can't find a Medicare provider. May save money unless you need frequent appointments or treatments.
Having a packaged plan may simplify choices.
Good for travelers or "snow birds". May save money for people needing high-cost or frequent care. Customize elements of your Medicare picture-choose doctors and drug plan.
How to comparison shop: Use pages inGuide (and/or call SHIBA!)
Plans are not standardized -use comparison pages in this Guide or at www.medicare.gov. Plans are regulated by Medicare/CMS; sales agents are licensed by OID.
Because Medigaps are standardized, price and customer service are the only difference. Try calling a few competitively priced plans. Regulated by Oregon Insurance Division (OID).
What is Medigap?
Medigap, also known as Medicare Supplement Plans or Medicare Supplemental Insurance, is health insurance that you can buy from a private company to pay for health care expenses that are not covered by Original Medicare (Medicare Part A and B). The term Medigap is derived from the idea that these particular plan's functions is to bridge the "gap" between what Original Medicare pays for your healthcare and what you pay out of pocket (such as copays and deductibles).
When can you enroll for Medicare Supplemental Insurance?
Open enrollment for Medigap supplemental insurance begins the first month you are covered under Medicare Part B. You then have six months to enroll. If you are under 65, check with your state's Social Security Administration to see if they offer additional open enrollment periods.
As long as you enroll during this six-month open enrollment period, the insurance company cannot refuse to sell you a Medigap policy, charge you more because you have health problems, or make you wait for coverage to begin. You may, however, have to wait up to six months for coverage of a pre-existing condition. That means, if you have a specific health problem when you enroll, you may have to wait up to six months to be covered for medical services associated with that health problem. Original Medicare will still cover that health problem even if your Medicare supplement plan doesn't cover your out-of-pocket costs.
If you do not enroll in a Medicare supplemental plan during your open enrollment period, then the private insurance company may "underwrite" the plan. That means you may be subject to a physical, and the insurance company can either refuse to sell you the plan or they can adjust your premium based on your health status.
What is the difference between Medicare Advantage and Medicare Supplement?
A Medigap plan is different from a Medicare Advantage Plan (Medicare Part C) because Medicare Advantage plans offer a way to get Medicare Benefits instead of going the Original Medicare (Part A and Part B) route and Medigap is designed to supplement your Original Medicare benefits.
Bear in mind that you can get a Medigap plan only if you have Medicare Part A and B. So if you are on a Medicare Advantage Plan or a Prescription Drug Plan (Medicare Part D) or any other private health insurance, Medicaid, Veteran's benefits or Tricare, you will not be able to join a Medigap plan.
What are some health care costs NOT covered by Medicare?
Original Medicare doesn't cover everything. For example, it doesn't cover cosmetic surgery, health care you get while traveling outside of the United States (except in limited cases), hearing aids, most hearing exams, long-term care (like care in a nursing home), most eyeglasses, most dental care and dentures, and more. Generally, Original Medicare does not cover prescription drugs, although it does cover some drugs in limited cases such as immunosuppressive drugs (for transplant patients) and oral anti-cancer drugs. Some of these services not covered by Original Medicare may be covered by a Medicare Advantage Plan (like an HMO or PPO).
Eligibility for Medicare Part C
Medicare Part C eligibility is based on your membership in or eligibility for Medicare Parts A and B (except if you have End Stage Renal Disease (ESRD)). Generally, if you have Medicare Parts A and B, you are eligible for Medicare Part C. However, you must live in the service area for the Medicare Advantage Plan that you're considering. The service areas may be more limited than Original Medicare.
If you have other health insurance coverage, for example through an employer or union, find out their rules before you enroll in a Medicare Advantage Plan. You may lose your other coverage if you enroll in the Medicare Advantage Plan. But that's not a hard and fast rule. It's best to talk it over with the other plan's benefits administrator. If you drop the other plan, you might not be able to get it back if you change your mind later.
Medicare Advantage vs. Medigap comparison chart
Comparison
Medicare Advantage
Medicare Supplement
Source: Oregon.gov DCBS SHIBA
Eligibility
Must have Parts A and B, and live in service area. Takes all applicants except those with End Stage Renal Disease (some exceptions).
Must have Parts A and B. Usually companies may deny, but must accept all applicants, all ages, during Medigap Open Enrollment and Guaranteed Issue periods.
All plan members pay same premium regardless of age,gender, or health. Cost sharing (copays) must be paid for most medical services. Many plans have an out-of-pocket annual maximum.
Premium varies with gender and health and goes up with age. Companies may underwrite (add to premium). Generally, no copay costs at time of service. No out-ofpocket maximum.
Provider choice and availability (Always ask your providers what insurance they accept!)
HMOs and PPOs maintain provider network; they must have available providers in order to accept new members. PFFS has no provider network; it may be hard to find providers who accept it in some areas. HMO: Generally covers in-network only. Referrals may be required for specialist visits. PPO: Covers out of network, but then costs may be higher. No referrals required.
No network: Go to any provider that accepts Medicare. No referrals required for specialist visits.
May be hard to find providers accepting Original Medicare in some areas.
May be used for treatments at major medical facilities, such as Mayo Clinics, OHSU, etc.
Prescription drug coverage (Make sure your choice covers your Rx!)
If you want Rx coverage, you must enroll in the included Rx coverage if choosing an HMO or PPO. (VA-eligible excepted.)
With PFFS, you may choose either the plan's Rx coverage, if offered, or a stand-alone PDP.
Not included. If you want Rx coverage, you may enroll in any stand-alone (PDP) plan available.
Renewable?
No, benefits may change yearly. However, you usually remain in a plan unless you disenroll at election times.
Yes, guaranteed renewable as long as you pay the premium and the application was correct. Benefits never change. No election season for Medigaps.
Extras?
Some plans include routine dental, vision, or physicals. Some offer additional alternative medicine package.
Covers only same as Original Medicare. No routine dental, vision, or physicals; no alternative medicine.
Whom it may be best for
Network plans may be good for people who otherwise can't find a Medicare provider. May save money unless you need frequent appointments or treatments.
Having a packaged plan may simplify choices.
Good for travelers or "snow birds". May save money for people needing high-cost or frequent care. Customize elements of your Medicare picture-choose doctors and drug plan.
How to comparison shop: Use pages inGuide (and/or call SHIBA!)
Plans are not standardized -use comparison pages in this Guide or at www.medicare.gov. Plans are regulated by Medicare/CMS; sales agents are licensed by OID.
Because Medigaps are standardized, price and customer service are the only difference. Try calling a few competitively priced plans. Regulated by Oregon Insurance Division (OID).
What is Medicare Advantage?
Medicare Advantage also known as Medicare Part C or MA is an option that allows private health insurance companies contracted by CMS to provide Medicare benefits in lieu of Original Medicare (Part A and B). Through Medicare Advantage (MA) plans, beneficiaries can choose to get their benefits through a private health plan (HMO or PPO). By law, MA plans must offer at least the same benefits as Original Medicare but can have different out-of-pocket costs, deductibles and restrictions on coverage.
Who is eligible for Medicare Advantage?
Generally, if you are eligible for Original Medicare you are also eligible for a Medicare Advantage program even if you have a pre-existing condition (if you have End Stage Renal Disease (ESRD) some exceptions exist). You also must live in the service area of the Medicare Advantage plan you want to join. If you are still covered by an employer or union's health insurance, make sure to review their guidelines prior to enrolling in an MA plan as you may not be able to re-enroll in the employer group or union plan once you cancel.
What is the Annual Enrollment Period (AEP)?
For most beneficiaries, The Centers for Medicare and Medicaid Services (CMS) allows for Medicare beneficiaries to change their MA and Medicare Part D coverage only during one time each year: the Annual Enrollment Period (AEP) which runs from October 15 to December 7, unless they qualify for a Special Election Period (SEP).
What is Medicare Part D?
Medicare Part D prescription drug coverage, often referred to as Part D, is available to anyone who is also eligible for Original Medicare. You have to get Medicare Part D through a private insurance company that is contracted with Medicare to offer these plans. Different insurers offer different types of plans, so your cost for the plan (premium) and your out-of-pocket expenses for prescription drugs (copayments, coinsurance and deductible) will vary. You'll have to shop around to decide which plan is best for you.
Medicare Part D in 2013
Much like last year's guide, this article provides an overview of some key highlights and changes to Medicare Part D in 2013. Before reading today's article, we recommend first checking out our Medicare Part D Prescription Drug Coverage overview. Also, if you are interested in learning about 2013 Medicare Advantage (Medicare Part C) highlights, you may also wish to check out our 2013 Medicare Advantage Guide. Without further ado,
let's jump into our Medicare Part D Guide for 2013.
What drugs are not covered under Medicare Part D?
Since the Part D insurer decides which drugs not to cover, this list cannot possibly be complete. However, Part D plans usually do not cover the following drugs:
Drugs that are otherwise covered under Medicare Part A or Part B
Drugs, or classes of drugs that are restricted under Medicare, such as:
Weight loss or weight gain drugs
Fertility drugs
Drugs for cosmetic purposes or hair growth
Nonprescription drugs
Barbiturates
Drugs for sexual or erectile dysfunction
What is Medicare Part D?
Medicare offers an optional prescription drug coverage program available to everyone eligible for Original Medicare through the Medicare Part D program. Medicare Part D is offered through private insurance companies may incur a separate monthly premium that varies in cost depending on the specific drugs you are covered for and the specific plan you are enrolled in. Those costs can include a deductible, flat copayment amounts, and a percentage of the full drug costs (called "coinsurance").
Who is eligible for Medicare Part D?
If you are eligible for Original Medicare (Part A and B) then you can get a Medicare Prescription Drug Plan (Part D). There are two ways a beneficiary can obtain drug coverage through Medicare:
The first option is through a standalone Medicare Prescription Drug plans (PDP). This is generally what beneficiaries who have Original Medicare, Medicare Private Fee-for-Service (PFFS), and Medicare Medical Savings (MSA) plans choose. You can sign up for a PDP via a Medicare insurance broker (like eHealth Medicare), an employer, a union group or through Medicare.
The second option is through a Medicare Advantage Drug plan (MA-PD). If you are in a Medicare Advantage Plan, then most likely you already have Part D coverage incorporated onto that MA plan. However, a few plans don't have a drug plan included so you may need to decide how to obtain Part D.
Are there certain drugs that Medicare Part D does not cover?
The Medicare Part D insurer determines which drugs to cover or not cover therefore, there isn't a complete list. However, Part D plans usually do not cover the following:
Drugs that are otherwise covered under Medicare Part A or Part B
Drugs, or classes of drugs that are restricted under Medicare, such as:
