Mind the Gaps: What Original Medicare Doesn’t Cover
Original Medicare, comprising Part A (hospital insurance) and Part B (medical insurance), offers essential health coverage to millions of seniors. However, it doesn’t cover everything. Beneficiaries are often surprised to discover they are still responsible for significant out-of-pocket expenses.
Part A includes a hospital deductible that resets at the beginning of each benefit period, daily coinsurance for extended hospital stays, and no coverage for long-term custodial care. Part B comes with a monthly premium, an annual deductible, and 20% coinsurance for most outpatient services, including doctor visits, diagnostic tests, and durable medical equipment.
Importantly, there is no annual out-of-pocket maximum with Original Medicare. This exposes beneficiaries to unlimited costs, especially ongoing or high-cost medical care. That’s where Medigap coverage comes in.
What Is Medigap? A Safety Net for Seniors
Medigap, also known as Medicare Supplement Insurance, is designed to cover the “gaps” in Original Medicare. Sold by private insurance companies, Medigap plans help cover expenses such as copayments, coinsurance, and deductibles that are not covered by Medicare Parts A and B.
A Medigap policy only works in conjunction with Original Medicare. You must be enrolled in both Part A and Part B to purchase a Medigap plan. These policies offer nationwide coverage, meaning you can see any doctor or specialist who accepts Medicare without worrying about network restrictions.
Medigap Plan A–N Explained
Medigap plans are standardized by the federal government and identified by letters A through N. While all insurers must offer the same basic benefits for each lettered plan, the costs can vary between companies and regions.
- Plan A: The most basic Medigap option. It covers coinsurance for hospital and medical services but not the Part A deductible.
- Plan B: Adds coverage for the Part A deductible.
- Plan C and F: Offer comprehensive coverage, including excess charges. (Note: These are no longer available to those newly eligible for Medicare after January 1, 2020.)
- Plan G: Now the most popular option for new enrollees, covering everything except the Part B deductible.
- Plan N: Offers lower premiums in exchange for small copayments and doesn’t cover Part B excess charges.
Choosing the right plan depends on your health needs, budget, and the level of risk you’re willing to accept in terms of out-of-pocket costs.
Enrollment Windows and Eligibility Timing
The best time to enroll in a Medigap policy is during your Medigap Open Enrollment Period, which begins the first month you are 65 or older and enrolled in Part B. During this six-month window, you have guaranteed issue rights, meaning insurers cannot deny you coverage or charge more based on pre-existing conditions.
If you wait until after this window, you may be subject to medical underwriting, higher premiums, or even denial of coverage. Some states offer additional guaranteed issue rights or special enrollment periods, so it’s essential to have information about your local options.
Medigap vs. Medicare Advantage
Medigap and Medicare Advantage are not the same. Medigap offers protections alongside Original Medicare, preserving access to any Medicare provider nationwide. Medicare Advantage (Part C) replaces Original Medicare with a private plan that may offer additional benefits but often comes with network restrictions and varying out-of-pocket limits.
You cannot have both Medigap and Medicare Advantage at the same time. The right choice depends on your preferences for flexibility, types of coverage, and issues related to deductibles
Get the Right Fit—We’ll Help You Bridge the Gap
Choosing a Medigap plan can feel overwhelming, but we’re here to guide you. AT Gullborg Insurance Agency, our licensed advisors will guide you through your options, compare plans, and help you find coverage that aligns with your health needs and financial goals. Reach out today at (724) 941-8200 to learn more about how Medigap can work for you.