Purpose of Medigap
Medicare Supplement insurance, commonly called "Medigap," is private insurance that helps pay for costs not covered by Original Medicare (Parts A & B). These policies are designed to fill the "gaps" in Medicare coverage, including deductibles, coinsurance, and copayments.
Why Medigap Exists
Gaps in Original Medicare Coverage
| Gap | Original Medicare Cost | What Medigap Pays |
|---|
| Part A deductible | $1,676 per benefit period (2025) | Most plans pay 100% |
| Part A coinsurance (days 61-90) | $419/day (2025) | Most plans pay 100% |
| Lifetime reserve days | $838/day (2025) | Most plans pay 100% |
| Part B deductible | $257/year (2025) | Some plans cover |
| Part B coinsurance | 20% of approved amount | Most plans pay 100% |
| Part B excess charges | Up to 15% above approved | Some plans cover |
The Problem Original Medicare Creates
| Issue | Details |
|---|
| No out-of-pocket maximum | 20% coinsurance applies indefinitely |
| Multiple deductibles | Part A (per benefit period) and Part B (annual) |
| No foreign travel coverage | Very limited exceptions |
| Excess charges | Non-participating doctors can charge 15% more |
Key Point: Original Medicare has NO annual out-of-pocket maximum. Someone with a catastrophic illness could face unlimited 20% coinsurance—this is the primary reason people purchase Medigap policies.
How Medigap Works
Basic Structure
| Feature | Details |
|---|
| Sold by | Private insurance companies |
| Regulation | Standardized by federal and state law |
| Who can buy | Must have Medicare Parts A and B |
| Premium payment | Monthly premium in addition to Part B premium |
| Covers | Cost-sharing in Original Medicare only |
What Medigap Covers
| Coverage | Description |
|---|
| Medicare Part A coinsurance | Hospital costs for days 61-90 and beyond |
| Medicare Part B coinsurance | 20% of doctor visits, outpatient care |
| Blood (first 3 pints) | Part A and Part B blood costs |
| Part A hospice coinsurance | Cost-sharing for hospice care |
| Skilled nursing facility coinsurance | Days 21-100 ($209.50/day in 2025) |
What Medigap Does NOT Cover
| Not Covered | Alternative |
|---|
| Prescription drugs | Medicare Part D |
| Dental care | Separate dental insurance |
| Vision care | Separate vision insurance |
| Hearing aids | Separate coverage needed |
| Long-term care | Long-term care insurance |
| Private-duty nursing | Not covered |
Exam Tip: Medigap policies NEVER include prescription drug coverage. Anyone wanting drug coverage with Medigap must enroll in a separate Part D plan.
Medigap Open Enrollment Period
The Best Time to Buy
| Feature | Details |
|---|
| When it starts | First day of month you're 65+ AND enrolled in Part B |
| Duration | 6 months |
| Protection | Guaranteed issue—cannot be denied for health |
| Pricing | Best available rate—no health surcharges |
| Availability | Can buy ANY Medigap plan sold in your state |
Open Enrollment Rights
| Right | Description |
|---|
| No medical underwriting | Health questions don't affect eligibility |
| No denial | Must be sold a policy regardless of health |
| No waiting periods | Pre-existing conditions covered immediately |
| Standard pricing | Cannot charge more due to health conditions |
After Open Enrollment Ends
| Situation | What Happens |
|---|
| Buying Medigap | Insurers CAN deny coverage based on health |
| Medical underwriting | Must answer health questions |
| Higher premiums | May charge more for health conditions |
| Denial for conditions | Cancer, heart disease, diabetes often rejected |
Key Point: The 6-month Medigap Open Enrollment Period is a ONE-TIME opportunity. It does NOT repeat each year. Missing this window can make Medigap difficult or impossible to obtain later.
Guaranteed Issue Rights
What Are Guaranteed Issue Rights?
| Feature | Description |
|---|
| Definition | Legal right to buy Medigap without underwriting |
| Protection | Cannot be denied or charged more for health |
| When they apply | Specific qualifying situations |
| Time limit | Usually 63 days from loss of coverage |
Situations Creating Guaranteed Issue Rights
| Situation | Plans Available | Time Limit |
|---|
| Leaving employer coverage (after 65) | A, B, C, F, K, L (varies by state) | 63 days |
| Medicare Advantage plan leaves area | A, B, C, F, K, L | 63 days |
| Leaving first MA plan (trial right) | A, B, C, F, K, L | 63 days |
| Loss of Medigap due to fraud/insolvency | A, B, C, F, K, L | 63 days |
| Returning from MA plan within 12 months | Original Medigap plan only | 63 days |
Medicare Advantage Trial Rights
| Scenario | Right |
|---|
| First MA enrollment at 65 | Can leave within 12 months and buy Medigap |
| Switching from Medigap to MA | Can return within 12 months to same Medigap |
| MA plan performance issues | Guaranteed issue if plan loses contract |
Exam Tip: Guaranteed issue rights typically last only 63 days from when coverage ends. Applying quickly is essential to avoid coverage gaps.
State Variations
States with Enhanced Protections
| State | Special Rules |
|---|
| New York | Continuous open enrollment—can buy anytime |
| Connecticut | Continuous open enrollment—can buy anytime |
| Massachusetts | Different standardized plans |
| Minnesota | Different standardized plans |
| Wisconsin | Different standardized plans |
Additional State Protections
| Protection | States Offering |
|---|
| Annual open enrollment | Several states |
| Birthday rule | CA, IL, LA, NV, OR (switch plans without underwriting) |
| Additional guaranteed issue | CA, OR, MO, and others |
Key Point: New York and Connecticut are unique—they allow Medigap enrollment at any time without medical underwriting. Other states only guarantee this during the 6-month open enrollment period.