12 Things to Know About Medigap Plans

The idea is that you and others in original Medicare buy Medigap policies early, right after you sign up for Part B but when you likely have fewer medical expenses. The premiums from many policyholders help cover people’s high bills, so the insurance will be there when your costs mount later on.Depending on the Medigap plan you choose, your policy also could cover skilled nursing facilities’ coinsurance and hospice care coinsurance and copayments. Some Medigap policies may help pay for emergency health care when you travel outside the United States, which Medicare usually doesn’t.

2. The best time to buy is when you first sign up for Medicare

If you’re 65 or older, the first six months after you sign up for Medicare Part B is your Medigap open enrollment period. It happens only once in your life, not every year like Medicare open enrollment when you can change your Part D prescription plan to suit your needs in the next year.During Medigap open enrollment, you can buy any Medigap plan available in your state. And insurers can’t turn you down or charge you more because of preexisting health conditions.

But after that time in most states, you could be denied or charged higher monthly premiums. Insurers will be able to look at your age, health history and lifestyle to tally a higher premium or even deny coverage, a process called medical underwriting.

3. Medigap can be a barrier to leaving Medicare Advantage

If you’ve chosen a Medicare Advantage plan, become unhappy with it and want to switch to original Medicare, qualifying for a Medigap plan could become a problem. Your first 12 months in Medicare Advantage are a trial period when you can leave your plan for original Medicare and either purchase supplemental insurance for the first time if you never had original Medicare or get the Medigap policy you had previously if the company still sells it.

After 12 months? That’s when buying Medigap becomes more complicated, and only a few states make it easier.

The list of potentially deniable medical conditions outside that Medigap open enrollment period include Alzheimer’s disease, asthma, cancer, congestive heart disease, diabetes with complications, and high blood pressure.

High blood pressure, for instance, affects more than 70 percent of adults 60 and older, the Centers for Disease Control and Prevention (CDC) says. Only about a third have their blood pressure under control.

4. You may qualify for a guaranteed-issue exception

If your Medicare Advantage plan pulls out of your area or you move out of the plan’s area, you could qualify for Medigap without being denied or charged higher premiums because of health conditions.

Medicare also provides what it calls guaranteed issue rights in other situations, including when the Centers for Medicare & Medicaid Services (CMS) determines that a Medicare Advantage plan’s provider network has changed significantly. The agency reviews those situations on a case-by-case basis.

The catch: You won’t be able to buy any Medigap plan you wish.

You’ll be restricted to Plan A, B, D or G unless you were eligible for Medicare before Jan. 1, 2020. If you pass that age threshold, you may be able to buy Plan C or F, which include the Part B deductible in their coverage. After that date, Medigap plans could not include that fee.

5. Some states set their own enrollment rules

Federal law standardizes Medigap plans with letters from A to N, but states regulate each of the plans sold within their borders.

Six plans — C, E, F, H, I and J — are no longer offered to new enrollees. But those turning 65 now generally have eight to 10 plans to choose from in their states.

If a state decides to set its own rules, the coverage must be as good or better than standards created by the National Association of Insurance Commissioners, a nonprofit organization of top insurance regulators in each state and territory, whose recommendations were included in the law.

Different plans. Insurers in Massachusetts, Minnesota and Wisconsin offer fewer than eight plans, and they differ from those in the federal lettering system. Minnesota and Wisconsin allow buyers to customize coverage by purchasing add-ons, called riders, to a basic policy.

Coverage when you want it. Five states make switching from Medicare Advantage to original Medicare easier by offering coverage guarantees with no health questions or waiting periods for preexisting conditions.

Connecticut and New York require companies to sell Medicare enrollees a Medigap plan at any time without being denied. Massachusetts requires a Feb. 1 to March 31 open enrollment, but insurers in the state offer the service year-round.

Maine allows its Medicare Advantage enrollees who never had original Medicare up to 36 months to decide to switch, as long as they buy any Medigap policy within 90 days of the end of their Medicare Advantage coverage.

Maine also requires each of its insurers to designate a one-month period when any applicant must be accepted for Plan A, which offers basic coverage. Each company can select its month. And if a policyholder hasn’t had a gap of more than 90 days in coverage, Maine allows a change in Medigap coverage at any time to a plan with the same or fewer benefits, a perk for those looking to cut their monthly premium.

Starting this year, Minnesota is offering Medicare enrollees ages 65½ to 70 a chance to buy one of its two Medigap plans during Medicare’s annual open enrollment season Oct. 15 to Dec. 7. Federal law covers many people who turn 65 and get Part B through their Medigap open enrollment period.

Enrollees can use the option only once and will be charged higher rates than if they had enrolled when they were younger. But they can’t be rejected.

Anniversary, birthday rules. Several other states — California, Idaho, Illinois, Kentucky, Louisiana, Maryland, Nevada, Oklahoma, Oregon — let you swap one Medigap plan for another with equal or fewer benefits around the time of your birthday. But these rules don’t apply to Medicare enrollees without Medigap.

Missouri’s law is centered around the policy’s anniversary date and allows you to change insurers offering the same lettered plan. Washington state lets you change Part A companies or switch among Plans B to N at any time if you haven’t had a gap of more than 90 days in coverage.

6. Medigap won’t fill every gap

Medigap plans typically don’t pay for medical treatments that Medicare doesn’t cover, such as most dental work, hearing aids and long-term nursing home care.

Whether or not Medigap plans cover your Medicare Part B deductible depends on when you first enrolled in Medicare. Plans sold to people who enrolled in Medicare for the first time on or after Jan. 1, 2020, aren’t allowed to cover their Part B deductible.

Medigap plans sold after 2005 also don’t include prescription drug coverage. If you want your medications covered, you’ll need to buy a separate Part D plan.

7. Some plans provide access to additional benefits

A small share of Medigap plans, about 7 percent — representing 12 percent of people with Medigap — offer additional benefits beyond the standard coverage, according to a 2021 Commonwealth Fund study. They are concentrated in a just few policy types, mostly Plan G.

Plan G is the most popular of all 10 plan types sold now, with 43 percent of all enrollees in 2024, the latest figures available, according to Washington, D.C.-based AHIP, formerly America’s Health Insurance Plans, the trade group for health insurers.

These “new or innovative benefits,” as they are called in federal regulations, can include dental, hearing and vision benefits, access to a 24/7 nurse phone line and wellness benefits like the SilverSneakers fitness program. Some policies offer coverage of specific dental services, similar to some Medicare Advantage plans, while others may provide discounts on dental services.

These plans often have in slightly higher premiums than other Medigap policies with the same letter that have only standard benefits.

8. Different plans, insurers can have very different prices

Premiums are based on factors such as a policyholder’s age, smoking status, gender and zip code — even before you decide what lettered plan will work best for you. Monthly costs can vary widely.

A 70-year-old nonsmoking woman in Charlottesville, Virginia, could pay $106 a month for a Plan A policy or $228 a month for a Plan C policy. A 65-year-old nonsmoking man in Albuquerque, New Mexico, could pay $51 a month for a Plan F high-deductible policy or $208 for a Plan C policy.

Some of this has to do with the way a plan’s premium is calculated; some of it might be the standard and extra benefits included. Because a Medigap plan is a long-term expense, understanding these plans’ pricing structures is important:

• Attained-age policies have regular premium increases based on age and inflation. These plans may be the least expensive at first but eventually become the most costly.
• Community-rated policies charge the same premium to everyone with the same policy, regardless of age. Premiums may go up because of inflation but not because you’re getting older.
• Issue-age policies base premiums on your age when you buy. Premiums are lower for people who buy early but can increase because of inflation. 

If you pay your premiums, your insurer can’t cancel your Medigap policy because of your age or health.

9. Federal rules don’t apply if you’re younger than 65

If you’re on Medicare before age 65 because of a disability, you may not be able to get the Medigap policy you want.

Federal law doesn’t require private insurers to sell a policy to anyone younger than 65. But you will be eligible for the one-time, six-month Medigap open enrollment period when you turn 65.

This is where your state comes in. Thirty-seven states — all except Alabama, Alaska, Arizona, Iowa, Nevada, New Mexico, North Dakota, Ohio, South Carolina, Utah, Washington, West Virginia and Wyoming — require insurers to sell at least one type of Medigap policy to people younger than 65 on Medicare. Some are more generous.

10. Let coverage needs determine your choice

It’s pretty simple: Pay less, get less coverage. Plans A and B don’t offer coverage for big-ticket, out-of-pocket costs for stays at skilled nursing facilities while Plan K offers 50 percent coverage of skilled nursing home coinsurance and copayments and Plan L will cover 75 percent of those costs.

Likewise, high-deductible plans require you to pay thousands up front, up to $2,950 in 2026, before coverage kicks in. Lower-cost policies can be fine if you are relatively healthy, but if something goes wrong, your personal costs can skyrocket.

If you’re looking for a discount and you and your spouse are shopping at the same time or one has Medigap and you’re interested in the same company, some insurers will offer spouse and even roommate discounts, a sort of family plan when no other part of Medicare has such savings. ​

11. Medicare and Medigap coordinate your claims

With most Medigap plans, the cost-sharing process works fairly seamlessly.

Medicare sends your Medigap insurer your claim information, and Medigap pays its share directly to your doctor. As long as your doc participates in Medicare, your Medigap plan is required to pay the practice.

That keeps you from having to file a pile of paperwork.

12. Unbiased help is a phone call away

The best place for more information is your State Health Insurance Assistance Program (SHIP), federally financed but locally maintained in your state or territory.

Its counselors can give you personalized help choosing a plan. The toll-free national number, 877-839-2675, can connect you with your local SHIP or you can find your area’s SHIP through an online directory.

SHIPs also help with Medicare initial and open enrollment and almost anything else Medicare. They are busiest toward the end of open enrollment, Oct. 15 to Dec. 7.

This story, originally published Oct. 11, 2023, was updated with details about the challenges of switching from Medicare Advantage to original Medicare with Medigap, additional state information and Medigap coverage for younger Medicare enrollees with disabilities.