Faq / Birthday Rule

What is the Medigap Birthday Rule?
The Medicare Supplement (Medigap) Birthday Rule is a state-level consumer protection that grants current Medigap enrollees a temporary window each year around their birthday to switch to a different Medigap policy without undergoing medical underwriting.
Outside of an initial enrollment window or specific ‘Guaranteed Issue’ scenarios, switching Medigap plans usually requires you to answer health questions. Insurance companies can look at your medical history and deny you coverage or charge you higher premiums due to pre-existing conditions. The Birthday Rule removes this obstacle with two main caveats:
• Equal or Lesser Benefits: In almost all participating states, you can only switch to a plan with equal or lesser benefits than your current policy (e.g., Plan G to Plan G, or Plan G to Plan N).
• Carrier Restraints: Most states allow you to switch to an entirely different insurance company to find a better price, but a few states require you to stay with your current carrier.

States with Active Birthday Rules
• California: A 60-day window beginning on the first day of your birth month. You can switch carriers.
• Delaware: Allows enrollees to switch starting 30 days before and up to 30 days after their birthday.
• Idaho: A 63-day window starting on your birthday. You can switch carriers.
• Illinois: A 45-day window following your birthday, available strictly for enrollees aged 65 to 75.
• Indiana: A 60-day window following your birthday to change to the same lettered plan.
• Kentucky: A 60-day window starting on your birthday to switch to a plan with the same benefits with any carrier.
• Louisiana: A 63-day window starting on your birthday.
• Maryland: A 30-day window starting on your birthday.
• Nevada: A 60-day window starting the first day of your birth month.
• Oklahoma: A 60-day window following your birthday.
• Oregon: An enrollment window starting 30 days before your birthday and lasting until 30 days after.
• Rhode Island: A 30-day window following your birthday.
• Utah: A 60-day window starting on your birthday to change to a comparable or lower-tier plan, but you must stay with your current insurance carrier.
• Virginia: A 60-day window starting on your birthday to switch to an equal or lesser plan.
• West Virginia: A 60-day window around your birthday to switch to equal/lesser benefits.
• Wyoming: A 63-day window starting on your birthday to switch to the same plan letter with any carrier.

Upcoming Changes
• New Mexico: Has signed birthday rule legislation into law, officially scheduled to take effect on January 1, 2027.

States with Even Better Protections
Some states offer year-round continuous open enrollment instead of a birthday rule. In these states, Medigap policyholders can switch plans at any time of the year without medical underwriting:
• Connecticut, Massachusetts, New York, and Vermont (Year-round open enrollment)
• Missouri (Features an ‘Anniversary Rule’ tied to the original plan purchase date rather than a birthday)

• • Option A (Original Medicare + Medigap + Part D): Best for total freedom. Use any doctor nationwide that takes Medicare. No referrals needed. Monthly premiums are higher, but out-of-pocket costs are highly predictable.
  • Option B (Medicare Advantage / Part C): Best for low monthly costs. Covers everything via one private plan, often including extra dental, vision, and gym perks. You must stick to a local network of doctors and often need prior approvals for care.

• • Providers: Check that your favorite doctors and hospitals are strictly “in-network” if you choose Medicare Advantage.
  • Prescriptions: Every plan has a unique “formulary” (list of covered drugs). Check that your specific medications are covered at a reasonable tier.
  • Priorities: Choose Original Medicare if you travel out-of-state frequently, as Advantage plans usually limit you to local networks.

• • The $2,400 Drug Cap: Standalone Part D and Advantage plans have an annual out-of-pocket spending limit of $2,400 for covered prescriptions. After you hit this, you pay $0 for your meds for the rest of the calendar year.
  • Base Part B Costs: You must pay the standard monthly Part B premium regardless of which path you choose.

• • Go to Medicare.gov/plan-compare to type in your ZIP code and exact medications to see a direct cost breakdown.
  • Contact SHIPhelp.org to get connected with free, local, and objective counselors who do not sell insurance.

While we specialize in Medicare Supplements, we also help with dental coverage options.   CLICK HERE to explore options for dental coverage options.

• • “Welcome to Medicare” Visit: A one-time introductory check-up available only within your first 12 months of having Part B coverage.
  • Annual Wellness Visit: A yearly follow-up visit to build or update a personalized illness prevention plan. 

• • Flu Shots: Covered once per flu season.
  • Pneumococcal Shots: Vaccines to protect against pneumonia.
  • Hepatitis B Shots: For those at medium or high risk.
  • COVID-19 Vaccines: Initial doses and updated boosters.
  • Note: Shingles and RSV vaccines are also fully covered, but are billed separately through your private Medicare Part D prescription plan. 

• • Mammograms: Baseline and annual screening mammograms to check for breast cancer.
  • Colorectal Cancer Screenings: Includes colonoscopies, multi-target stool DNA tests (like Cologuard), flexible sigmoidoscopies, and barium enemas.
  • Cervical & Vaginal Screenings: Pap tests and pelvic exams, covered every 24 months (or 12 months if high risk).
  • Prostate Cancer Screenings: Annual PSA blood tests (digital rectal exams may require a copay).
  • Lung Cancer Screenings: Annual low-dose CT scans for qualified long-term smokers aged 55–77. 

• • Cardiovascular Screenings: Blood tests to check your cholesterol, lipid, and triglyceride levels every 5 years.

  • Diabetes Screenings: Up to two fasting blood sugar tests per year if you have specific risk factors.
  • Bone Mass Measurements: Bone density tests every 24 months to screen for osteoporosis.
  • Glaucoma Screenings: Annual eye exams for people at high risk (those with diabetes, family history, or specific age brackets).
  • Abdominal Aortic Aneurysm Screening: A one-time ultrasound for at-risk individuals (such as men 65–75 who have smoked). 

• Depression Screenings: One formal mental health screening per year in a primary care setting.
• Tobacco Cessation Counseling: Up to 8 counseling sessions per year to help you stop smoking or using tobacco.
• Obesity Behavioral Therapy: Intensive counseling and behavioral therapy for individuals with a BMI of 30 or higher.
• Alcohol Misuse Screenings: One annual screening and up to 4 face-to-face counseling sessions if you screen positive.
• Medical Nutrition Therapy: Specialized dietary counseling for individuals with diabetes or kidney disease.

What should I expect during my exam?

During the exam, your doctor will record your medical history and check your blood pressure, vision, and weight and height to measure your body mass index. Body mass index (BMI) is a measure of body fat based on height and weight that applies to both adult men and women. Your doctor will check to make sure that you are up-to-date with preventive screenings and services, such as cancer screening and shots. Depending on your general health and medical history, further tests may be ordered if necessary. For example, a person at risk for an abdominal aortic aneurysm may get a referral for a one-time screening ultrasound at their “Welcome to Medicare” physical exam.

Your doctor will also give you advice to help you prevent disease, improve your health or stay well. You will also get a written plan (such as a checklist) when you leave letting you know which screenings and other preventive services you should get.

Starting in 2009, your doctor will also talk with you about end-of-life planning, including advance directives. Advance directives are legal documents that allow you to put in writing what kind of health care you would want if you were too ill to speak for yourself. Talking to your family, friends, and health care providers about your wishes is important, but these legal documents ensure your wishes are followed.

Remember! Once you enroll in Part B, it’s important to schedule your “Welcome to Medicare” physical exam right away. Medicare will only cover this physical exam if it occurs within the first 12 months that you have Part B. If your doctor thinks this 12-month period has passed, he or she should give you a notice that says Medicare probably won’t pay for this service. If you still want to get the service, you will be asked to sign an agreement that you will pay for the service yourself if Medicare doesn’t pay for it. This is called an Advance Beneficiary Notice.

How much does the exam cost?

You pay 20% of the Medicare-approved amount, and no Part B deductible.

What should I bring with me to the exam?

You should bring the following things with you when you go to your “Welcome to Medicare” physical exam:

– medical records, including immunization records (if you are seeing a new doctor for the first time)
– family health history – try to learn as much as you can about your family’s health history before your appointment. Any information you can give your doctor can help determine if you are at risk for certain diseases.
– a list of prescription drugs that you currently take, how often you take them, and why.

• Most Dental Care: Routine cleanings, X-rays, fillings, extractions, and dentures are excluded.
• Routine Vision Care: Standard eye exams, refractions, eyeglasses, and contact lenses are not covered, except following cataract surgery.
• Hearing Care: Routine hearing exams and the cost of hearing aids themselves are entirely excluded.
• Cosmetic Surgery: Any elective procedures done for appearance rather than treating an illness or injury are not covered.

• Long-Term or Custodial Care: Help with daily living activities (like bathing, dressing, and eating) in a nursing home or at home is not covered.
• Medical Care Outside the U.S.: Health services received internationally are not covered, except under very rare emergency circumstances.

• Self-Administered Prescription Drugs: Most retail medications you pick up at a pharmacy and take yourself are excluded (these require a Medicare Part D prescription plan or Part C).
• Routine Physical Exams: Comprehensive annual physicals are not covered, though the introductory Welcome to Medicare visit and regular Annual Wellness Visits are covered.
• Alternative Therapies: Massage therapy is completely excluded. Acupuncture and chiropractic services are heavily restricted and only covered for very narrow, medically necessary reasons (e.g., chronic low back pain).

• Provider services: Medically necessary visits to primary care doctors, specialists, physician assistants, and nurse practitioners.
• Outpatient hospital care: Services received at a hospital or surgical center that do not require an overnight inpatient admission.
• Emergency services: Ambulance transportation and emergency room visits for sudden, acute illnesses or injuries.

• Wellness visits: The initial Welcome to Medicare visit during your first year and annual wellness visits in subsequent years.
• Screenings and tests: Early detection checks for conditions like diabetes, cardiovascular disease, various cancers, and depression.
• Vaccines: Annual flu shots, pneumococcal shots, hepatitis B shots for those at medium or high risk, and COVID-19 vaccines.

• Clinical laboratory services: Diagnostic blood work, urinalysis, and tissue processing.
• X-rays and imaging: Medically necessary diagnostic tests, including MRIs, CT scans, ultrasounds, and standard X-rays.
• Durable medical equipment: Medical devices used at home, such as wheelchairs, walkers, oxygen equipment, blood sugar monitors, and CPAP devices.

• Physical, occupational, and speech therapy: Outpatient rehabilitation sessions prescribed by a doctor to treat a specific medical impairment.
• Mental health care: Outpatient counseling, psychiatric evaluations, and partial hospitalization programs.
• Limited prescription drugs: Certain medications that are not self-administered, such as injections or infusions given by a doctor in an office or outpatient setting.

Since 1972, individuals receiving Social Security retirement benefits, individuals receiving Social Security disability benefits for 24 months, and individuals otherwise entitled to Medicare Part A, are automatically enrolled in Part B unless they decline coverage. Others must enroll in Part B by filing a request at the Social Security office during certain designated periods.

The major benefit under Part B is payment for physicians’ services. In addition, home health care, durable medical equipment, outpatient physical therapy, x-ray and diagnostic tests are also covered. Since January 1, 1998 home care is covered under Part B if the individual does not meet the Part A prior institutional requirements, received coverage under Part A for the maximum annual 100 visits, or only has Part B.

The following is a list of items and services which can be covered under Part B:

1. Physicians’ services;
2. Home Health Care;
3. Services and supplies, including drugs and biologicals which cannot be self-administered, furnished incidental to physicians’ services;
4. Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests;
5. X-ray therapy, radium therapy and radioactive isotope therapy;
6. Surgical dressings, and splints, casts and other devices used for fractures and dislocations;
7. Durable medical equipment;
8. Prosthetic devices;
9. Braces, trusses, artificial limbs and eyes;
10. Ambulance services;
11. Some outpatient and ambulatory surgical services;
12. Some outpatient hospital services;
13. Some physical therapy services;
14. Some occupational therapy;
15. Some outpatient speech therapy;
16. Comprehensive outpatient rehabilitation facility services;
17. Rural health clinic services;
18. Institutional and home dialysis services, supplies and equipment;
19. Ambulatory surgical center services;
20. Antigens and blood clotting factors;
21. Qualified pyschologist services;
22. Therapeutic shoes for patients with severe diabetic foot disease;
23. Influenza, Pneumococcal, and Hepatitis B vaccine;
24. Some mammography screening;
25. Some pap smear screening, breast exams, and pelvic exams;
26. Some other preventive services including colorectal cancer screening, Diabetes training tests, bone mass measurements, and prostate cancer screening.

• Long-Term Nursing Home Stays: Part A only covers short-term, skilled rehabilitative care in a skilled nursing facility. It does not cover permanent or long-term residential stays.
• Custodial Care: Ongoing assistance with daily activities like bathing, dressing, eating, or using the bathroom is completely excluded if that is the only care you require.
• 24-Hour Home Care: Continuous, around-the-clock medical or personal care at your residence is not covered.

• Private Hospital Rooms: Part A covers a semi-private room. A private room is excluded unless your doctor notes it is strictly medically necessary, such as for infection control.
• Personal Comfort Items: Television placement, phone services, or personal care items like razors and slippers provided by the hospital are not covered if charged separately.
• Private-Duty Nursing: Individual, private-duty nursing care inside the hospital or facility is excluded.

• Outpatient Doctor Care: Regular clinic visits, emergency room treatment without an inpatient admission, and physical therapy fall under Part B, not Part A.
• Routine Vision, Dental, and Hearing: Routine dental procedures, eyeglasses, vision tests, and hearing aids are excluded from Part A entirely.
• The First 3 Pints of Blood: If you need a blood transfusion during an inpatient stay, you must cover the cost or replace the first 3 pints of blood used per calendar year.

• Take-Home Prescription Drugs: Part A covers medications administered to you directly while you are a registered inpatient. It does not cover prescriptions you fill at a pharmacy to take home once you are discharged.

• Semi-private rooms: Your hospital room and board during an inpatient admission.
• Meals and nursing: Standard meals and general nursing services provided by the hospital staff.
• Hospital supplies and medications: Medications, medical supplies, appliances, and lab tests administered while you are an admitted inpatient.
• Specialized units: Intensive care unit (ICU) stays, operating room fees, and recovery room costs.

• Short-term rehabilitation: Post-hospital care following a qualifying inpatient hospital stay of at least 3 days.
• Skilled care services: Physical therapy, occupational therapy, speech therapy, and skilled nursing care to help you recover.
• Room and board: Semi-private rooms, meals, and necessary medical supplies during your covered stay.

• End-of-life support: Palliative care and support for individuals with a terminal illness and a life expectancy of 6 months or less.
• Pain management: Medications for symptom control and pain relief related to the terminal diagnosis.
• Comprehensive support: Nursing care, medical equipment, social worker services, and grief counseling for the family.

• Part-time intermittent care: Skilled nursing care or physical, occupational, and speech therapy for homebound individuals.
• Medical social services: Intermittent home health aide services and medical supplies required for your home treatment.

• Access to major carriers: They pull quotes from various prominent providers like Blue Cross, Blue Shield, Mutual of Omaha, and AARP.
• Unbiased guidance: Because they are an independent broker, they offer objective plan comparisons rather than pushing a specific corporate policy.
• Standardized comparisons: They analyze how different plan letters, such as Plan G versus Plan N, fit your budget and medical needs.

• Dedicated service agents: The firm employs full-time, licensed agents specifically to handle customer enrollment and policy updates.
• Policy reviews: They track annual rate changes and offer policy health checks to see if another carrier can provide the same standardized Medigap coverage for less money.
• Flexible communication: You can work with their agents face-to-face at their office in Chico, California, or manage the entire enrollment over the phone and computer.

Congressional discussions about health care reform legislation are entering their final stages. The Affordable Health Care for America Act, H.R. 3962, was introduced in the House of Representatives on Thursday, October 30, 2009, and is expected to be voted upon in November. The Senate is in the process of merging bills that were passed by the Senate Finance Committee and the Senate Health Education Labor and Pensions (HELP) Committee.

Medicare plays an important role in these discussions. Congress hopes to use Medicare to develop innovative delivery system reforms that will improve quality of care and slow the growth of health care costs. Congress also would like to address issues pertaining to the solvency of the Medicare Part A trust fund as part of reform efforts.

This Alert focuses on those Medicare provisions in the legislation that are of greatest interest to beneficiaries and their advocates, as well as on some related Medicaid provisions. It also briefly discusses provisions of the House legislation that would be effective immediately, before the 2013 effective date of the basic coverage expansions for the uninsured that are the primary focus of the legislation.

Ensuring Access to Doctors

Opponents of health care reform have threatened Medicare beneficiaries that they would not be able to see their doctors if health care reform legislation is enacted. The opposite is true. Reforms are needed to ensure that physicians will continue to be reimbursed adequately enough to accept Medicare beneficiaries as patients. Under current rules, physicians are scheduled for a 21% reduction in their Medicare reimbursement starting in January 2010.

Unfortunately, for political reasons, a “Doc Fix” designed to reform the physician payment system is not included in H.R. 3962 or its Senate counterpart. A separate bill to redesign doctor payment, H.R. 3961, was introduced in the House of Representatives on the same day as HR 3962; the Senate is considering a modification that is more short-termed. H.R. 3962 does, however, include other payment reforms that create incentives for primary care physicians and other practitioners to serve Medicare beneficiaries.

Reducing Overpayments to Medicare Advantage Plans

Both the House and the Senate address the 14% overpayment to Medicare Advantage (MA) plans. The House bill would adopt the Medicare Payment Advisory Commission (MedPAC) recommendation to create a “level playing field” with traditional Medicare. It also eliminates the fund set-aside for regional MA plans, and extends permanently the authority of the Secretary to adjust payments when MA plans claim their beneficiaries have higher health care needs than claims data establish.

The Senate bill would create a competitive bidding process for MA plans that would not achieve as much in savings, and that would still result in MA plans in some areas being paid more than traditional Medicare. Both bills include bonus payments for quality. The Senate bill may include a provision to “grandfather” in extra benefits for plans in areas, such as Miami, that would otherwise see the most dramatic change in their compensation.

Closing the Part D Donut Hole and Other Reductions in Drug Costs

Under H.R. 3962, the phase-out of the Donut Hole would begin in 2010. The bill would increase the initial coverage limit, the point at which people enter the Part D coverage gap, by $500 for next year. The phase-out of the donut hole would be completed by 2019. Meanwhile beneficiaries would be charged only 50% of the cost of certain drugs in the coverage gap. Additionally, drug manufacturers must agree to Medicaid drug rebates for dual eligibles in order for their drugs to be covered by Part D beginning in 2010. The House also provides for negotiation of drug prices by the Secretary of Health and Human Services, with Part D plan sponsors still having the opportunity to try to negotiate greater drug price savings for their plans.

The bill that passed the Senate Finance Committee only included a provision to reduce the cost of brand name drugs in the coverage gap. It did not close the Donut Hole, require pricing rebates, or provide for negotiation of drug prices by the Secretary. The final bill introduced in the Senate may do more to close the Donut Hole.

Preventive Services

Much of the focus on health care reform is on prevention of health conditions. The House bill eliminates co-payments and deductibles for preventive services that are covered by Medicare. It is expected that the Senate bill will do the same. The House bill also provides that all Medicare-covered vaccines will be covered under Medicare Part B. This ensures access to vaccines for all beneficiaries and should make them available without any cost-sharing.

Provisions to Assist Beneficiaries with Limited Incomes and Resources

Neither the House bill nor the bill passed by the Senate Committees include all of the improvements that beneficiary advocates would have liked to see included in health care reform legislation. The Senate bill so far includes only minor adjustments.

H.R. 3962 increases the resource limit for the Part D Low Income Subsidy (LIS) and for Medicare Savings Programs to $17,000/ individual, $34,000/couple and provides for self-verification of income and resources. It establishes a process for reimbursement to beneficiaries who are found retroactively eligible for the Part D Low Income Subsidy. It eliminates Part D cost-sharing for dual eligible individuals who are in a Medicaid waiver program and who require nursing facility or intermediate care facility for the mentally retarded level of care. It provides for a different methodology for calculating the Part D plan benchmark for the Low Income Subsidy which will result in far fewer low income individuals having to be reassigned to new Benchmark plans each year. It gives the Secretary authority to assign low income beneficiaries to plans that meet their individual needs. It also extends the Qualified Individual (QI) program, which helps pay for Part B premiums, for two years.

The House bill provides authority for the Internal Revenue Service to share data with the Social Security Administration that would allow the latter to better target its outreach efforts. It also includes a technical correction to last year’s Medicare legislation, the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), concerning data transmission from the Social Security Administration to the states.

Coordination of Care

H.R. 3962 provides for a variety of demonstrations and pilot projects to move Medicare toward reimbursement for coordination of care for beneficiaries with chronic conditions. These programs include:

– Transitional care services: Follow-up services designed to prevent avoidable hospital re-admissions, including pre-and post-discharge planning services, care coordination, medication orders, and translator/interpreter services;
– Accountable care organizations (ACOs): An ACO is a group of physicians and other providers who use patient-centered processes and other best practices to coordinate care and avoid duplication of services. Payment incentives are based on improved quality and reduced expenditures. ACOs must agree not to deny, limit, condition coverage or the provision of care based on the health status of an eligible beneficiary.
– Medical home: A medical home directs or provides access to primary care and all health care needs, taking responsibility for arranging for care and ensuring access.
– Independence at home: Home-based primary care teams provide coordinated care to high need populations at home to reduce hospital admissions and re-admissions, to reduce duplicative testing, and to improve outcomes.

Medicare Commission

The House, the Senate, and President Obama all expressed interest in having some independent entity review Medicare payment mechanisms. H.R. 3962 authorizes two studies by the Institute of Medicine (IOM). One looks at geographic adjustment factors under Medicare, including issues concerning workforce recruitment and retention. The other looks at geographic variation in health care spending and promoting high value health care, including variations in prices, health status, practice patterns, access and supply, and socio-economic factors.

The Senate Finance bill included a provision to establish a Medicare Commission with authority to review Medicare payment structures and make recommendations to effectuate cost-savings. The recommendations would become effective if Congress did not act within specified, and very fast, time periods. The provision also included targeted caps on Medicare spending. Although the provision said that the Commission could not make recommendations about beneficiary premiums and cost-sharing, a last-minute amendment would allow the Commission to make recommendations concerning Part D premiums.

Other Beneficiary Provisions

H.R. 3962 incorporates some additional consumer protections. The Senate bill is also likely to include provisions designed to provide additional protection to beneficiaries. The following are examples of some of these protections:

– Change the time frame for enrollment in Medicare Advantage and Part D plans;
– Limit cost-sharing in Medicare Advantage plans;
– Require MA plans to make available to beneficiaries information on their administrative costs (Medical Loss Ration);
– Allow payments by ADAP and Indian Health Service programs to count toward the Part D out-of-pocket limit;
– Calculate the Part D benchmark premium amount before application of MA plan subsidies;
– Extend the exception process for the Part B therapy caps;
-Create a demonstration project for reimbursement for culturally and linguistically appropriate services.

Medicaid Provisions Relevant to Medicare Beneficiaries

The House bill expands Medicaid coverage to non-disabled, childless adults under age 65 who are not eligible for Medicare and whose incomes are at or below 150% of the federal poverty level (FPL). It also extends coverage to certain “traditional” Medicaid populations – children, parents and people under 65 with disabilities – with incomes at or below 150% FPL. The latter expansion does not exclude people under 65 with Medicare, but none of the expansions includes people 65 and older. There is no asset test for individuals covered by these expansions. The Senate bill will likely expand Medicaid, as well, but less generously.

Medicare cost-sharing protections are added for people under 65 who, but for their income, meet the definition of a Qualified Medicare Beneficiary and whose incomes are less than 150% FPL.

Medicaid payments for primary care are increased over several years, with increases linked to Medicare payments.

Temporary increases in the federal matching payment to states that were made in the American Recovery and Reinvestment Act of 2009 are extended through June 2011.

The House bill requires the Secretary of Health and Human Services to establish an office or program within the Centers for Medicare & Medicaid Services to improve coordination between Medicare and Medicaid and protection for dual eligibles. The Senate bill is likely to have a similar provision, though the functions and duties of such an office or program are described somewhat differently.

Provisions of the House Bill Effective Immediately or Shortly After Passage

Various private insurance market reforms are effective in 2010. These include provisions establishing a temporary insurance program for those who have been uninsured for several months; requiring that insurers use 85% of premiums for benefits; prohibiting the rescission of policies except for instances of fraud; requiring annual review of premium increases by the Secretary of Health and Human Services; requiring insurers to allow for the continuation of coverage of children through age 26; shortening the time allowed for exclusion of coverage for pre-existing conditions; and prohibiting acts of domestic violence from being treated as pre-existing conditions.

Additional provisions effective in 2010 require insurers to pay for reconstructive surgery for children with deformities; eliminate lifetime aggregate limits on benefits; prohibit discriminatory reductions in retiree health coverage compared with coverage for active employees; establish a temporary reinsurance program to reduce retiree (age 55-64) out-of-pocket costs for those in employment based plans; establish a grant program for small employers to create non-discriminatory wellness programs; extend COBRA eligibility until the Health Insurance Exchange established by the bill is up and running; expand existing grant programs to states to promote coverage for the uninsured prior to 2013 when the Exchange begins, and require the Secretary of HHS to adopt standards for transactions between providers and insurers.

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While we specialize in Medicare Supplements, you can CLICK HERE to learn more more and even apply online for the Humana Part D Plan.

• Premium-free: Most people pay 0 dollars because they or their spouse paid Medicare taxes for at least 40 quarters (10 years) of work.
• Reduced premium: People with 30 to 39 quarters of work coverage pay 311 dollars per month.
• Full premium: Individuals with fewer than 30 quarters of work coverage pay 565 dollars per month.

• Deductible: 1,736 dollars per benefit period, which covers your share of costs for the first 60 days of inpatient care.
• Days 1 through 60: 0 dollars coinsurance per day.
• Days 61 through 90: 434 dollars coinsurance per day.
• Days 91 through 150 (Lifetime Reserve Days): 868 dollars coinsurance per day.
• Beyond Day 150: You are responsible for all costs.

• Days 1 through 20: 0 dollars coinsurance per day.
• Days 21 through 100: 217 dollars coinsurance per day.
• Beyond Day 100: You are responsible for all costs.

• Standard Premium: 202.90 dollars per month. Most enrollees pay this amount, which is often deducted automatically from Social Security checks.
• Income-Related Adjustments (IRMAA): Individuals with higher incomes (typically above 103,000 dollars for single filers or 206,000 dollars for joint filers based on past tax returns) pay an additional surcharge on top of the base premium.

• Annual Deductible: 283 dollars per calendar year. You must pay this amount out of pocket before Part B begins to pay.
• Coinsurance: 20 percent of the Medicare-approved amount for most outpatient services, doctor visits, and durable medical equipment after the annual deductible is met.

Yes! Because of our relationship with some insurance companies, we are one of a handful of agencies that can actually provide you with a true online application process for your Medicare Supplement Coverage. Other Internet sites tell you that they can do your application online, but once you enter your information – you find that it was not true. NOT WITH US! You can submit or application online in real time or we can help you also. Just call us at 1-800-247-9889. You can submit your application to us by clicking on “Apply Online Now” (on the right side of your screen). If the company you are applying for requests a “wet signature”, we will send, email or fax it to you to complete.

A Medigap policy is health insurance sold by private insurance companies to fill the “gaps” in Original Medicare Plan coverage. Medigap policies help pay some of the health care costs that the Original Medicare Plan doesn’t cover. If you are in the Original Medicare Plan and have a Medigap policy, then Medicare and your Medigap policy will pay both their shares of covered health care costs.

Insurance companies can only sell you a “Modernized” Medigap policy (as of June 1, 2010). These Medigap policies must all have specific benefits so you can compare them easily.

You may be able to choose up to 10 different Modernized Medigap policies (Medigap Plans A through N). Medigap policies must follow Federal and State laws. These laws protect you. A Medigap policy must be clearly identified on the cover as “Medicare Supplement Insurance.” Each plan, A through N, has a different set of basic and extra benefits.

It’s important to compare Medigap policies because costs can vary. The benefits in any Medigap Plan A through N are the same for any insurance company. Each insurance company decides which Medigap policies it wants to sell.

Generally, when you buy a Medigap policy you must have Medicare Part A and Part B. You will have to pay the monthly Medicare Part B premium. In addition, you will have to pay a premium to the Medigap insurance company.

You and your spouse must each buy separate Medigap policies. Your Medigap policy won’t cover any health care costs for your spouse.

For additional information on Medigap policies, including why you would want to buy a Medigap policy and information about what Medigap policies cover, please read this publication, Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare.

Medicare Supplement Open Enrollment Period

The best time to purchase a Medicare Supplement insurance policy (also called a Medigap policy) is during your Medigap open enrollment period. This 6 month period begins on the first day of the month in which you are both age 65 or older and enrolled in Medicare Part B. Once you enroll in Part B, your Medicare Supplement open enrollment period begins and cannot be changed. During this period, an insurance company cannot use medical underwriting. This means they can’t refuse to sell you any Medigap policy that they offer, make you wait for coverage to start, or charge you more for a Medigap policy because of past or present health problems.

Please note that you are allowed to apply early, before your Medicare Supplement open enrollment period starts. You should not wait until your health coverage has almost ended. This will allow you to have continuous coverage.

Medigap Guaranteed Issue Rights

Even if you are no longer in your Medigap or Medicare Supplement open enrollment period, there are situations in which you still have a guaranteed right to buy Medicare Supplement insurance. In these situations, an insurance company must sell you a Medigap policy (plan choices may be limited), must cover all of your pre-existing conditions, and can not charge you more for your policy because of health problems.

When Are Guaranteed Issue Rights Granted?

In most situations, you have guaranteed issue rights if you have other health care coverage that is changing in some way, or you are losing this coverage. Here is a summary of these situations:

#1: You are enrolled in a Medicare Advantage Plan, and this plan is leaving the Medicare Program or stops servicing your area, or you are moving out of your plan’s service area.

#2: You have employer health coverage or union coverage that pays after Medicare pays, and that coverage is ending.

#3: You have a Medicare SELECT policy, and you are moving out of the plan’s service area. You can keep your Medigap policy or switch to another Medigap policy.

#4: (Trial Right) You enrolled in a Medicare Advantage Plan or PACE when you were first eligible, and within your first year of joining, you wish to switch to the Original Medicare Plan.

#5: (Trial Right) You dropped a Medicare Supplement policy (Medigap policy) to join a Medicare Advantage Plan (or to switch to a Medicare SELECT policy) for the first time; you have been in the plan for less than a year and you want to switch back.

#6: Your Medicare Supplement insurance (Medigap) company goes bankrupt causing you to lose coverage, or your Medigap policy coverage ends through no fault of your own.

#7: You decide to drop a Medigap policy or leave a Medicare Advantage Plan because the company hasn’t followed the rules or misled you.

Additional Medigap Protection

The guaranteed issue rights listed on this page are from from Federal law. Many states include additional Medigap rights. Also, it is possible that more than one of these situations applies to you. If so, choose the guaranteed issue right that gives you the best choices of available plans for your situation. For more information on qualifying, call your State Health Insurance Assistance Program.

Most of our companies have NO Preexisting waiting periods on any health conditions you may have when you join the plan.

Beneficiary – General term used for one who receives a benefit. Used on this site to describe those people receiving Medicare benefits, or Medicare and Medicaid benefits when preceded by “Dual Eligible”.

CMS – Abbreviation for the Centers for Medicare & Medicaid Services, the federal agency that administers the Medicare program and works in partnership with the states to administer Medicaid, the State Children’s Health Insurance Program (SCHIP), and health insurance portability standards.

Creditable Coverage – Any health insurance coverage you had within 63 days of securing a new insurance policy that can be used to shorten the waiting period for pre-existing conditions.

Disenrollment – Leaving a health plan like an HMO.

Dual Eligible – A person who has both Medicare and Medicaid.

Doughnut Hole – deliberately designed gap in coverage in Medicare Part D; essentially a second huge deductible.

Election Periods – The times when a Medicare-eligible person can choose to join or leave Original Medicare or a Medicare Advantage plan. There are four types of election periods: the annual election period, the initial election period, the special election period, and the open enrollment period.

Enrollment – Joining Original Medicare or becoming a member of a private health plan, like a Medicare HMO.

FAQs – Frequently Asked Questions

Formulary – List of covered drugs

Lock-in – Inability to change Medicare plans for a certain amount of time

LIS – Low Income Subsidy, also called “Extra Help” that offers reduced cost-sharing to eligible beneficiaries.

Medicare Advantage – Formerly “Medicare+Choice”, or “Medicare Part C”; Medicare managed care/non-traditional Medicare plans; Medicare plans offered by Private companies, rather than through the traditional Medicare program

MA-PD – Medicare Advantage Plan with Prescription Drug Coverage

Medicare Part B – Medicare coverage for physicians’ services, some outpatient services & therapy, durable medical equipment, prosthetic devices, ambulance services, home health services not covered under Part A, some pap smear and mammography screens, flu shots, and some therapeutic shoes.

Medicare Part C – See Medicare Advantage

Medicare Part D – The Medicare prescription drug program

Medicare Portability – The ability – currently nonexistent – of a Medicare Eligible person to receive services from a Medicare approved provider outside the United States. Portability may also be an issue between states or service areas of Medicare Advantage plans, which are not always accepted nationwide, as traditional Medicare is.

Medicare Savings Programs (MSP) – Also known as Medicare Buy-In programs, they help pay your Medicare premiums and sometimes also coinsurance and deductibles. There are three Medicare Savings Programs, with different eligibility limits: QMB, SLMB, and QI-1.

Part D – Shorthand for Medicare Part D, the Medicare prescription drug program.

Plan – A program or policy stipulating services or benefits. In relation to Medicare, “plan” may be used in reference to Medigap, managed care, or prescription drug services.

Preferred Drug List – A drug list (formulary) includes selected brand name drugs that are considered preferred because of their overall ability to meet patient needs at a reasonable cost. If a brand-name drug is necessary, those classified as preferred may result in lower cost-sharing than non-preferred brand-name drugs.

Prescription Drug Plan – (PDP) Stand-alone drug plans under Part D. These plans offer drug Coverage only, allowing the beneficiary to remain in the traditional Medicare program for their other needs.

Re-importation – Purchasing prescription drugs from foreign countries

Rx – Prescription Drug

SPAP – State Pharmaceutical Assistance Plans

Special Needs Plan – MA plans in that they are intended to enroll, exclusively or disproportionately, only specific high-needs subpopulations of the Medicare population (dually eligibles, institutionalized beneficiaries, or beneficiaries with chronic conditions or disabilities). A SNP must be a “coordinated care” plan, either a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO) and must provide coverage for Part D, as well as for Parts A and B.

Spend-down – Process by which individuals who would be eligible for Medicaid except for their monthly income subtract their medical costs from their income to get it down to or below the limits for Medicaid.

True Out-of-Pocket Costs – (TrOOP) Prescription drug expenses paid by beneficiary, charity or SPAP.

Wrap around – Supplemental coverage offered in some states to fill in the gaps left by the Part D program.

Generally, Medicare is available for people age 65 or older, some younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or transplant).

If you already get benefits from the Social Security Administration or the Railroad Retirement Board, you are automatically entitled to Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) starting the first day of the month that you turn 65. You do not need to do anything to enroll. Your Medicare card will be mailed to you about 3 months before your 65th birthday. If you wait until you are 65, or sign up during the last three months of your initial enrollment period, your Medicare Part B start date will be delayed.

**EXAMPLE: If your 65th birthday is August 20, your Medicare effective date would be August 1. If your birthday is on the 1st day of any month, Medicare Part A and Part B will be effective the 1st day of the prior month. For example, if your 65th birthday is August 1, your Medicare effective date would be July 1.**

If you are not receiving Social Security, Railroad or disability benefits, you can enroll in Medicare and a Medicare drug plan up to 3 months before your 65th birthday and no later than 3 months after the month of your birthday. This is called the initial enrollment period. You will need to submit an application to the Social Security Administration. You can also sign up for Part B at your local Social Security office. They will determine if you are eligible, and then send you a Medicare card. Some government employees who have not paid into Social Security may also have to file an application. Social Security can answer any questions about your application.

If you want both Medicare Part A and Medicare Part B, you should sign your Medicare card and keep it in your wallet. If you don’t want Part B coverage, you must put an “X” in the refusal box on the back of the Medicare card form. You should then sign the form and return it in the enclosed envelope to the address shown (below where you sign the Medicare card). In about 4 weeks, you will receive a new card showing you only have Medicare Part A coverage.

Please be aware that if you decide to pick up Part B coverage at a later date, the cost of Part B may go up 10% for each 12-month period that you could have had Part B but did not sign up for it. Also, if you decline or cancel your Part B coverage, you will not be eligible to receive Medicare covered preventive services.

If you live in Puerto Rico and are receiving Social Security or Railroad Retirement benefits, you will be automatically enrolled in Medicare Part A only. If you would like to enroll in Medicare Part B, you’ll need to contact the Social Security Administration to fill out an application. If you do not enroll in Medicare Part B, you will be sent a Medicare card showing Part A only.

Note: A Special Enrollment Period is available if you waited to enroll in Medicare Part B because you or your spouse was working AND had group health coverage through a current employer or union. If this applies, you can sign up for Medicare Part B:

– While you are still covered by an employer or union group health plan, through your or your spouse’s employment, or
– During the 8 months following the month when the employer or union group health plan coverage ends or when the employment ends (whichever comes first).