Medi Gap Introduction 

A Medi-Gap policy is private health insurance that helps supplement Original Medicare. This means it helps pay some of the health care costs that Original Medicare doesn’t cover (like copayments, coinsurance, and deductibles). These are “gaps” in Medicare coverage.

If you have Original Medicare and a Medigap policy, Medicare will pay its share of the Medicare-approved amounts for covered health care costs. Then your Medigap policy pays its share.   A Medigap policy is different from a Medicare Advantage Plans – Part C  (HMO) because those plans are ways to get Medicare benefits, (here’s a comparison of the differences) while a Medigap policy only supplements the costs of your Original Medicare benefits. ^{Medicare.Gov Guide to Medigap} *

Scroll or jump down to see a side by side comparison of what Medicare Pays, what Medi Gap pays and then what you pay.

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  • Skilled Nursing — Home Health — Acute Care
    • Sub Acute Care
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• Medi-Gap or Medicare Advantage?
• G Extra? or ?

Evidence of Coverage

2022 Open Plans

Plan A 
Plan F Extra* 
Plan G 
Plan G Extra 
Plan G Inspire 
Plan N 

<<<<<<<<<<<<<<<<<Historical>>>>>>>>>>>>>>>>>>>>>>

Plan A, Jan. 2018 (PDF)
Plan F Extra, Oct. 2018  (PDF)
Plan G, Jan. 2018 (PDF)

Plan G Extra, Jan. 2020 (PDF)
Plan N, Jan. 2018 (PDF)

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  • 2023 Enrollment Material & Formulary by Plan
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References, Links & Bibliography 

• Coverage
  • SNF Skilled Nursing Medicare.Gov
• • Medicare.Gov  Glossary
  • Definitions 
• Benefit Period
  • CMS on Benefits Periods Official Detailed Manual
  • Medicare Rights.org
  • Medicare Interactive 

    • Benefit periods measure your use of inpatient hospital and skilled nursing facility (SNF) services. A benefit period begins the day you are admitted to a hospital as an inpatient, or to a SNF, and ends the day you have been out of the hospital or SNF for 60 days in a row. After you meet your deductible, Original Medicare pays in full for days 1 to 60 that you are in a hospital. For days 61-90, you pay a daily coinsurance.

      If you have used your 90 days of hospital coverage but need to stay longer, Medicare covers up to 60 additional lifetime reserve days, for which you will pay a daily coinsurance. These days are nonrenewable, meaning you will not get them back when you become eligible for another benefit period.

      Medicare will stop paying for your inpatient-related hospital costs (such as room and board) if you run out of days during your benefit period. To be eligible for a new benefit period, and additional days of inpatient coverage, you must remain out of the hospital or SNF for 60 days in a row. When you start a new benefit period, you will also have a new Part A deductible.

      Note: Medigap policies A through N pay for your hospital coinsurance and provide up to an additional 365 lifetime reserve days. Additionally, Plans B through N pay some or all of your hospital deductible. ^{Medicare Interactive} 

• Skilled Nursing over 100 days
  • SNF Skilled Nursing past 100 days Medicare Interactive
• Lifetime Reserve Days
  • Medicare Interactive from Medicare
  • Additional 365 from Medi Gap – EOC Page 4 II A 1 c 
    • c) Upon exhaustion of the Medicare hospital inpatient coverage including the sixty (60) lifetime reserve days, coverage for the Medicare Part A Eligible Expenses for hospitalization will be paid at the appropriate standard of payment which has been approved by Medicare, subject to a lifetime maximum benefit of an additional 365 days (except that psychiatric care in a psychiatric hospital participating in the Medicare program is limited to 190 days during the Subscriber’s lifetime);

    • CA Insurance Code (b) With respect to the standards for basic (core) benefits for benefit plans A to J, inclusive, every issuer shall make available a policy or certificate including only the following basic “core” package of benefits to each prospective insured. An issuer may make available to prospective insureds any of the other Medicare supplement insurance benefit plans in addition to the basic core package, but not in lieu of it. However, the benefits described in paragraphs (6) and (7) shall not be offered so long as California is required to disallow these benefits for Medicare beneficiaries by the Centers for Medicare and Medicaid Services or other agent of the federal government under Section 1395ss of Title 42 of the United States Code.

      • (1) Coverage of Part A Medicare eligible expenses for hospitalization to the extent not covered by Medicare from the 61st day to the 90th day, inclusive, in any Medicare benefit period.

        (2) Coverage of Part A Medicare eligible expenses incurred for hospitalization to the extent not covered by Medicare for each Medicare lifetime inpatient reserve day used.

        (3) Upon exhaustion of the Medicare hospital inpatient coverage including the lifetime reserve days, coverage of 100 percent of the Medicare Part A eligible expenses for hospitalization paid at the appropriate Medicare standard of payment,

             cms.gov/Physician Fee Schedule
        health care value hub.org/medicare-rates-benchmark-too-little-or-just-right
        AHA.org Fact Sheet
        Kaiser Health News What A Hospital Charges Vs. What Medicare Pays

        

        subject to a lifetime maximum benefit of an additional 365 days. The provider shall accept the issuer’s payment as payment in full and may not bill the insured for any balance.

    • (c) The following additional benefits shall be included in Medicare supplement benefit plans B to J, inclusive, only as provided by Section 10192.9.

      • (2) With respect to skilled nursing facility care, coverage for the actual billed charges up to the coinsurance amount from the 21st day to the 100th day, inclusive, in a Medicare benefit period for post hospital skilled nursing facility care eligible under Medicare Part A. ^{CA Insurance Code 10192.8 b} 

• Law, Legal Codes   &  Clinical Guidelines
  • CA Law on Medi Gap Policies 
  • Medicare General Information, Eligibility, and Entitlement
    • Chapter 3 – Deductibles, Coinsurance Amounts, and Payment Limitations
  • • Oscar (just for reference) Home Care – Skilled Nursing Care (RN, LVN/LPN) (CG020) English PDF
      • Home Care – Physical Therapy (PT) and Occupational Therapy (OT) (CG021) English PDF
      • Home Care – Home Health Aides (HHA) (CG022) English PDF
      • Home Care – Speech Language Pathology (SLP) Services (CG023) English PDF
      • Skilled Nursing Facility Care (CG042) English PDF
    • Blue Shield Medical Policy List
    • Medical Necessity
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• What is #Subacute Level of Care?

  • Sub acute rehab (also called subacute rehabilitation or SAR) is complete inpatient care for someone suffering from an illness or injury. SAR is time-limited with the express purpose of improving functioning and discharging home.1

    SAR is typically provided in a licensed skilled nursing facility (SNF).

    • A hospital, which is sometimes called “acute care,” is appropriate only for significant medical issues with the goal of a very short stay.

      An acute rehab center is designed for high-level rehab needs, typically requiring more than three hours a day of physical, occupation, or speech therapy

      Sub acute rehab (SAR) centers are usually most appropriate for people who need less than three hours of therapy a day, thus the label of “sub acute,” which technically means under or less than acute rehab.  ^{Very Well.com} *

  • Subacute patients are medically fragile and require special services, such as inhalation therapy, tracheotomy care, intravenous tube feeding, and complex wound management care.
    • Adult subacute care is a level of care that is defined as comprehensive inpatient care designed for someone who has an acute illness, injury or exacerbation of a disease process.
    • Pediatric subacute care is a level of care needed by a person less than 21 years of age who uses a medical technology that compensates for the loss of a vital bodily function.
    • There is some confusion, IMHO on if this is Hospitalization or Skilled Nursing ^dhcs.ca.gov * ^{Cedars Sinai} * ^{Knollwood Nursing Center} *
  • Subacute care, or subacute rehabilitation (SAR) is care received inpatient when recovering from an injury or illness. The care is usually received in a skilled nursing facility (SNF). ^{Medicare World} *
  • Review of the subacute care literature
  • Which patients benefit from Subacute care?
  • B. Subintensive Care Type Units.–Some hospitals have units which provide a level of care between other general routine and intensive care. These units are typically designated as subintensive, subacute, progressive, intermediate care units, etc. ^CMS.gov *
  • Medicare Benefit Policy Manual Chapter 8 – Coverage of Extended Care (SNF) Services Under Hospital Insurance  CMS.gov *
  • Subacute level of Care in a Skilled Nursing Facility (SNF) under Medicare Part A
  • OVERVIEW: Subacute nursing and rehabilitation services: services, furnished pursuant to physician orders, for members that are in a Skilled Nursing Facility and covered by Medicare Part A, that:• Require the skills of qualified technical or professional health personnel such as registered nurses, licensed practical nurses, physical therapists, occupational therapists, and speech-language pathologists or audiologists.
    • Must be provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the patient and to achieve the medically desired result.  and
    • Require a short term, goal-oriented treatment plan including complex skilled nursing care and/or high intensity level skilled rehabilitation.NOTE: Subacute care is generally more intensive than traditional nursing facility care and less intense than acute care.  ^{Common Wealth Care} * 
  • Medical Necessity Guideline
    Some examples of complex medical conditions that may require subacute skilled nursing or rehabilitative care:• Presence of serious injury or illness that requires inpatient treatment but not acute hospital care
    • Ventilator Program
    • Complex Respiratory Care and Treatments
    • Specialized Infusion Therapy
    • Brain Injury Rehabilitation
    • High Intensity Stroke
    • High Intensity Orthopedic Program
    • Specialized Post-Surgical Recovery Programs
    • Complex pain management ^{Common Wealth Care} *