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.
Plans at a Glance
- Medi Gap Enrollment #Kit -- Summary of Benefits Rev October .2022
- A, F Extra, G, G Extra, G Inspire, and N Plan G
- Be sure to return the Paper application to us or see link above to enroll online
- Rates Los Angeles Scroll down for other counties
- No tobacco surcharge if you are applying during a guaranteed issue period, like turning 65 or lucking out and there is a Underwriting Holiday
- Going Forward ONLY ONE rate change per year!
- Ways to pay premium
- Don't like Rate Charts - Get Medi Gap quotes here
- Rate increases & rebates are subject to MLR Medical Loss ratio rules
- Rates go up by age, CA does not have community rating or attained issue age see FAQ
- April 2022 Rate Change on Closed Plans (no longer being sold) FAQ's
- Auto Pay FAQ's - Call Member Services to set it up 1-800-248-2341
- Paper #Application 10/2021 see above
- No extra charge for us to assist you! 17 reasons why...
Medicare Part A Hospital coverage helps pay for care in hospitals as an inpatient,... skilled nursing facilities, hospice care, and some home health care (see publication # 10969) but not Long Term Care.
Most people get Part A automatically when they turn age 65 at no charge, since they or a spouse paid Medicare taxes while they were working. You need to sign up close to your 65th birthday, even if you will not be retired by that time. (If you are getting Social Security benefits when you turn 65, your Medicare Hospital Benefits - Part A - start automatically.)
Here's a chart it's just a illustration and is NOT official that shows what Medicare pays, the gaps in Medicare and what you may get when you add a Medi Gap Plan or Medicare Advantage to cover those gaps.
Medi Gap – Supplement Plans
Pays on top of Medicare Parts A & B – Any Medicare Provider
Part B - Outpatient helps Pay For Doctors' services, outpatient hospital care, and some other medical services that Part A does not cover, such as the services of physical and occupational therapists, and some home health care see publication 10969, but not Long Term Care. Part B helps pay for these covered services and supplies when they are medically necessary.
Our Webpages with more detail:
- Coverage in Part A Hospital & B Doctor Visits? Part D Rx
- Chiropractic – Medicare A & B – MAPD
- Diabetes – Prevention & Coverage under Medicare & ACA
- Durable Medical Equipment
- End Stage Renal – Kidney Failure
- Hearing Aids
- Physical therapy – occupational speech
- Skilled Nursing SNF & Home Health What Medicare Pays
- Togetherness – Loneliness Social Determinants of Health
- Mental Health
- How to sign up for Medicare?
- FAQ Medical Necessity our Medical Necessity Webpage
- Original Medicare & Medi-Gap – Supplement vs Medicare Advantage MAPD
- 2022 Official Medicare Guide to choosing a Medi Gap Policy # 02110
- Anthem Blue Cross Information & Enrollment
- United Health Care
- Blue Shield – Medi-Gap Information & Enrollment
- Your Rights to Enroll without Health Questions
Medi Gap pays the medical expenses that Original Medicare Part A (Hospital) and Part B (Doctor) doesn't. Check out the chart on this page to see what Medicare Pays, what you pay and what a Medi Gap plan pays.
Original Medicare, Medicare Advantage nor Medi Gap pay for long term care either in a nursing home or at home care. Get more information on Long Term Care here. Even if you think you can't afford any extra premiums, there's a lot of valuable information to help with planning.
- Our Webpage on Medicare Assignment – Doctor Participating or Not?
- Compare Hospitals - Search Medicare.gov
- Medicare Guide to Choosing a Hospital Publication # 10181
- Hospital Readmission Penalty Look Up
- Long-Term Acute Care Hospital (LTACH) Clinical Guidelines - Oscar
- US News & World Report America's Best Hospitals
Dental PPO Plan and Dental + Vision brochure and enrollment application
EOC Evidence of Coverage
Evidence of Coverage
2022 Open Plans
Evidences of Coverage for 2010 Standardized Closed Plans (closed 9/30/2019)
Evidences of Coverage for Standardized and Pre-Standardized Closed Plans (closed prior to 5/31/2010)
Get complete descriptions of our closed Medicare Supplement plans.
Plan A (pre June 2010) (PDF)
Plan B (pre June 2010) (PDF)
Plan C (pre June 2010) (PDF)
Plan D (pre June 2010) (PDF)
Plan F (pre June 2010) (PDF)
Plan G (pre June 2010) (PDF)
Plan J (pre June 2010) (PDF)
Plan K (pre June 2010) (PDF)
Plan H Standard (PDF)
Plan H Plus Rx (PDF)
Plan I Standard (PDF)
Plan I Plus Rx (PDF)
Coronet Major Medicare (PDF)
Coronet Senior Standard (PDF)
Coronet Senior Plus Rx (PDF)
Golden Coronet Senior Standard (PDF)
Golden Coronet Senior Plus Rx (PDF)
Preferred Senior (PDF)
Closed plan rate sheets
Resources & Links
Member Services 1-800-248-2341
- Medicare Provider Finder (Any MD that takes Medicare works on this plan)
- Blue Shield guaranteed.acceptance.guide.
- Silver Sneakers.com
- Blue Shield CA .com – Explanation
- Blue Shield Financial Strength
- Medicare Supplement Plan Transfer Application – be sure to put in our name as agent and email [email protected] to us
- Medicare Enlightenment – Entire Video 18 minutes
- Different Parts of Medicare
- Original Medicare Parts A& B: What’s Not Covered
- When can I enroll in Medicare
- Your Medicare Coverage Choices at a Glance
- Medicare Advantage Plans – Part C
- Medicare Supplement Plans
- Prescription Drug Plans
Blue Shield Medi Gap Forms
- Member Portal
- Medicare Supplement Plan Transfer Application – Helpful tips, be sure to put in our name as agent and email to us Appoint us as your Broker – No Extra Charge
- Medi Gap Plan Replacement Form
- Silver Sneakers
- Blue Shield Brochure
- Email [email protected] or call us 310.519.1335
- Broker ONLY – Forms on Blue Shield Site
Prescription Drug 2022 #RxGuide
PDF # 11109
Coverage Gap - Donut Hole $2,000 Cap
- Premiums for those with High Income Parts D Rx & B Doctor Visits
- Medicare Rules for High Income People Medicare Costs # 11579
- Our #High Income Surcharge Video Explanation
- Our webpage on High Income Surcharge IRMAA
- Kaiser Foundation Introduction - Overview
- Medicare Rx Benefit Manual Rev 1.2016 83 pages
- Network Pharmacies, Formularies & Common Coverage Rules # 11136
- Insulin Maximum Co Pay $35
- Graphic on Part D Premium Increases & Why?
- Maximus Appeals LEP Late Enrollment Penalty
- VIDEO How Part D Late Enrollment Penalty is calculated
- Shop & Compare Tools Part D Rx
- Get Instant Quotes, Information & Enroll online
- MANDATED wording!: ‘‘We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1–800–MEDICARE to get information on all of your options.’’ § 422.2267(e)(41).
- We disagree with the above wording, as we can use the same tools on Medicare.gov as they do!
Child & Related Pages – Site Map
References, Links & Bibliography
- SNF Skilled Nursing Medicare.Gov
- Medicare.Gov Glossary
- 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,
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
- Oscar (just for reference) Home Care – Skilled Nursing Care (RN, LVN/LPN) (CG020) English PDF
- Blue Shield Medical Policy List
- Medical Necessity
- Appoint us or someone else the authority to get confidential information from Blue Shield on your account
- Get a Blue Shield Member Portal
- Get ONLINE Account for Medicare & Social Security
- 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 *
How does Medicare pay for #SkilledNursing Homes - 10153
- Your costs for Skilled Nursing in Original Medicare You pay:
Days 1–20: $0 for each benefit period .
- Days 21–100: $194.50 coinsurance per day of each benefit period.
Days 101 and beyond: All costs. Medicare.gov *
- Clinical Guidelines explain the coverage so much better and in logical order!
- Medicare's VIDEO Nursing Home / Long-Term Care
- Planning for Discharge from a Health Care Setting VIDEO
- Long Term #Acute Care Publication # 11347
- Long-Term Acute Care Hospital (LTACH) Clinical Guidelines - Oscar
- Differences between Skilled Nursing, Long Term Acute Care & Inpatient Rehabilitation Facility
- Our FAQ on Sub Acute Care
- Find & compare nursing homes, hospitals & other providers near you Medicare.Gov
- Learn more about providers
- Calculate Cost of Long Term Care in your Area Genworth
- Our Webpagse on Long Term Care
- I think it’s fairly simple — if you want the most coverage, you get A, B, D + F.. Am I correct?
- Depends what you mean by “most.” Part A covers hospital. Part B doctor visits. Learn More Part D covers outpatient prescriptions, rx. Plan F pays the co pays and deductibles in A & B. See the comparison below and note that the standard F doesn’t have the $2,240 deductible.
- Some would say “most” might be a Medicare Advantage plan, in that the premiums are usually nil. One downside is the limited HMO doctor list Medicare Advantage MAPD may also cover vision and dental. Check our Medicare Advantage pages to learn more. Here’s our page on comparing Medi Gap vs MAPD. Medi Gap though gives you MUCH more freedom of choice of doctors.
- I’m thinking of getting Hi F, with the $2,240 deductible. How do I know if that’s the right plan for me?
- There is no FREE LUNCH when you buy Insurance. The Insurance Companies are in business to make a profit. Either way, the Insurance Company has calculated that they will pay out 80 cents on each dollar of premium they take in.
- Check out the sample rates below from the Blue Shield Medi Gap Brochure
- Does saving around $120/month or $1,400/year make it worth it to get back $2,200 if you have that many claims?
- Why not get Long Term Care, where the stakes are higher and there is the potential for real loss and hardship. The difference between F and Hi F is $800. I don’t think that will bankrupt anyone.