Medigap in Massachusetts

Medigap, also known as Medicare Supplement insurance, covers the gaps of Original Medicare benefits. It primarily helps to cover the out-of-pocket costs associated with Original Medicare, such as coinsurance and deductibles. While Medigap plans are standardized in most states, Medigap options in Massachusetts differ. 

Medicare Supplement plans for Massachusetts residents are the Core Plan, Supplement 1 Plan, and Supplement 1A Plan, rather than the lettered Plans A, B, C, D, F, G, K, L, M, and N. Along with Wisconsin and Minnesota, Massachusetts is one of only three states that have their own set of Medigap plans.

Massachusetts is also a guaranteed issue rights state. This means that regardless of preexisting health conditions, you cannot be denied Medicare Supplement coverage, nor can you be charged more for that coverage because of your health status.

What Are Medicare Supplement Plans?

Medicare Supplement plans offer coverage for out-of-pocket costs associated with Original Medicare. Original Medicare is a federal healthcare program for people 65 years of age and older, or those who have certain diseases and conditions. It provides coverage for hospital care (Part A) and medical care (Part B), and has associated out-of-pocket costs, including coinsurance and deductibles.

Based on your medical needs and frequency of care, the cost of a Medigap plan premium may be significantly less than the out-of-pocket costs it helps to cover. In these cases, Medigap can help make Medicare expenses more affordable.

Though provided by private insurance companies, Medigap plans must still adhere to federal and state regulations.

To enroll in a Medicare Supplement plan, you must first enroll in both Parts A and B of Original Medicare. Medicare Supplement plans can help cover the following costs from Medicare: 

• Deductibles coverage: Your deductible is the amount of money you must pay each year on eligible healthcare expenses before your Medicare healthcare coverage begins. Many Medigap plans cover Part A of your Original Medicare coverage deductible by up to 50%, reducing the amount you need to pay before Medicare steps in to begin coverage of your healthcare needs.
• Coinsurance coverage: After you’ve met your yearly deductible for Medicare coverage, you’ll still be responsible for a percentage of the cost of your healthcare services. For example, Medicare beneficiaries are typically responsible for paying 20% of all covered inpatient services. Medicare Supplement plans help reduce or completely cover that coinsurance amount.

Note that only those enrolled in Original Medicare are eligible for Medigap. Those with a Medicare Advantage plan are not eligible to enroll in Medigap.

Your Options for Medicare Supplement Plans in Massachusetts

Benefits	Core Plan	Supplement 1A	Supplement 1
Basic benefits	Yes	Yes	Yes
State-mandated benefits	No	Yes	Yes
Part A: inpatient hospital deductible	No	Yes	Yes
Part A: skilled nursing facility coinsurance	No	Yes	Yes
Inpatient days in mental health hospitals	60 days per calendar year	120 days per benefit year	120 days per benefit year
Foreign travel emergency	No	Yes	Yes
Part B: deductible	No	No	Yes

Core Plan

The Medicare Supplement Core Plan for Massachusetts is the foundational plan for gap coverage. The other Medigap plans in Massachusetts all build on top of the Core Plan.

• Part A hospital coinsurance for inpatient hospital care: If you are hospitalized, the Core Plan will cover Part A coinsurance costs.
• Part B medical coinsurance: If you need labwork done or access to durable medical equipment like canes, crutches, wheelchairs, or oxygen equipment, the Core Plan will pay for the Part B coinsurance costs. This is typically 20% of the cost of covered services.
• The first three pints of blood each calendar year: If you need blood transfusions, the Core Plan will cover the initial three pints.
• Part A hospice coinsurance: If you require hospice care, the Core Plan will cover your portion of coinsurance and copayments.
• Up to 60 days of inpatient mental health facility care: Should you need mental health care of any kind, you may visit an inpatient facility for up to 60 days per year without having to consider out-of-pocket costs.
• Annual Pap tests and mammograms: This is a Massachusetts-specific required cost coverage for Medigap plans.

Supplement 1A

Medicare Supplement 1A plans provide additional coverage on top of what you get from a Core Plan. The main difference between Supplement 1A plans and Supplement 1 plans is that Supplement 1A plans do not cover your medical insurance (Part B) deductible. This means with the 1A plan, you will still need to meet your policy’s deductible out of pocket before Medicare coverage begins.

In addition to Core Plan coverage, Supplement 1A plans also cover:

• Inpatient Part A hospital deductible: If you are hospitalized, not only will the Supplement 1A plan provide coinsurance coverage, but it will also cover your deductible before your Original Medicare benefits kick in.
• Part A skilled nursing facility coinsurance: If you require care in a skilled nursing facility after injury, the Supplement 1A plan will cover your portion of coinsurance.
• Medicare-covered healthcare services while traveling abroad in foreign countries: In most cases, Medicare does not cover healthcare costs if you’re in a foreign country. The Supplement 1A plan, however, can assist you with payments for Medicare-covered healthcare services.
• Up to 120 days of inpatient mental health facility care: Supplement 1A plans extend your coverage for staying in mental health facilities by an additional 60 days beyond Core Plan coverage.

Supplement 1

Supplement 1 plans are currently being phased out in Massachusetts. They are no longer available to anyone who became eligible for Medicare after Dec. 31, 2019, though those who became eligible for Medicare before that date may still enroll in a Supplement 1 plan. The Supplement 1A plan is available for those who became eligible for Medicare on January 1, 2020 or later.

In addition to Core Plan coverage, Supplement 1 plans also cover:

• Part B medical deductible, such as getting lab work done or seeing a general practitioner
• Inpatient Part A hospital deductible
• Part A skilled nursing facility coinsurance
• Medicare-covered healthcare services while traveling abroad in foreign countries
• Up to 120 days of inpatient mental health facility care

Medigap Eligibility in Massachusetts

Those who are eligible for Medicare and 65 years of age or older are eligible for Medigap in Massachusetts. You must also already be enrolled in both Parts A and B to enroll in a Medigap plan. Those who receive their Medicare coverage with a Medicare Advantage plan are not eligible for Medigap.

Those who are younger than 65 years old and on Medicare due to disability have more limited options for Medigap in Massachusetts, as insurers must offer at least one option for those under 65. In addition, if you became eligible for Medicare on or after Jan. 1, 2020, you are not eligible for Supplement 1 plans.

When to Enroll in Medigap in Massachusetts

Because Massachusetts is a guaranteed issue rights state, you cannot be denied coverage due to pre-existing conditions or be charged higher rates due to your health status. This is unlike most other states, where outside of an individual’s initial enrollment period, insurers may use medical underwriting to raise prices or deny coverage.

Also unlike most states, where you may apply for a Medigap plan throughout the year, Massachusetts has one Open Enrollment Period each year outside of your Individual Initial Enrollment Period.

Individual Initial Enrollment Period

• When: Begins the first month you have Medicare Part B and lasts for 6 months after.
• What You Can Do: Enroll in Medigap

This period typically begins on or around your 65th birthday, but may also be delayed if you delay enrollment in Medicare Part B. It will automatically trigger once your Part B enrollment begins.

Medigap Open Enrollment Period

• When: February 1 – March 31 each year
• What You Can Do: Enroll in a Medigap plan if eligible

During the state’s annual Medigap Open Enrollment Period, even if you have health problems, you can buy any policy a company sells for the same price as people with good health. In most cases, you may not switch Medigap policies except during a Special Enrollment Period.

Special Enrollment Periods

• When: Varies
• What You Can Do: Enroll in a Medigap plan or change Medigap plans

Certain events can trigger Special Enrollment Periods, which allow for you to enroll in a Medigap plan or change plans outside of your Initial Enrollment Period and the annual Open Enrollment Period. Common triggers for Special Enrollment Periods include:

• If your current insurance company stops offering coverage in your area
• If you move out of your plan’s coverage area

Medigap vs. Medicare Advantage

While Medigap plans act as a supplement to Original Medicare, Medicare Advantage plans are an alternative that replaces Original Medicare. As such, Medigap plans do not provide any health coverages on their own; their primary purpose is to help with the costs associated with Original Medicare. Medicare Advantage plans, on the other hand, offer health benefits.

All Medicare Advantage plans offer at least the same health coverages as Original Medicare, and many have additional benefits too, such as Part D prescription drug coverage, vision care, and dental care. Some Medicare Advantage plans feature $0 premiums, but all have their own deductibles, copays, and coinsurance costs, which could end up costing more than paying for Original Medicare and Medigap, depending on your healthcare needs.

You may find a Medicare Supplement plan better if:

• You have regular healthcare needs, such as recurring appointments
• You frequently travel or think you may need coverage outside of your immediate area
• You want to limit your deductible (or in some cases, remove it entirely), giving you a more predictable level of expense for your healthcare

You may find a Medicare Advantage plan more suitable if:

• You do not need to use your health coverage often so that your premium is typically the only expense you have
• You do not mind having a more limited network of healthcare practitioners to choose from
• You do not anticipate needing to access healthcare outside of your particular healthcare network area