Medigap Definitions

Information Provided by a Medigap Plan Representative

It’s important to be familiar with some key terms as you maneuver through the Medicare maze. Following are some important terms and definitions related to Medigap plan coverage:

Excess Charge

Original Medicare permits a doctor or other health care provider to charge more than the Medicare-approved amount for health care. The amount exceeding the Medicare-approved amount is the excess charge. By federal law, the excess charge is capped at 15%.

Guaranteed Issue Rights (also called “Medigap Protections”)

These are rights you have in situations where insurance companies are required by law to sell or offer you a Medigap plan. In such situations an insurance company cannot deny you a Medigap policy, place conditions (such as exclusions for pre-existing conditions) on a Medigap plan, or charge you more for a Medicare supplement insurance plan because of a past or present health problem.

More about Guaranteed Issue Rights

Guaranteed Renewable

This refers to an insurance policy that cannot be terminated by the insurance company unless you make false statements, commit fraud, or don’t pay your premiums. All Medigap policies issued since 1992 are guaranteed renewable.


Medicaid is a joint federal and state program that helps with medical costs for some people with limited income and resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

Medical Underwriting

Based on your medical history, this is the process that an insurance company uses to decide whether or not to accept your application for insurance, whether to add a waiting period for pre–existing conditions (if your state law allows it), and how much to charge you for insurance.

Medicare Advantage Plan (Medicare Part C)

Medicare Advantage is a health plan offered by a private company that contracts with Medicare to provide all your Medicare Part A and Medicare Part B benefits. Medicare Advantage plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you’re enrolled in a Medicare Advantage plan, Medicare services are covered through the plan and aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer Medicare prescription drug plans.

Medicare Cost Plan

Under this type of Medicare health plan, Original Medicare will pay for Medicare-covered emergency or urgently-needed services you receive outside the plan’s network without a referral.

Medicare Health Maintenance Organization (HMO) Plan

This type of Medicare Advantage (Medicare Part C) plan is available in some areas of the country. Most HMO plans require going to doctors, specialists, or hospitals on the plan’s list except in an emergency. Most HMOs also require you to get a referral from your primary care physician.

Medicare Medical Savings Account (MSA) Plan

Money deposited into your account is used to help cover health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount so you’ll probably have to pay out of pocket before coverage begins.

Medicare Preferred Provider Organization (PPO) Plan

Under this type of Medicare Advantage plan, not available in all areas of the country, you pay less by using doctors, hospitals, and other health care providers belonging to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

Medicare Prescription Drug Plans (Medicare Part D)

These stand-alone drug plans add prescription drug coverage to Original Medicare, some Medicare cost plans, some Medicare private-fee-for-service plans, and Medicare Medical savings account plans. If you have a Medicare supplement insurance plan without prescription drug coverage, you can add a Medicare prescription drug plan. These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage plans may also offer prescription drug coverage that follows the same rules as Medicare prescription drug plans.

Medicare Private Fee–for–Service (PFFS) Plan

This type of Medicare Advantage plan generally allows you to choose any doctor or hospital you could go to under Original Medicare providing the doctor or hospital agrees to treat you. The plan determines how much it will pay doctors and hospitals, and how much you must pay when receiving care. A Private Fee-for-Service plan is quite different from Original Medicare, and you must follow the plan rules carefully when you go for health care services. When enrolled in a PFFS plan, you may pay more, or less, for Medicare-covered benefits than you would if enrolled in Original Medicare.

Medicare SELECT

This type of Medicare supplement plan may require you to use hospitals and, in some cases, doctors within its network to be eligible for full benefits.

Medicare Special Needs Plan (SNP)

This is a special type of Medicare Advantage plan that provides focused and specialized health care. Those who may benefit from enrollment in an SNP plan include people enrolled in both Medicare and Medicaid, those residing in nursing homes, and people having certain chronic medical conditions.

Open Enrollment Period (Medigap)

This one-time only, six–month period mandated by federal law allows you to buy any Medicare supplement insurance plan you want that is sold in your state. It starts in the first month you’re covered under Medicare Part B after reaching age 65. During this period, you can’t be denied a Medigap policy or charged more due to past or present health problems. Some states may have additional open enrollment rights under state law.

More about Open Enrollment

Original Medicare

Original Medicare is fee-for-service coverage under which the government pays your health care providers directly for your Part A and/or Part B benefits.

Pre–Existing Condition

This is a health problem or condition you had before the date an insurance policy took effect.

State Health Insurance Assistance Program (SHIP)

A State Health Insurance Assistance Program receives money from the federal government in order to provide free local health insurance counseling to people with Medicare.

State Insurance Department

This is a state agency that regulates insurance and can provide information about Medicare supplement insurance plans and other private insurance.

That’s a lot to remember! It’s important to know the vocabulary relating to Medigap plans, but it’s even more important to compare plans and rates to make sure you find the policy that’s best for you. MedicareMall is the expert at shopping the market on your behalf, and we’re ready to find the Medicare supplement plan that will work for you. Contact us now and we’ll guide you through the Medicare maze to the place you want to be.

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