The Medicare program provides healthcare coverage to approximately 44 million Americans, making it America's largest government-sponsored healthcare program in which qualifying consumers can enroll. However, even though it provides coverage for many health-related issues, Medicare often does not cover the full cost of healthcare for participants. Participants, therefore, need to be aware of what is and is not covered by their particular plan in order to ensure that they purchase necessary Medicare Supplement insurance or enroll in additional coverage plans, if needed.

In order to determine what kind of Medicare Supplement insurance participants may need, they should first determine what type of Medicare plan they currently have. There are two types of coverage plans for participants: Medicare Part A and Part B.

Gaps in Medicare Part A

Part A is known as the Hospital Insurance plan because it covers inpatient hospital fees, inpatient skilled nursing facility fees, home health fees, and hospice services. However, Part A has a significant amount of gaps in coverage that you will not be reimbursed for.

  • A hospital deductible for each unique illness. In 2009, this deductible was $1,068.
  • Coinsurance payments for the hospital. After the deductible has been met, Plan A will cover the first 60 days of fees in full. However, for days 61 to 90, the coinsurance payment is $267 in 2009. For days 91 to 150, the coinsurance payment is $534 in 2009.
  • Hospital fees if a patient needs to stay beyond 150 days in the hospital.
  • Some coinsurance payments in skilled nursing facilities; Part A pays for the first 20 days in full. However, for days 21 to 100, the daily coinsurance payment in 2009 is $133.50.
  • Coverage for home health aide services that are provided on more than a part-time or an intermittent basis. - Coverage for any home health nursing or aide services where there is no skilled care.

Gaps in Medicare Part B

Part B is also known as Supplementary Medicare Insurance because it provides healthcare coverage for many physician and outpatient services that participants may need. Part B also provides coverage for many types of durable medical equipment, prosthetic devices, supplies needed to perform physician services, and even ambulance transportation. Gaps in Part B include:

  • The Part B deductible. An annual deductible needs to be met before Plan B will pay for covered services. This annual deductible for 2009 was $135.
  • The Part B coinsurance payment of 20 percent. Plan B will pay for 80 percent of an approved charge for services and items covered by Part B. This amount, of course, varies based on the services and items required.
  • Any portion of a bill that is not covered by Medicare. Participants need to keep in mind that many healthcare providers charge more than the fee that is approved by Plan B. Participants will need to pay the uncovered balance.

How to Fill Medicare Coverage Gaps

When a plan participant has a coverage gap, it is often wise for the participant to fill in the gap in order to ensure that he or she has more comprehensive healthcare coverage. There are several popular ways to fill these coverage gaps, including:

  • Government programs, including Medicaid, Qualified Medicare Beneficiary Program (QMB), Qualified Individual Program (QI), and Special Low Income Medicare Beneficiary Program (SLMB).
  • Non-standardized group retirement policies.
  • Non-standardized individual Medicare Supplement plans that were issues before July 31, 1992.
  • Standardized individual Medicare Supplement plans that were issued after July 31, 1992.

Participants should be aware that those who are eligible to receive Medicaid will not need Medigap insurance because Medicaid will provide coverage for their healthcare expenses. However, if participants do not qualify for Medicaid but are within 100 percent of the federal poverty level, they can be covered by the QMB. QMB covers Medicare premiums, annual deductibles, and coinsurance payments.

If individuals do not qualify for Medicaid but make too much money to qualify for QMB, they may qualify for the SLMB or the QI. SLMB and QI pay for a portion of the Part B premium, so participants who receive SLMB or QI support may want to purchase Medigap insurance to help with additional costs.

All Medicare participants should be aware of the gaps in coverage that apply to them. By understanding what their coverage gaps are, they can make arrangements to enroll in programs that can help to fill all or some of these coverage gaps, which will help to ensure that they are adequately covered for their healthcare costs, no matter what happens in the future.

Author's Bio: 

By Wiley Long - President, MedigapAdvisors.com - The nation's leading independent agency specializing in Medicare Supplemental Insurance. Our professional MediGap advisors look forward to the opportunity to help you get the best insurance for your healthcare needs.