Step 1 of 2: Medical profile   Gender Date of birth Height Weight Smoker? Applicant* M F / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Spouse -- M F / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children 0  1 2 3 4 5 6         Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Currently Insured?* Yes No Have conditions?* yes   no Please specify  Take medications?* yes   no Please specify  Step 2 of 2: Tell us about yourself First Name* Last Name* Address* City* State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip* Day Phone* Evening Phone* Contact Time* Morning Afternoon Evening Email* By submitting this form, you agree to be legally bound to, and abide by, the Privacy Policy.

Medigap (Medicare Supplement Plans)

Medigap plans are health insurance policies sold by private insurance companies designed to fill in the "gaps" in the Original Medicare Plan coverage. A Medigap policy is not needed in a Medicare + Choice plan.

There are 10 standardized Medigap plans, "A" through "J". Plan A covers only the basic benefits (included in all of the plans), while plan J offers the most benefits.

Medicare SELECT is a type of Medigap policy available in some states. Medicare SELECT policies generally cost less but require you to use specific hospitals and, in some cases, specific doctors to get full insurance benefits.

What it covers: Medigap plans pay most, if not all, of the Original Medicare Plan coinsurance and outpatient copayment amounts. Medigap may also cover Original Medicare Plan deductibles.

Some examples of Gaps in Medicare covered services What YOU Pay in 2003	A Medigap Policy May Help Pay These Costs
Hospital Stays $840 for the first 60 days $210 per day for days 61 -90 $420 per day for days 91 -150
Skilled Nursing Facility Stays Up to $105 per day for days 21-100
Blood Cost of the first 3 pints
Medicare Part B yearly deductible $100 per year
Medicare Part B covered services 20% of Medicare-approved amount for most covered services 50% of the Medicare-approved amount for outpatient mental health treatment* Copayment for outpatient hospital services
*All Medigap policies must pay 50% coinsurance for outpatient mental health treatment services.

       *Chart reproduced from www.medicare.gov

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