What Medigap Programs Don't Cover Compared to Medicare
Part 3, Chapter 10: Medicare and Medicare Related Programs: Medigap and Secondary Health Insurance Policies Page 7
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Although Medigap policies are clearly important for individuals who are covered by the traditional Medicare plan, Medigap policies do have one serious limitation: They may not provide reimbursement for a service or for medical equipment that Medicare does not consider to be a covered expense. However, some secondary insurance plans -- employer-sponsored group health insurance plans that continue in place after retirement and that act as Medicare supplements -- may provide benefits in such situations. In some cases, secondary insurance plans may provide reimbursement of up to 80% of the cost of such services or medical equipment. They may also pay for a percentage of the cost of prescription medications and of other items that are not generally covered under the traditional Medicare program.
For example, let's say that a Medicare beneficiary has developed severe arthritis, is unable to walk more than a block or so because of pain and joint inflammation, and needs a wheel chair for longer distances. Since the arthritis has also affected her arms and shoulders, making it impossible for her to handle a manual wheelchair, a power chair or an electric scooter is necessary. In order to qualify for reimbursement under Medicare, her doctor would generally have to be able to certify that her condition made the use of a wheelchair medically necessary, and that it would not be medically possible for her to make use of a manual wheelchair.
In addition, the doctor would also need to be able to certify that she required the wheelchair for use in the house. Since the individual in this case is able to walk a block, she would probably not meet Medicare's definition of medical necessity. Thus, she would not qualify for reimbursement for the purchase of a power wheelchair or an electric scooter. If the qualifications for reimbursement for a power wheelchair or electric scooter are not met according to Medicare standards, a Medigap policy would probably not provide reimbursement either.
However, a secondary health insurance policy might include a much wider definition of medical necessity. In some cases, a secondary health insurance policy might provide for reimbursement of up to 80% of the cost of the power wheelchair or electric scooter -- assuming it provides for coordination-of-benefits with Medicare on an 80/20 basis -- even though Medicare did not consider the wheelchair to be a covered expense. Since a power wheelchair may cost as much as $20,000 -- depending on the particular wheelchair and on the accessories -- the difference in reimbursement between a Medigap policy and a secondary insurance policy would be highly significant in a situation such as this.
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