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Congressional Research Service 7-5700 www.crs.gov R42745 Summary Medicare is a nationwide health insurance program for individuals aged 65 and over and certain disabled individuals. The basic Medicare benefit package (termed "original Medicare" in this report) provides broad protection against the costs of many health care services. However, Medicare beneficiaries may still have significant additional costs, including co-payments, coinsurance, deductibles, and the full cost of services that are not covered by Medicare. To decrease their potential financial liability, some Medicare beneficiaries enroll in employer-sponsored insurance, Medicare Advantage, or Medicaid. This report focuses on another option. In 2010, about 22% of Medicare beneficiaries purchased the private supplemental insurance known as Medigap to fill some of the cost gaps left by original Medicare. All Medigap plans cover some percentage of Medicare's cost sharing. Some plans offer additions to these basics, including various combinations of greater coverage of Medicare cost sharing, and care associated with foreign travel emergencies. The most popular plans are the most comprehensive, and cover all deductibles, co-payments, and coinsurance not covered by Medicare. Medigap generally does not cover medical treatments not covered by Medicare, although it does extend coverage for certain covered services, such as coverage for additional hospital days beyond the Medicare benefit limit. Medigap is financed through beneficiary payments to private insurance firms. Federal law requires that Medigap insurers observe many consumer protections. Consumer protections are especially strong during open enrollment, which is a six month period that begins for most individuals during the month they turn 65. During this period, individuals are protected against insurers refusing to sell them any Medigap policy that the insurer offers, insurers setting premiums based on the individual's health, and insurers imposing waiting times on the start of the policy, other than a maximum of a six-month waiting period for preexisting conditions. Following the open-enrollment period, beneficiaries have other rights in limited situations, such as when they move to a different state. Guaranteed issue (or the right to buy a plan, to have the plan's premium not depend on health status, and in some cases to have the plan start coverage of preexisting conditions immediately) is one such right. The right of guaranteed renewability is available in a wide variety of situations, and genetic discrimination is forbidden. Moreover, Medigap insurers must pay out at least 65% (and sometimes 75%) of total premiums as claims to the beneficiaries. Recent data show that Medigap premiums vary by states and other factors. Medigap beneficiaries are concentrated in certain areas of the country and are more likely to have lower incomes than those holding employer-sponsored retiree health insurance. A relatively small number of insurance firms sell Medigap plans. The Patient Protection and Affordable Care Act (ACA; P.L. 111-148 as amended by P.L. 111-152) requested that the Secretary of Health and Human Services ask the National Association of Insurance Commissioners (NAIC) to review and revise existing standards to examine the feasibility of requiring greater cost sharing for Medigap beneficiaries. The NAIC did so, and recommended that the current cost sharing not be changed. The Secretary accepted this recommendation. This report provides a broad overview of Medigap insurance. It covers the history of Medigap legislation, the various types of Medigap plans, consumer protections awarded to Medigap beneficiaries, and the requirements facing the insurance providers and the NAIC. The report ends with an empirical description of Medigap markets. Contents Introduction 1 Medicare Coverage 2 Supplementing Medicare 4 Medigap Plans 5 History of Medigap Statutes 6 During the 1980s 6 During the 1990s 7 During the 2000s 8 Coordination of Payment Between Medicare and Medigap 9 Plan Characteristics 9 Standardized Plans 9 Pre-standardized Plans 11 Older Standardized Plans Available for Renewal Only 11 Medigap Plans for States with Waivers 12 SELECT Plans 12 High-Deductible Plans 12 Plan Enrollment 12 Consumer Protections 14 During the Open Enrollment Period 14 After the Open Enrollment Period 15 Guaranteed Issue 15 Guaranteed Renewal 17 Genetic Nondiscrimination 17 Switching Medigap Plans 17 Medigap for Individuals Under the Age of 65 17 Insurers' Requirements 18 Required Plans 18 Premiums 18 Medical Loss Ratios 19 The Role of the National Association of Insurance Commissioners 20 Descriptions of Medigap Markets 20 Medigap Premiums and Plan Choice 20 Medigap Market Participation by Individuals Across States 21 Medigap Markets by Characteristics of Enrollees 23 Figures Figure 1. Sources of Supplemental Coverage Among Medicare Beneficiaries, 2012 5 Figure 2. Distribution of Current Medigap Plans, All Medigap Beneficiaries, 2013 13 Figure 3. Medigap Enrollment by State, 2013 22 Figure 4. Percentage of Medicare Enrollees with Medigap Coverage by State, 2012 23 Tables Table 1. Select Original Medicare Cost-Sharing Levels, 2015 3 Table 2. Standard Medigap Plans, Effective On or After June 1, 2010 10 Contacts Author Contact Information 24 Introduction Medicare is a nationwide health insurance program for individuals aged 65 and over and certain younger disabled individuals. The basic Medicare benefit package (termed "original Medicare" in this report) provides broad protection against the costs of many health care services. However, Medicare beneficiaries may still have significant additional costs. Medicare requires beneficiaries to pay part of the cost for most covered services, provides only limited protection for some services (e.g., medical costs incurred outside of the United States), and provides no protection for other services (e.g., custodial long-term care, hearing aids, and dentures). Furthermore, unlike most large group health insurance policies, original Medicare contains no upper ("catastrophic") limit on out-of-pocket expenses. As a result, Medicare beneficiaries have the potential to incur high out-of-pocket costs for their health care. Most Medicare beneficiaries therefore have some form of (private or public) additional coverage to pay for some or all of their out-of-pocket costs for Medicare benefits. Medigap is one form of private supplemental coverage; Medigap fills some of the cost gaps left by Medicare, such as deductibles, coinsurance, and co-payments. In order to be eligible to purchase Medigap, individuals must be enrolled in both Part A (Hospital Insurance) and Part B (Supplementary Medical Insurance) of original Medicare, and not enrolled in Medicare Advantage (an HMO-type plan). Medigap is financed through beneficiary payments to private insurance firms, although retirees may have premiums paid on their behalf by their former employers. There are no government contributions toward Medigap premiums. This report provides an overview of Medigap, which is also known as Medicare Supplement insurance. After a review of Medicare coverage, the report covers the ways in which Medicare is supplemented. A discussion of the Medigap plans includes standardized plans, pre-standardized plans, older standardized plans available for renewal only, plans in states with Medigap waivers, SELECT plans, and high-deductible plans. The analysis then covers various consumer protections, and the requirements for the insurance companies that offer Medigap. Next, the role of the National Association of Insurance Commissioners (NAIC), a nongovernmental advisory body, is discussed. The report then provides an empirical picture of Medigap markets. The report concludes with a brief discussion of several current policy issues. First, how much of the total collected premiums might each insurer be expected to return to its beneficiaries as payment for claims? Second, what is the potential effect on Medicare spending of increasing the share of health care costs that the individual must pay out of his or her own pocket? This second question relates to the recent prohibition against Medigap insurers from covering the deductible for Medicare outpatient services. Medicare Coverage Medicare consists of four parts: Part A, Hospital Insurance (HI), covers inpatient hospital services, skilled nursing care, some home health care, and hospice care. Part B, Supplementary Medical Insurance (SMI), covers physician and non-physician practitioner services, outpatient services, some home health care, durable medical equipment, clinical laboratory and other diagnostic tests, preventive services, Part B drugs and biologics, and other medical services. Part C, Medicare Advantage (MA, a private plan option for beneficiaries) covers all Part A and Part B services, except hospice care. Part D covers prescription drug benefits. Together, Part A and Part B of Medicare comprise original Medicare, which covers benefits on a fee-for-service (FFS) basis. Currently most Medicare beneficiaries choose original Medicare, obtaining covered services through the providers of their choice with Medicare paying its share of the bill for each rendered service. Most individuals aged 65 and over are automatically eligible for premium-free Part A based on either their own or their spouse's work history. These individuals also are eligible for voluntary enrollment in Part B, which requires a premium of $104.90 a month for most individuals. Higher-income enrollees pay higher premiums. In 2015, individuals whose modified adjusted gross income exceeds $85,000 and each member of a couple filing jointly whose modified adjusted gross income exceeds $170,000 are subject to higher premium amounts. Everyone enrolled in Part A and/or Part B can elect Part D, with premiums varying by the Part D plans. In 2015, about 54 million beneficiaries are enrolled in Medicare. Table 1 provides a brief overview of the coverage offered under Medicare Part A and Part B, along with the associated cost sharing. Table 1. Select Original Medicare Cost-Sharing Levels, 2015 Benefits Cost Sharing for Beneficiariesa Medicare Part A Inpatient Hospital Stay, per Benefit Periodb Days 1-60 $1,260 deductible Days 61-90 $315 per day Additional Days 100% Lifetime Reserve Days (up to 60 lifetime) $630 per day Home Health Care $0 Hospice Care Care $0 Prescriptions Up to $5 Inpatient Respite Care 5% Skilled Nursing Facility Care, per Benefit Period Days 1-20 $0 Days 21-100 $157.50 per day After Day 100 100% Medicare Part B Medical and Other Services (includes physicians)c 20% Excess Chargesd 100% Home Health Care $0 Part B Deductiblee $147 per year Blood Varies by the treatment setting and other factors Foreign Travel Emergency No coverage of foreign travel emergencies Out-of-Pocket Limit No out-of-pocket limit Sources: Centers for Medicare & Medicaid Services, Medicare 2015 Costs at a Glance, at http://www.medicare.gov/your-medicare-costs/costs-at-a-glance/costs-at-glance.html. Cost sharing is waived for certain screenings and preventive services. The deductible is waived for home health services, community health services, preventive services, and some other services. A benefit period begins the day the beneficiary is admitted to a hospital or skilled nursing facility, and ends when the beneficiary has not received hospital or skilled nursing care for 60 consecutive days. There is a 190-day limit on lifetime inpatient mental health care days in a psychiatric hospital. Part B also covers clinical laboratory and other diagnostic tests; durable medical equipment, prosthetics, orthotics, and supplies; certain specified outpatient prescriptions, drugs, and biologics; hospital outpatient department services; ambulatory surgical center services; ambulance; and rural health clinics and federally qualified health centers. Excess charges are the difference between the Medicare approved amount and actual charges, subject to charge limitations set by Medicare or state law. Home health services, community health services, some preventive services, and some other services are not subject to the Part B deductible. Medicare does not cover all medical goods and services, including custodial long-term care, routine dental care, dentures, vision care, cosmetic surgery, acupuncture, most care received in other countries, charges above what Medicare reimburses, and hearing aids, among others. There is no out-of-pocket limit under original Medicare. Alternatively, some beneficiaries are enrolled in Medicare Advantage (MA), which is also known as Part C. These beneficiaries obtain all covered Medicare services except hospice care through private insurers, such as health maintenance organizations (HMOs). Some Part C enrollees may be offered additional benefits beyond what is available in original Medicare; the scope of additional benefits varies by the health insurance plan. MA plans may include drugs through MA-PD (prescription drug) plans. Individuals who are enrolled in an MA plan may not be sold a Medigap plan. Supplementing Medicare Many individuals have additional health insurance coverage to help pay for some of the costs that Medicare does not cover. Figure 1 presents the breakdown across supplemental coverage types in 2012. Figure 1. Sources of Supplemental Coverage Among Medicare Beneficiaries, 2012 Source: America's Health Insurance Plans (AHIP) Center for Policy and Research, Beneficiaries with Medigap Coverage, April 2015, p. 2, at http://www.ahip.org/epub/MedigapBeneficiaries. Notes: Data are from the Medicare Current Beneficiary Survey, Access to Care File. Individuals are assigned to the supplemental coverage category according to a hierarchy developed by AHIP used for the first time in this report. Therefore, these data are not comparable to data from earlier years, even if the earlier data were provided by AHIP. Of all individuals enrolled in Medicare in 2012, 17% had no supplemental coverage; these individuals relied solely on original Medicare. The largest percentage of all Medicare beneficiaries with supplemental coverage (27%) was enrolled in Medicare Advantage. Beneficiaries in next-largest group of individuals (23%) received supplemental health insurance from their employer. Medigap (21%) and Medicaid (11%) were other sources of supplemental insurance. Nationally (but excluding California), 10.2 million policyholders had Medigap coverage in 2012. Medigap Plans Medigap policies are sold in both the individual and the group health insurance markets. Whether purchased in the individual or the group market, each Medigap policy covers one individual. Plans are identified by letter, and each plan is associated with a specific benefit package. For example, all Plan As have the same benefit package. The term plan refers to all the Medigap insurance contracts with a common benefit package (e.g., Plan A), and the term policy refers to an insurance contract sold by an insurer to a beneficiary (e.g., United Healthcare's Plan A). Federal law governing the sale of Medigap plans is contained in Section 1882 of the Social Security Act. This section of the report first provides a history of Medigap legislation, and then characterizes the various Medigap plans. History of Medigap Statutes Health insurance regulation largely has been and continues to be the province of the states; Medigap is a partial exception. Congressional changes to Medigap over the years can be characterized along several dimensions. What began as voluntary standards governing the behavior of insurers increasingly became requirements. Consumer protections were continuously strengthened, and there was a trend toward the simplification of Medigap reimbursements whenever possible. During the 1980s The federal government first provided a voluntary certification option for Medigap insurers in Section 507 of the Social Security Disability Amendments of 1980 (P.L. 96-265), commonly known as the "Baucus Amendment." To meet the Baucus Amendment's voluntary minimum standards, the Medigap plan was required to meet or exceed the NAIC model standards for such plans, and return to policyholders as aggregate benefits at least 75% of the aggregate amount of premiums collected in group policies and at least 60% of the aggregate amount collected in individual policies. Whether or not the insurers met these voluntary standards, the Secretary of Health, Education, and Welfare (now Health and Human Services, HHS) was required to make information available to Medicare beneficiaries about the value of Medigap policies, study the methods the states used to regulate Medigap plans, and report to Congress, at least once every two years, on the effectiveness of the certification procedure. The move toward increased consumer protections was evident beginning in the late 1980s. The Medicare and Medicaid Patient and Program Protection Act of 1987 (P.L. 100-93) provided that individuals who knowingly and willfully make a false statement or misrepresent a medical fact in the sale of Medigap are guilty of a felony. The Omnibus Budget Reconciliation Act of 1987 (OBRA87; P.L. 100-203) permitted the participating physicians or suppliers to be paid directly by the Medigap plans. The Medicare Catastrophic Coverage Act of 1988 (MCCA; P.L. 100-360) improved the information available to potential Medigap purchasers by directing the Secretary of HHS to inform them about sales abuses, publish a toll-free phone number to report such abuses, and inform potential beneficiaries of the addresses and telephone numbers of state and federal offices that provide information and assistance. MCCA also required that Medigap plans offered in a state meet or exceed the NAIC guidelines; if this requirement was not met, federal model standards would be established for that state. Several provisions in MCAA would have made additional changes to Medicare, but they were repealed (before they went into effect) by the Medicare Catastrophic Coverage Repeal Act of 1989 (P.L. 101-234). The changes included expanding Medicare Part B benefits; imposing an annual supplemental Medicare premium on Part A beneficiaries whose tax liability equaled or exceed $150; and imposing an out-of-pocket maximum on Part B expenditures. These changes would generally have lowered the Medicare beneficiary's level of cost sharing, and therefore interact with Medigap. During the 1990s The Omnibus Budget Reconciliation Act of 1990 (OBRA90; P.L. 101-508) replaced some voluntary guidelines with federal standards. In particular, OBRA90 provided for the sale of only 10 standardized Medigap plans (in all but three states) known as Plan A through Plan J; guaranteed plan renewability (with rare exceptions); prohibited the selling of policies that duplicated certain health insurance provisions to which a beneficiary was entitled, for instance through a retiree health plan; curtailed the use of preexisting condition limitations and other forms of health-based pricing; required that insurers return to policyholders as aggregate benefits at least 75% of the aggregate amount of premiums collected in group policies and at least 65% of the aggregate amount collected in individual policiesl and introduced Medigap SELECT plans in 15 states, where SELECT plans provided a managed-care option for beneficiaries with reimbursement within a limited network. The Act to Amend the Omnibus Budget Reconciliation Act of 1990, which was passed in 1995 (P.L. 104-18), extended the 15-state Medicare SELECT demonstration program to every state, at state option. Two of the statutes enacted during the 1990s continued to emphasize consumer protections. The Balanced Budget Act of 1997 (BBA97; P.L. 105-33) imposed restrictions on preexisting condition exclusions during the initial Medigap open enrollment period when the plan purchaser is at least age 65 and meets a requirement for previous health insurance coverage. In addition, the BBA97 required that the Secretary of HHS ask the NAIC to develop two high-deductible Medigap plans, which became known as Plan F—High Deductible Version and Plan J. The Ticket to Work and Work Incentives Improvement Act of 1999 (P.L. 106-170) permitted disabled Medicare beneficiaries more flexibility in moving into and out of a Medigap policy. A few Medigap statutes passed in the 1990s primarily affected the insurance firms. The Social Security Act Amendments of 1994 (SSAA94; P.L. 103-432) modified the OBRA90. As listed above, the OBRA90 barred the sale of policies that duplicated other (non-Medigap) coverage to which a beneficiary was entitled. The OBRA90 therefore had the unintended consequence of insurers refusing to sell Medigap policies to beneficiaries who had any other type of private coverage, however limited. SSAA94 amended the OBRA90 requirements by narrowing the anti-duplication provisions and clarifying the circumstances under which insurers could sell health insurance policies with duplicative (non-Medigap) coverage. The Omnibus Consolidation and Emergency Supplemental Appropriation Act of 1999 (P.L. 105-277) required that providers or facilities that paid Medigap premiums for beneficiaries be subject to civil penalties. This legislation attempted to avoid conflicts of interest created when providers or facilities first paid premiums and then self-referred patients. During the 2000s The Consolidated Appropriations Act, 2001 (P.L. 106-554) specified various anti-discrimination provisions. In particular, individuals who experienced certain changes in their health insurance status (e.g., involuntary termination of a Medigap plan) were guaranteed the right to purchase a new Medigap plan and were protected against preexisting conditions exclusions. The Medicare Prescription Drug Improvement and Modernization Act of 2003 (P.L. 108-173, MMA) included various changes in Medigap plans. Because the MMA added the Medicare Part D drug provisions, Medigap plans containing drug benefits could no longer be sold to those who did not already have them. Those whose Medigap policies were issued before January 1, 2006, and did contain drug coverage were allowed to keep their existing Medigap policy as is, in some cases keep their existing policy minus the drug benefit, or purchase Medicare Part D together with either their old Medigap plan minus the drug benefit or certain new Medigap plans. In particular, individuals with Medigap Plan H, Plan I, and Plan J were guaranteed the right to purchase any of Plan A, Plan B, Plan C, and Plan F with the same insurance carrier. Moreover, the carrier could not use the individual's health status, claims experience, receipt of health care, or medical condition to determine the premium. Excluding preexisting conditions from these policies was also prohibited. The MMA also requested that the Secretary of HHS request the NAIC to develop additional Medigap plans. Two plans were to incorporate coinsurance and a maximum out-of-pocket limit; no plans available in 2003 had these features. These two plans became Plan K and Plan L. Any other Medigap plans developed by the NAIC did not have to incorporate these features, but were required to exclude prescription drug benefits; Plan M and Plan N fell into this category. I n some instances, the MMA changes created two identical plans; existing Medigap Plan E, Plan H, Plan I, and Plan J were eliminated because they duplicated other plans. The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA; P.L. 110-275) set standards for which plans insurers must offer. In particular, insurers who wanted to offer plans beyond the basic least comprehensive plan (Plan A) were required to offer at least one of the most comprehensive plans (Plan C or Plan F). The Genetic Information Nondiscrimination Act of 2008 (GINA; P.L. 110-343) prohibited discrimination by health insurers and employers based on genetic information. Finally, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA, P.L. 114-10) prohibits Medigap policies from covering the Part B deductibles for beneficiaries newly eligible for Medicare on or after January 1, 2020. These beneficiaries may be newly eligible because they have turned 65 or because they qualify under disability provisions. This prohibition also applies to policies issued in waiver states. Coordination of Payment Between Medicare and Medigap The rules governing coordination of the health insurance payments from the insurers to the Medicare service providers for services covered by Medicare Part B are mandated by Section 1842(h)(3)(B) of the Social Security Act. In most cases, when a beneficiary receives care covered by Medicare Part B, the Medicare contractor pays the provider its portion of the bill. The claim is automatically forwarded to the Medigap insurer, and the Medigap insurer pays the provider its portion of the bill. Some insurers also provide this service for Medicare Part A. Plan Characteristics This section first describes the 10 (current) standardized Medigap plans that differ in their deductibles, co-payments, coinsurance, and covered services. The section then describes the nonstandard plans: pre-standardized plans, older standardized plans available for renewal only, plans in states with Medigap waivers, SELECT plans, and high-deductible plans. Unless otherwise noted, the text refers to those who qualify for Medicare because they are at least age 65; Medigap options for those who qualify for Medicare because they are under age 65 and disabled are discussed later in the report. The current standardized plans are the third generation of Medigap plans included in statute. The first group of plans predated the plan standardization mandated by the OBRA90. The second group of plans (labeled Plan A through Plan J) were standardized and became effective in a state when the terms of the OBRA90 were adopted by the state. Many states adopted these terms in 1992. Standardized Plans Table 2 provides information on the 10 current, standardized Medigap plans. These plans became effective on June 1, 2010, and an individual purchasing a Medigap policy for the first time (in a state without a waiver) must choose among these plans. However, not every Medigap plan is offered in each state. Table 2. Standard Medigap Plans, Effective On or After June 1, 2010 Medigap Benefits Medigap Plansa A B C D Fb G Kc Lc M N Medicare Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up yes yes yes yes yes yes yes yes yes yes Part A Hospice care coinsurance or co-payment yes yes yes yes yes yes 50% 75% yes yes Skilled nursing facility care coinsurance yes yes yes yes 50% 75% yes yes Medicare Part A deductible yes yes yes yes yes 50% 75% 50% yes Medicare Part B coinsurance or co-payment yes yes yes yes yes yes 50% 75% yes d Medicare Part B excess charge yes yes Medicare Part B deductible yes yes Blood yes yes yes yes yes yes 50% 75% yes yes Foreign travel emergency (up to plan limits) 80% 80% 80% 80% 80% 80% Out-of-pocket limit in 2015 $4,940 $2,470 Sources: Centers for Medicare & Medicaid Services, Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare, 2015, p. 11, at http://www.medicare.gov/pubs/pdf/02110.pdf and Centers for Medicare & Medicaid Services, K & L Out-of-Pocket Limits Announcements, September 2014, at https://www.cms.gov/Medicare/Health-Plans/Medigap/KandL.html. Notes: This table lists plans available for purchase by new Medigap enrollees as of June 1, 2010. Some of the plans had different benefits before this time. For example, the pre-June 1, 2010, Plan G contained an 80% Medicare Part B excess charge benefit and an at-home recovery benefit, while the post-June 1, 2010, Plan G contained a 100% Medicare Part B excess charge benefit and no at-home recovery benefit. A "yes" in a cell indicates that Medigap covers 100% of the cost of the benefit. A percentage in a cell gives the percentage of the cost that Medigap covers. Plan E, Plan H, Plan I, and Plan J are no longer offered for sale to new beneficiaries. Plan F also is available with a high-deductible option, where the deductible is $2,180 in 2015. Excess charges are the difference between Medicare's recognized amount and actual charges, subject to charge limitations set by Medicare and state law. Plan K and Plan L pay 100% of covered services after the Medigap out-of-pocket limit is met. Plan N pays 100% of the Part B coinsurance, except for a co-payment of up to $20 for some office visits and up to $50 for emergency room visits that do not result in an inpatient admission. These 10 plans differ with respect to generosity of benefits, cost-sharing provisions, deductibles, and other features. Plan A provides a basic set of benefits, and Plan F has the most generous benefits. Plan C and Plan F cover all Medicare co-payments and deductibles, and therefore provide "first dollar" or "wraparound" coverage for all covered services. Plan K and Plan L represent a move away from first dollar coverage. In addition to their outpatient co-payments, these plans have "catastrophic coverage" in that, once the beneficiary has exceeded an annual out-of-pocket spending limit, Medigap pays 100% of the covered costs for the remainder of the insurance year. Plan N pays 100% of the Part B coinsurance, except for a co-payment of up to $20 for some office visits and up to $50 for an emergency room visit that does not result in an inpatient admission. It should be noted that standardization is not absolute; rather, it serves as a national benefit floor within each plan. In each state, Medigap insurers are permitted, with the prior approval of the state insurance commissioner, to offer plans with new or innovative benefits. For example, a version of Plan F offered by Regence Blue Shield of Idaho offers preventive dental benefits. New or innovative benefits, however, may not be used to reduce standardized benefits. Pre-standardized Plans Medigap plans offered before the OBRA90 became effective are known as pre-standardized plans. Although these plans cannot be sold to new beneficiaries, individuals who already have them may keep them. In other words, pre-standardized plans are grandfathered as long as the insurer continues to offer them. About 5% of Medigap plans were pre-standardized in 2013. Older Standardized Plans Available for Renewal Only Older standardized Medigap plans that were once available for purchase but are now only available for renewal are Plan E, Plan H, Plan I, and Plan J. An individual who purchased one of these plans may continue to renew his or her plan provided the insurer keeps offering the plan. However, the insurer may not sell these plans to new enrollees. As with pre-standardized plans, older standardized plans are grandfathered. There is considerable variation among the benefit packages offered by these older plans. Some benefits no longer offered to new beneficiaries may be covered in these plans. For example, Plan H, Plan I, and Plan J can include drug coverage (as long as the beneficiary is not enrolled in Medicare Part D). Those who did not elect Part D may keep the drug benefits in their Medigap plans. A second example of variation is the at-home recovery benefit, which is currently available in Plan D, Plan G, Plan I, and Plan J if the plans were originally sold before May 31, 2010. Medigap Plans for States with Waivers The standardized Medigap plans do not apply to residents of Massachusetts, Minnesota, and Wisconsin. These states had their own standardized Medigap plans prior to the enactment of the federal standardization requirements. The insurance carriers were permitted to continue existing state standardized plans. The states, however, were required to modify their regulatory requirements to comply with the MMA requirements (e.g., the prohibition against renewing Medigap policies with prescription drug coverage for those enrolled in Medicare Part D). The Medigap plans themselves are broadly similar to the nationally standardized plans, although they differ in their details. For example, at the time these states were granted waivers, their mandated benefits differed. In addition, Wisconsin covers 40 visits of home health care in addition to those covered by Medicare. S