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Published on September 23, 2015

medigap coverage

Medigap Coverage: Don’t let your window of opportunity close

In need of advanced technology and ultimately a heart transplant to sustain his life, Edwin Velez became depressed, frustrated and even hopeless about how he could pay for it all.

Seven years ago, Velez became ill with pneumonia, yet didn’t feel he could take time off. “I just kept pushing myself. I got to the point when I couldn’t breathe when I was going up the stairs.” Unfortunately, his illness weakened his heart, resulting in congestive heart failure.

Doctors told Velez, in his late 30s, that he had the heart of an 80-year-old. “I got a pacemaker and defibrillator put in but I kept deteriorating. I like to be active, so I got to feeling pretty low.” He was close to dying three times. “I had last rites more than once.”

Even though he’s not the traditional Medicare age, Velez, now 43, qualified for Medicare disability and Social Security due to his condition. But he did not sign up for Medicare Supplement Insurance, also known as Medigap, for coverage of deductibles and co-payments that Medicare does not pay. There’s no cap on these expenses, putting Velez at risk of owing thousands upon thousands of dollars. “When you have an existing condition, no one wants to insure you. I felt like my back was up against the wall, and I was out of options,” he said.

A change in outlook

Velez’s outlook changed drastically when he happened to walk in the Avera Health Plans office near his home in Sioux Falls to find answers. He learned from sales agent Kory Feltman that he could apply for a Medigap policy, with guaranteed coverage, during Avera’s open enrollment period, which was right around the corner.

All Medicare recipients qualify to purchase guaranteed Medigap coverage for six months before and six months after their Medicare Part B coverage becomes effective. “However, if people miss this window, they can be forced to go without supplemental insurance for the rest of their life, if they can’t find a company that’s willing to cover them due to a pre-existing condition,” Feltman said.

But Avera Health Plans chooses to have its own open enrollment period, which for 2015 is from Sept. 1 to Feb. 15, when anyone on Medicare can receive Medigap coverage – guaranteed.

“This news was a tremendous weight off his shoulders,” Feltman said. “It was hope – when I needed it,” agreed Velez, who is now working on losing weight so he can qualify for a heart transplant. In the meantime, he was able to have an LVAD (left ventricular assist device) implant.

The LVAD allows Velez to be up and walking – three miles or more a day. “Before, I couldn’t walk a block or up a couple of stairs,” he said. “If I get a transplant, I’d like to go back to my field of culinary work, have a good life, maybe have a family.”

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