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  • Workers Age 65 and Older
  • Retiree Health Benefits and Medigap
  • Under 65 Disabled
  • Does Medicare Cover Nursing Home Care?

  • Workers Age 65 and Older
    Most people 65 and older who continue working full-time for an employer of 20 or more and who are covered under an employers group health insurance should defer enrollment in Medicare Part B until they lose that coverage. Then the worker and spouse will have: (1) a special seven month open enrollment for Medicare, as well as (2) open enrollment for the six months after their Part B enrollment date.


    Retiree Health Benefits and Medigap
    Until recently, it was illegal for an insurer to sell you a Medigap policy if it would duplicate other benefits you had under another policy such as a retiree health plan. This is no longer true.

    You may now have both a Medigap plan and a retiree health plan, even if the Medigap plan duplicates your retiree health plan benefits.
    The Medigap plan must pay full benefits even when the retiree plan pays for the same services. You should check the provisions of your retiree health plan, however, to see if it contains a "coordination of benefits" clause. If it does, it probably wonít pay duplicate benefits.

    Since retiree health plans are often limited in their benefits it may be to your advantage to purchase a Medigap plan so that you have sufficient coverage.


    Under 65 Disabled
    According to state law, each company must offer at least one of its available plans to people under age 65 who are eligible for Medicare because of disability. Within Plans A through G, the rate will be the same as that applicable to the non-disabled.

    Most companies offer only Plan A to this population. The only exception is United American, which offers Plan A & Plan C.

    In the past, those who became eligible for Medicare before age 65 did not have an Open Enrollment period when they turned 65, as other seniors did.


    New Federal Law
    A new federal law now gives this population an Open Enrollment opportunity at age 65. This means that when a disabled person on Medicare turn age 65, he or she has a six month open enrollment period during which he or she has the right to enroll in any plan that is offered to those 65 and older (Plan A-Plan J), regardless of their health status. 

    This six month time period begins on the first of the month in which the person turns 65. (If the personís birthday is on the first day of the month, the six-month period begins the first of the preceding month.)


    Does Medicare Cover Nursing Home Care?
    One subject that causes much confusion is nursing home care. You may wonder if Medicare covers it, especially because one of Medicareís benefits is called "skilled nursing facility care".

    In a nut shell, however, the answer is, "No, Medicare does not cover nursing facility care." The skilled nursing benefit is for a different level of care; it covers care in a facility that primarily furnished skilled nursing and rehabilitation services, such as a stroke or a hip fracture. It may be a separate facility or a distinct part of another facility, such as a hospital, and it is different from a nursing home.

    To qualify for care in a skilled nursing facility, you must meet all of the following requirements:

  • Require daily skilled care that, as a practical matter, can only be provided in a skilled nursing facility on an inpatient basis.
  • Be in the hospital for at least three consecutive days (not counting the day of discharge) before entering a skilled nursing facility that is certified by Medicare.
  • Be admitted to the skilled nursing facility for the same condition for which you were treated in the hospital.
  • Generally, be admitted to the facility within 30 days from your discharge from the hospital.
  • Be certified by a medical professional as needing skilled rehabilitation services on a daily basis.
  • If you qualify for this type of care, Medicare can help pay for up to 100 days during a benefit period. All covered services for the first 20 days of care are fully paid by Medicare; for the next 80 days; you (or your Medigap policy) must pay $95 per day (1997 co-insurance amount). If you require more than 100 days of care in a benefit period, you are responsible for all charges beginning with the 101st day. (See definition of "benefit period")

    It is important for you to understand that neither Medicare, nor Medigap, nor an HMO will pay for your stay if the services are primarily personal care or custodial services, such as assistance in walking, getting in and out of bed, eating, dressing, bathing and taking medicine. This is the type of care; Medicare will pay for part-time or intermittent home health care, but only if you are homebound and need skilled services.

    If your condition improves, however, you may not be eligible for coverage. Homemakers and home health aides are covered by Medicare only if the services are provided along with skilled medical nursing or rehabilitation services, Medicare does not cover on going home health care for chronic illness.

    Now, consider some statistics published by the state of Connecticut, Office of Policy and Management:

  • Nearly 50% of people who reach age 65 will spend some time in a nursing home.
  • Nursing home care in Connecticut averages more than $60,000 per year; the average nursing home stay in Connecticut is 2.5 years.
  • Medicare covers only 2% of long-term care needs, and Medicaid requires that the individual spend down most assets to the poverty level.
  • Of those nursing home residents on Medicaid, 40% had to impoverish themselves to qualify.
  • The government has placed stricter rules and larger penalties on transferring assets to become eligible for Medicaid. This has made those in need of long-term care more vulnerable than ever to impoverishment.
  • If you a want insurance coverage for nursing home care, you must purchase a separate policy that specifically covers long-term care or nursing home care. Some policies also cover at-home care and, sometimes, care in a skilled nursing home facility when Medicare benefits are not available.

    When comparing policies, be sure to learn which types of nursing homes and services are covered, the waiting periods you can choose before coverage begins, and the requirements you must meet in order to qualify for coverage. Find out if there are built-in benefit increases to allow for inflation. Make sure, too, that a policy you are considering does not duplicate any other coverage you may currently have.

    Many insurance companies offer coverage for long-term care. When you contact our office (1-800-573-0218 or e-mail us at ), we can help you shop for and select options in a plan that will fit your personal circumstances. In general, long-term care insurance rates have become more affordable. Contact us for a personal quote.


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