Medicare Supplemental Insurance
Age 65 and Older
Health Benefits and Medigap
Medicare Cover Nursing Home Care?
News & Information
Workers Age 65 and
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.
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.
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.
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.)
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
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
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
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
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
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.