28- Oct2016
Posted By: Tony Fischer

Beware of Medicare Advantage Plans

As open enrollment for health insurance approaches, people all over the country are weighing the cost of their health care plans.  For seniors with Medicare coverage, there is pressure to convert straight Medicare insurance into an HMO or Advantage Plan. 

Late night infomercials and even entire TV channels are dedicated to promoting the advantages of Medicare HMOs with some insurers even promising lower monthly premiums if your join their network.  There are several positives to joining a Medicare HMO but can also be several disadvantages.

Before you join a Medicare based third party insurance plan there are several general concepts you should understand before sitting down with your insurance agent.

Medicare Advantage Plans vs. Medigap

The difference between Medicare based health plans and Medigap insurance are often misunderstood.  Medicare based heath insurance plans, often called Advantage plans, combine your Medicare and third party health insurer into one plan.  In most cases, members of Medicare based insurance plans pay one premium to their insurance company. The two insurance coverage’s become one and cannot be separated.

Medigap insurance plans are billed separately from your Medicare coverage and serve as a secondary insurance or co-payer to Medicare.  Medigap insurance can also be used to cover prescription medications.

How Medicare HMOs work.

Medicare based health plans get a monthly stipend from Medicare to manage your health insurance cost.  It helps the government control medical cost by allowing the insurer to determine coverage’s depending on the insured’s contract.

Medicare based plans still follow guidelines set forth be Medicare but they have their own rules regarding coverage amounts and the types of services covered.  In short the insurance company, not Medicare, is calling the shots.

Advantages of Medicare HMOs

Medicare HMOs offer a couple of unique advantages over having straight Medicare.  They can often lower monthly premiums and offer the ease of dealing with a single insurance company.  Depending on the company, Medicare based insurance plans also offer outreach and health maintenance programs as part of their coverage.

Medicare based plans coming from large employers as part of a pension benefit often have the most benefits. The ease of use, additional programs and lower premiums are the major reasons some seniors choose these types of insurance plans.


It is important to note that most every healthcare provider is licensed by Medicare and accepts Medicare insurance coverage.    However, not all healthcare providers accept all Medicare HMOs. Providers have to negotiate contracts with health insurance companies in order to be a part of their network.  So even if your insurance is Medicare based, it may not be accepted by every provider.

Additionally, insurance coverage rules are standard for every provider billing Medicare.  Not so for Medicare HMOs as each company has there own rules and coverage based on the contracts they have with their members and providers.  Deductibles also vary based on the insurance company.

Not All Insurances Are Created Equal

We are getting closer to a universal single payer healthcare system but we have a long way to go. Even though an insurance is Medicare based, the types of services, networks, costs and deductibles vary greatly form company to company.  HMOs offer some nice advantages but they aren’t a fit for everyone.

Before You Enroll

Before you make any changes to your insurance coverage you should ask the following questions:

  • Will all the Doctors I use be covered with my new insurance?
  • How will my out of pocket expense change related to how I use my coverage now?
  • What is the process for appeals if I don’t agree with a coverage decision?
  • Are the services covered by the insurance network close to home and convenient to use?
  • How does the insurance company service their customers?

Insurance companies offering Medicare based plans boast extensive networks and coverage’s. But straight coverage is often more widely accepted and covers most costs.

Whatever choice you make understand how your insurance coverage fits into lifestyle and unique healthcare concerns. Developing a senior care plan is a great way to define you unique healthcare needs and coordinate care based on your human, insurance and financial resources.  We can help you develop this plan.  For more information of our senior care planning services CLICK HERE.

22- Jul2016
Posted By: Tony Fischer

What Does Medicare Cover?

Getting Medicare has turned into an aging milestone for most Americans.  For most, getting the government insurance card in the mail means you are officially retired. Every taxpaying citizen of the United States is automatically enrolled in Medicare when they are 65.  In fact you should be getting your care around 3 months before your 65th birthday.

Everyone knows what Medicare is but most still don’t understand what exactly it covers especially when it comes to senior care. This post will give you a brief summary of what types of senior care Medicare covers and for how long.

The Purpose of Medicare

Many assume that because you get Medicare automatically at age 65 that it covers all types of senior care including long-term care. But Medicare was only intended to cover short-term care services like those at the hospital or rehab center. In fact when it comes to long-term care, Medicare’s coverage is very limited and varies based on the type of care being received.

Read Related: How To Pay For Long-Term Care

Medicare is the Default Hospital Coverage for 65 Year Olds and Older

Medicare is the default hospital coverage for folks who are 65 years or older.  The length of stay depends on why the patient was admitted and how they respond to treatment.

Nursing Home Rehab

Today’s nursing homes offer two levels of care.  The level most people are familiar with is long-term care. That is when the patient (referred to as a resident) is expected to stay anywhere from 3 months to multiple years.

Short-term rehab (or Sub-Acute) is they type of care that requires interventions from a physical therapist or registered nursing.  Patients needing short-term rehab may be recovering from an extended hospital stay, stroke, heart failure, Chronic Obstructive Pulmonary Disorder or joint replacement just to name a few.

Doctors often recommend short-term rehab in a nursing home for seniors who cannot keep up with the pace of an inpatient hospital rehab unit.  That is not to say that patients in the nursing home rehab setting aren’t required to show progress.  In fact a patient must show progress and participate in therapy in order to keep their Medicare coverage.

Coverage can last up to 100 days if progress is being shown but even then Medicare doesn’t cover the entire bill.  Medicare covers 100% of a nursing home rehab stay for only 20 days.  If the stay lasts beyond 20 days, Medicare covers roughly 80% with the remaining 20% being covered by a Medi-Gap insurance or coming out of the patient’s pocket.

Home Care

When the senior is ready to discharge from the hospital or nursing home rehab; home care may be prescribed by the doctor.  Home Care is approved in 60-day increments and is typically covered 100% by Medicare. However like short-term rehab coverage the patient must show progress in therapy treatments.

Read Related: Home Care: How It Works.

Outpatient Rehab

If the patient doesn’t require a skilled nursing environment like that of a nursing home or meet the home bound criteria for Home Care, outpatient rehab may be needed.  Medicare covers outpatient therapy but co-payments may be needed depending on the type of diagnosis and length of care.  Check with the outpatient rehab clinic for coverage details.

More Questions?  Senior Care Sherpa Can Help

We are here to help.  Our Senior Care Sherpa’s are experts in senior care and can help you develop a senior care plan.  CLICK HERE for more information about how one of experts can help you.