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.

18- Jul2016
Posted By: Tony Fischer

Answers to Common Questions About Medicare In The Nursing Home

The most common questions seniors have about paying for long term care involves Medicare.  Most people assume Medicare covers long-term care in the nursing home.  Others confuse it with its state-funded cousin Medicaid.

The confusion is caused by Medicare’s coverage of sub-acute services or short-term rehab.  This service is often provided in a nursing home and can last up to 100 days if the patient is able to show progress toward therapy goals. Unfortunately most patients admitted under Medicare coverage for nursing home rehab will stay between only 14 and 21 days depending on their condition.  In order for someone to be covered for 100 days of sub-acute care they would have to be either very sick or have used their coverage over the course of several admissions.

Here are some common questions about using Medicare while in a nursing home.


A patient becomes eligible for sub-acute care after a qualifying three-day hospital stay.  In order to have a qualifying stay a patient must be ADMITTED to the hospital. Observation stays don’t count.  They must be admitted.  This has become an important distinction in recent years as hospitals will sometimes avoid admitting patients because of new rules meant to reduce readmission.

If you are not sure if the senior you care for has been admitted to the hospital ask the nurse in charge. It may not only affect your eligibility for nursing home coverage but you may find yourself looking at a big bill.


Each nursing home patient is assigned members of the Interdisciplinary Team (or IDT for short.)  The IDT meets on a regular basis and develops a care plan for each sub-acute patient based on diagnosis, current condition and projected discharge plan.

They work together to develop goals that the patient must achieve in order to become discharged.  These goals and the progress made toward them determine the amount of time a patient is covered.  Coverage ends when a patient reaches those goals or has reached their maximum rehab potential.

Medicare coverage can renew if a person goes for 60 days without using their Medicare for admission to the hospital or sub-acute care.


Medicare is only designed to cover patients for the short term. Medicare coverage alone is not enough to cover long-term care services whether in a nursing center or at home.  Medicaid, long-term care insurance or Veterans Aid and Attendance are benefits that can cover long-term care.  Otherwise patients will have to pay out-of-pocket.

Read Related: Paying For Long Term Care

Editors Note:  The nursing home industry uses the term Resident to refer to people who have been admitted for either short-term or long-term care. To avoid confusing the reader we have used the more universal term patient to refer to those admitted to nursing homes.