Insurance For Over 65

Serving Georgia, Alabama, and Florida

Medicare FAQs

What’s the census of Medicare in America?

What’s the difference between an HMO and a PPO Medicare Advantage plan?

Are rehab services covered by Medicare?

Is home health care covered by Medicare?

What’s the difference between home healthcare services and home care services?

Does Medicare cover the cost of hospice care?

What “preventative services” are covered by Medicare with no copay and no coinsurance cost to the Medicare enrollee?

Does Medicare cover chiropractic care?

Is Medicare Part B optional?

What’s the penalty for late enrollment in Medicare Part B?

What’s the penalty for late enrollment in Part D (Prescription Drug coverage)?

What’s the difference between “Deductibles”, “Copays”, and “Coinsurance”?

What are the things that Medicare does not cover?

Can my Medicare Supplement plan enrollment application be declined?

Are all Medicare Supplement plans the same?

What’s the best way to be protected from the high costs of Long Term Care?

What are the eligibility requirements for enrollment in Medicaid in Georgia?

  • What’s the census of Medicare in America?
    • About 10,000 Americans turn 65 every day and are automatically enrolled in Medicare (at least Part A).  This rate will continue for the next 18 years.  By 2030, 81M Americans will be enrolled in Medicare (about 18% of the total population of the USA at that time).  Currently, there are 65M Americans enrolled in Medicare of which 56.2M are over 65 (the other 8.8M are enrolled under disability).  Currently, 30.1M Medicare enrollees are using a Medicare Advantage plan while 14.3M are using a Medicare Supplement plan.  The other 20.6M are using Original Medicare only and are vulnerable to the coverage gaps inherent in Original Medicare.

    • What’s the difference between an HMO and a PPO Medicare Advantage plan?
      • HMO stands for Health Maintenance Organization.  PPO stands for Preferred Provider Organization.  Insurance companies form networks of doctors, hospitals, and other healthcare providers with whom they negotiate fixed pricing for their services.  A Medicare Advantage HMO plan typically requires Medicare enrollees to use healthcare providers that are members of that particular HMO network in order to be covered.  In cases of emergency, this restriction is waived.  A Medicare Advantage PPO plan requires Medicare enrollees to use healthcare providers that are members of that particular network in order to receive the negotiated pricing for services.  However, Medicare enrollees are still covered when using out-of-network healthcare providers although they will likely pay more for those services.

  • Are rehab services covered by Medicare?
    • A Medicare enrollee may need skilled nursing or rehabilitation services after a hospital stay.  Medicare coverage for skilled nursing facility care currently requires that the Medicare enrollee is hospitalized as an inpatient (not under observation) for at least three days prior to entering a skilled nursing facility.  In such a case, Medicare Part A will help pay for skilled nursing care for up to 100 days.  Medicare will pay all approved charges for the first 20 days.  For days 21 through 100, the Medicare enrollee pays a coinsurance amount of $200.00 per day (in 2023).  After 100 days, the Medicare enrollee is responsible for the full cost of the skilled nursing facility care.

  • Is home health care covered by Medicare?
    • If a Medicare enrollee meets certain conditions (listed below), Medicare will pay the full approved cost of covered home health care services for up to 100 days.  This includes part-time or intermittent skilled nursing services prescribed by a physician for the treatment of homebound patients.  The following conditions must be met for coverage eligibility:
      • The home healthcare services must be ordered by a doctor as part of a Plan of Care and provided by a Medicare-certified home health agency.
      • The home healthcare services must be associated with inpatient hospitalization or skilled nursing facility care.
      • The patient must be confined to the home. A reasonable allowance is made for trips to a beautician, visits to family members, or church services.
      • The amount of skilled nursing and home health aide services combined must total fewer than 8 hours per day and 35 hours per week. Such services include physical therapy, occupational therapy, speech therapy, and medical social services.

  • What’s the difference between home healthcare services and home care services?
    • Many people confuse the term “home health care” with the term “home care”.  They are different things with different meanings.  Home care services (such as those provided by Visiting Angels) are services provided by a personal (non-skilled) care provider for assistance with activities of daily living such as eating, bathing, dressing, continence, and transferring from a bed or chair.  In contrast, home healthcare services address the needs of an individual for professional care from a registered nurse, physical therapist, speech therapist, occupational therapist, or doctor for medically-necessary in-home visits.  Medicare does not cover the cost of home care services.

  • Does Medicare cover the cost of hospice care?
    • Medicare helps pay for hospice care for terminally ill Medicare enrollees ie; those with fewer than six months to live (as certified by a doctor) and who select the hospice care benefit.  There are no deductibles, but the insured pays limited costs for drugs and inpatient respite care.  The hospice medical team can prescribe care at home or in a Medicare-approved facility.

  • What “preventative services” are covered by Medicare with no copay and no coinsurance cost to the Medicare enrollee?
    • The following is a partial list:
      • A one-time initial preventative physical exam (the “Welcome to Medicare” benefit) within 12 months of first becoming enrolled in Medicare Part B.
      • A yearly wellness exam, starting 12 months after the “Welcome to Medicare” physical exam. This is intended to develop or update a personalized prevention plan and is not intended to be a physical exam.
      • Screening for: prostate cancer, heart disease, abdominal aortic aneurysm, diabetes, depression, HIV, obesity, sexually transmitted infections, alcohol misuse, glaucoma
      • Colorectal exam (colonoscopy)
      • Pap smears and pelvic exam, including cervical and vaginal cancer screening
      • Mammography and breast exam
      • Testing for bone-mass density loss
      • Flu shot (one per season) and pneumonia inoculation
      • COVID 19 vaccinations
      • Hepatitis B vaccination
      • Tobacco use cessation counseling (if ordered by a doctor)

  • Does Medicare cover chiropractic care?
    • Medicare does cover medically necessary chiropractic services.  Medicare Part B covers 80% of the cost for manipulation of the spine if medically necessary to correct a subluxation.  There is no cap on the number of medically necessary visits to a chiropractor.

  • Is Medicare Part B optional?
    • Yes, Medicare Part B is optional but it’s a pretty good deal at only $164.90 per month (in 2023 for most people).  Unless you notify Social Security that you don’t want to be enrolled in Part B when you turn 65, you’ll be enrolled automatically.  This is particularly relevant if you’re still working and covered by a group health insurance plan at work.  In that case, you may want to delay enrollment in Part B.

  • What’s the penalty for late enrollment in Medicare Part B?
    • If you decide not to enroll in Medicare Part B during your initial enrollment period (3 months before to 3 months after the month of your 65th birthday), and you later decide to enroll in Part B, you may be subject to a late enrollment penalty.  The penalty is 10% of the premium per year for each 12 month period following when you were initially eligible to enroll.  This penalty will be assessed as long as you remain enrolled in Part B.  No penalty applies if after turning 65, you were enrolled in a group health insurance plan at work (which is considered “creditable coverage”).  Note: COBRA is not considered “creditable coverage.”

  • What’s the penalty for late enrollment in Part D (Prescription Drug coverage)?
    • If you decide not to enroll in Medicare Part D during your initial enrollment period (3 months before to 3 months after the month of your 65th birthday), and you later decide to enroll in Part D, you may be subject to a late enrollment penalty.  The penalty is 1% of the national average premium for Part D plans ($31.50 in 2023) for each month that you were without Part D since you were initially eligible to enroll.  For example, if you delay your Part D enrollment for five years, you will pay a penalty of 60% of the yearly average Part D premium forever.  No penalty applies if after turning 65 you were enrolled in a group prescription drug plan at work (which is considered “creditable coverage”).  Note: Enrollment in a Medicare Advantage plan with Prescription Drug coverage (MAPD plan) satisfies the Medicare Part D enrollment requirement.

  • What’s the difference between “Deductibles”, “Copays”, and “Coinsurance”?
    • Deductibles simply mean that when you need a particular Medicare-covered service, you (or your insurance policy) must first pay a certain stated amount after which Medicare will pay its stated share.  Copays mean that you will have a certain stated up-front fee to pay for the service you need.  That fee is established by Medicare and your Medicare Supplement plan or Medicare Advantage plan can be structured to pay the copay amount for you.  Coinsurance means that you are required to pay a stated percentage of the cost for a service.  It’s different from a stated copay fee because the amount you must pay is a percentage of the cost of the service rather than a fixed amount.  This is the primary reason why all Medicare enrollees should also be enrolled in either a Medicare Advantage plan or a Medicare Supplement plan.

  • What are the things that Medicare does not cover?
    • The following is a partial list:
      • Prescription drugs
      • Most dental care (unless medically necessary as the result of an accident where surgery may be involved)
      • Dentures
      • Eye exams related to prescribing eyeglasses
      • Eyeglasses (except for one pair of standard frames after cataract surgery)
      • Hearing aids and hearing exams for fitting them
      • Cosmetic surgery
      • Orthopedic shoes
      • Private hospital room (unless medically necessary)
      • Hospital room conveniences such as telephones and television
      • Long-Term Care

  • Can my Medicare Supplement plan enrollment application be declined?
    • If you apply for a Medicare Advantage plan within 6 months of your Medicare Part B enrollment date (as stated on your Medicare ID card), your application cannot be declined by the insurance company no matter what pre-existing medical condition that you may have.  After that 6 month window of guaranteed acceptance, your application will be subject to underwriting and may be declined.  This is why I would recommend enrollment in a Medicare Supplement plan when you first become eligible for Medicare if you have a chronic medical condition requiring ongoing treatment.

  • Are all Medicare Supplement plans the same?
    • Regardless of the insurance company offering the Medicare Supplement plan, all Plan A’s, all Plan B’s, all Plan C’s, all Plan D’s, all Plan G’s, etc. must offer the exact same coverage.  Medicare Supplement plans do what their name implies, they supplement what original Medicare covers.  As such, they only cover what Medicare covers but doesn’t completely pay for.  The only thing that’s different from company to company is the premium they charge for the plan and how they increase the premium as the insured gets older.

  • What’s the best way to be protected from the high costs of Long Term Care?
    • The average annual cost for skilled nursing care in Atlanta, GA is $90,885 for a private room, $83,585  for a semi-private room, and $43,514 for an Assisted Living Facility.  It’s a mistake to think of Medicare as protection from the high costs of long-term care in a skilled nursing facility (nursing home).  Medicare benefits for such care run out after 100 days.  One solution is to purchase a Long-term Care insurance policy which can be quite expensive and require underwriting.  Another solution is to purchase a life insurance policy that includes a long-term care rider whereby a portion of the policy’s face amount can be used to pay for long-term care costs.  Another relatively new solution is what is called a Short Term Care policy.  These products are significantly less expensive than the traditional long-term care products but offer more limited terms of coverage.  Long-term care is a very real problem in America and will get worse as the generations pass through the continuum of healthcare.  With the exception of Medicaid, the government hasn’t yet been able to provide a solution, so most people are on their own.

  • What are the eligibility requirements for enrollment in Medicaid in Georgia?
      • To be eligible for enrollment in Medicaid in the state of Georgia one must be over 65 or legally blind, or totally disabled and must meet certain financial criteria.  The financial criteria are divided into two groups, income, and assets.  In determining eligibility, a DFCS (Dept. of Family and Children’s Services) worker will consider the total gross monthly income of the applicant from all sources.  This includes Social Security benefits and pensions, retirement, wages, interest, dividends, etc.  If the applicant is living with a spouse, the case manager will also consider the income of the spouse.  In 2023, for institutionalized care ie; nursing home expense coverage by Medicaid, the individual income limit for eligibility is $2,742 per month ($32,904 per year); $5,482 per month ($65,784 per year) if both spouses are applying.  In addition, the countable assets limits are $2,000 per individual and $3,000 per couple.  Countable assets do not include the individual’s home or one vehicle per household.