Category Archives: Medicare/Medicaid

Paying for Home Health Care: What Do Medicare and Medigap Cover?

Prescribed only by a physician, home health care is skilled nursing care that aids in the recovery from illness, injury, or surgery in the patient’s home. And fortunately for many seniors who are now opting for care at home, Medicare insurance covers most costs related to home health care.

The government, however, has set some limitations on payouts – you are only eligible if you need intermittent care (usually defined as seven days a week or less than eight hours a day over 21 days or less) (1), physical/occupational therapy or speech language pathology; you are homebound; and the home health care agency providing care is approved by your Medicare insurance program.

In addition to medication administration, general supervision, and therapy services, the Medicare home health benefit covers a number of other necessities, including medical aids and supplies to aid in recuperation. On the occasion, though, you may be required to cover some of the costs associated with home health care. But what can you expect to pay out-of-pocket that’s not covered by Medicare dollars?

Medicare Insurance: Part A and Part B

Hospital Insurance (Medicare Part A) helps cover the costs of your inpatient care at hospitals, skilled nursing facilities, or religious non-medical health care establishments. Part A can also help cover hospice and home health care services. Individuals aged 65 and older are usually automatically enrolled in Medicare Part A and do not have to pay a monthly premium if Medicare taxes were paid while working. If you did not pay taxes, you are still eligible, but you will be required to pay a monthly premium.

Medical Insurance (Medicare Part B) helps cover services such as those offered by your physician and outpatient care. Many seniors maintain their enrollment in Part A, but elect not to use Part B, which requires a monthly premium that is dependent upon income, the requirements of which change yearly. Unfortunately, if you didn’t sign up for Part B when you were first eligible for insurance, your premium may be slightly higher (2).
For questions on your Medicare insurance benefits, you should contact 1-800-MEDICARE or read the handbook mailed to you each year entitled “Medicare and You.”

What’s Covered and What’s Not?

Medicare insurance pays for physical and occupational therapy and speech language pathology services, counseling, some medical supplies, durable medical equipment (which must meet coverage criteria), as well as general assistance with daily activities which include dressing, bathing, eating, and toileting. For most other medical equipment, Medicare insurance will cover 80% of its cost (3).However, Medicare will not cover twenty-four hour care at home, meals delivered to your home, and services unrelated to your care such as housekeeping. Of course, as mentioned above, you will be required to pay 20% for medical equipment not fully covered by Medicare insurance such as wheelchairs, walkers, and oxygen tanks (4).In some cases, your home health care agency may present you with a Home Health Advance Beneficiary Notice (HHABN), which, simply put, means if your agency is ceasing your care services, you will be presented with a written statement outlining the supplies and services the agency believes your Medicare insurance benefits will not cover as well as a detailed explanation of why. Should this situation arise, you do have recourse – the HHABN lists directions on acquiring the final decision on payment issues or filing an appeal if Medicare refuses to cover costs for home health care. In the meantime, you should continue receiving home health care services, but keep in mind that you will be paying for these services out-of-pocket until Medicare accepts your claims and remits past expenses.

Medigap and Other Out-of-Pocket Expenses

Medigap, a supplemental insurance policy, is sold privately and covers the services and supplies not paid for by Medicare insurance. When used in conjunction, Medigap and Medicare can often cover a large majority of the costs of your home health care. Insurance companies offer a variety of different Medigap policies (A through L), but since each one comes with specific benefits, you’ll need to compare the highlights closely. Medigap policies vary by cost, and many insurance companies require you to have both Medicare Parts A and B in order to purchase a supplemental plan (5). For seniors with both Part A and Part B Medicare, your home health care situation is usually covered, save for the 20% out-of-pocket expenses for medical equipment. Just remember to keep track of your Medicare insurance benefits (and Medigap if applicable) by verifying with your physician, home health care agency, and insurance representative. Paying for home health care does not have to cost you an arm and a leg, but do be prepared for the occasional (but necessary) out-of-pocket medical expenses.

1. Centers for Medicare and Medicaid Services, Medicare and Home Health Care, page 6
3. Ibid.
4. Ibid.

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About the Author:

Jill Gilbert is the President and CEO of Gilbert Guide, a comprehensive website helping seniors and their loved ones find a senior care provider along with extensive tools and resources to solve the challenges of aging. She is the author of “Leading by Example,” a monthly column in McKnight’s Long-Term Care News, the chief industry publication for long-term care providers. Jill has been interviewed for a CBS News special, was a key presenter at the Pennsylvania Assisted Living Association’s annual conference, and was recently interviewed on San Francisco TalkBack. Gilbert Guide was founded on the concept that quality matters, and its primary goal is to educate consumers on a breadth of senior care issues. Visit for a comprehensive provider database, expert advice, and quality assessment tools that help consumers conduct their own “expert” evaluations of providers.

 Top Ten Medicaid Myths

Medicaid is the nation’s largest health coverage program. The program was originally a welfare-based health coverage program, but has become a health insurance and long-term care program for those who are struggling financially and for people with disabilities. Because of its complexity, there is a lot of misunderstanding about the Medicaid program.

MYTH: Medicaid is obsolete.

FACT: Medicaid is an innovative program that has changed as the American health care system has evolved. Through the waiver process, states experiment with benefit design, eligibility, and delivery systems. Currently, several states are experimenting with transitioning long-term care services to home based setting.

MYTH: Medicaid is an inflexible program.

FACT: Medicaid has minimum federal standards, but states have flexibility to customize their Medicaid program beyond those minimum standards. In many ways, Medicaid operates like fifty individual state coverage programs.

MYTH: Medicaid spending is out of control.
The cost growth per enrollee for Medicaid is lower than comparable coverage under Medicare, private health insurance, and employer-sponsored insurance. Medicaid costs continue to increase, but so do health care costs across the board in the American health system.

MYTH: Medicaid provides “Ritz Carlton” coverage.

Medicaid has a unique role as a safety net for the weaknesses in our health system. The populations served by the Medicaid program require services that are not readily available in typical health insurance plans. Medicaid not only functions as an acute care plan for low-income families, but it is also the only alternative available for many individuals with disabilities and low-income elderly who require long-term care.

MYTH: Medicaid covers too many people and competes with private insurance.

FACT: The vast majority of the people who are covered by Medicaid do not have access to other insurance. Many work for employers who do not offer coverage. Many are priced out of the private market because of illness or disability. Studies of Medicaid have demonstrated that Medicaid as an alternative to private coverage is limited. Those who are newly enrolled into Medicaid were previously uninsured.

MYTH: Medicaid is for people who don’t work.

FACT: Working families make up 65% of those who receive Medicaid coverage. For those who are not in the workforce, like people with severe disabilities, Medicaid supplements cash assistance and makes available essential health care coverage.

MYTH: Medicaid foots the nursing home bill for affluent seniors.

FACT: Medicaid is only available to the very poor or those with health care expenses that have depleted their savings. The new Medicaid rules make it difficult to transfer assets to qualify for nursing home care. About three out of five nursing home residents are not on Medicaid at the time of their admission. Even when a person’s assets are depleted, they still must apply their income towards the cost of care, except for a meager personal needs allowance.

MYTH: Federal financing of Medicaid encourages wastefulness.

FACT: During hard economic times, more people need Medicaid coverage and spending increases. But, unlike the federal government, most states are required to balance their budgets so they are hindered from over spending. States struggle to control Medicaid spending even as more people are covered.

MYTH: The Medicaid program is inefficient.

FACT: Medicaid has lower administrative costs per claims paid than private sector health insurance. And, year in and year out, the per capita growth of Medicaid is about half the rate of growth found in private sector health insurance.

MYTH: Medicaid is a second rate program.

FACT: There is substantial evidence that Medicaid has improved access to primary and preventive health care comparable to that of those with private insurance. In particular, Medicaid’s inclusion of pregnant women and children has helped reduce infant mortality and acute health conditions.

The rules and regulations concerning Medicaid are not only very complicated, but also work independently from, and often contrary to, tax laws, veterans benefit and estate planning. Careful considering to individual circumstances is critical. Don’t go it alone. Call me at (203) 488-5586 to discuss specific situations to avoid making an inadvertent mistake.

Author: Mark R. Connell Attorney At Law, LLC
420 East Main Street, Suite 12
Branford, CT 06405
Phone: (203) 488-5586

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Confused about what happens when you turn 65? 

Are you turning 65 this year? You are probably full of questions. When does Medicare start? How much will it cost? I’m here to help you.

Most people are eligible for Medicare when they turn 65. More specifically if you have received your Medicare card it will begin the first day of the month you are born. For example My mother will turn 65 December 20th. Medicare actually starts for her December 1st. The exception to this rule is if you were born on the 1st of the month. An example is if your birthday is July 1st. Your Medicare will start June 1st.

People on disability for a certain amount of time also qualify for Medicare but I will focus on those turning 65 for today.

Your Medicare card and information about what amount will be coming out of your Social Security check every month should come a few months before you turn 65. Normally you don’t have to do anything unless you DON’T want Medicare.

2009 Premiums

Everybody pays a premium for Medicare part B. Some people will argue and say that they don’t pay. They just don’t realize it because it almost always comes directly out of Social Security. The premium goes up a little bit most years. The premium for 2009 is $96.40. Those who have high incomes may pay more for their part B premium. It comes out of your check every month which saves you from having to send it in.

Some people also pay a premium for part A but it is much less common. For 2009 it is either $244.00 or $443.00 depending on circumstances.

Those are the only premiums you pay for Medicare. Most people only pay $96.40 for their Medicare which is pretty cheap insurance and is also pretty decent insurance. You are required to have a Medicare Prescription Drug plan. If you choose not to you may have to pay a penalty in the future if you decide to enroll in a plan.

You are not REQUIRED to have any supplement to Medicare although many choose to.

Turning 65 may mean making changes but don’t worry they won’t hurt too bad.


Many choose to have some sort of supplemental coverage in addition to Medicare. While Medicare Advantage (MA) and Medicare Advantage Prescription Drug Plans (MAPD) are not supplements they can be very helpful for people. Especially folks who need a bit more than Medicare alone but can’t quite afford a supplement. Keep in mind that you don’t have to worry about pre-existing conditions. In some states MA’s and MAPD’s are free while in others you will pay a low premium. You then make reasonable co-payments. You may ask why you would want to do that when Medicare is already paid for.

A couple of reasons. First you won’t pay deductibles. You have immediate coverage. Secondly in many cases you will have a maximum out of pocket. This may not seem important but if you have a tough year and end up in the hospital a few times your out of pocket expenses on Medicare alone can be kind of expensive. At this point there is NO maximum out of pocket on Medicare alone.

About the Author:
Dora Guldborg is an insurance agent, Marketer, Mom and much more. Find out more about her at
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