Frequently Asked Questions about Medicare, Health, and Life Insurance

Frequently Asked Questions

Explore our FAQ section for comprehensive answers to common Medicare questions, as well as health, life, and long-term care insurance. Find quick solutions to your queries, demystify complex topics, and gain the knowledge you need to make more informed and confident decisions about your healthcare.

Medicare Questions

  • Many insurance companies offer individual policies that supplement the benefits available under Medicare. These policies are referred to as Medicare Supplement or Select policies. Medicare Advantage Plans are also offered by private companies that sign a contract with Medicare. Medicare pays a set amount of money to these private health plans for your health care. They manage the Medicare coverage for their members.

  • Medicare is health insurance for people over the age of 65, or for people who have been collecting social security disability benefits for 24 months. Medicaid is government assistance for people who qualify due to income and assets. People who qualify for both are called “dual-eligible.”

  • Individual Medicare supplement policies are designed to supplement the benefits available under the original Medicare program. Medicare supplement policies pay the 20% of Medicare-approved charges that Medicare does not pay. These plans typically do not restrict you to a network of doctors, but rather allow you to go to any doctor or facility that takes Medicare. Individual Medicare supplement policies include a basic core of benefits. In addition to the basic benefits, Medicare supplement insurers offer specified optional benefits. Each of the options that an insurance company offers must be priced and sold separately from the basic policy.

  • Medicare Advantage is a special arrangement between the federal Centers for Medicare & Medicaid Services (CMS) and certain insurance companies. Under this arrangement the federal government pays the insurance company a set amount for each Medicare beneficiary. The insurance company agrees to provide all Medicare benefits. The insurance company may provide some additional benefits, but it may also require payment of an additional premium. Beneficiaries under Medicare Advantage plans continue to pay the Part B Medicare premium to CMS. Your Medicare Advantage plan can terminate at the end of the contract year if either the plan or CMS decides to terminate their agreement.

  • Medicare select policies supplement the benefits available under the Medicare program and are offered by insurance companies and health maintenance organizations (HMOs). Medicare select policies are similar to standard Medicare supplement insurance. However, Medicare select policies pay supplemental benefits only if covered services are obtained through plan providers selected by the insurance company or HMO. Each insurance company that offers a Medicare select policy contracts with its own network of plan providers to provide services. If you buy a Medicare select policy, each time you receive covered services from a plan provider, Medicare pays its share of the approved charges and the insurance company pays the full supplemental benefits provided for in the policy. Medicare select insurers must pay supplemental benefits for emergency health care furnished by providers outside the plan provider network. In general, Medicare select policies deny payment or pay less than the full benefit if you go outside the network for non-emergency services. However, Medicare still pays its share of approved charges if the services you receive outside the network are services covered by Medicare. All Medicare select policies include a basic core of benefits.

  • Medicare prescription drug coverage, sometimes known as Part D or a PDP, is insurance that helps cover the cost of medications. Medicare will contract with private companies to offer this drug coverage. These companies will offer a variety of options, with different covered prescriptions, and different costs. Costs will vary depending on which drug plan you choose. Some plans may offer more coverage and additional drugs for a higher monthly premium.

  • Everyone with Medicare, regardless of income, health status, or prescription drugs used, can get prescription drug coverage. You may sign up when you first become eligible for Medicare (three months before the month you turn age 65 until three months after you turn age 65). If you get Medicare due to a disability, you can join from three months before to three months after your 25th month of disability. If you don't sign up when you are first eligible, you may pay a penalty.

Long Term Care Questions

  • Long term care refers to assistance with the very basic activities of daily living (ADL) that the general population can do with no assistance. As a result of illness, injury or advanced age, many people need assistance in order to eat or dress or bathe. The need for long term care may also result because a person has cognitive impairment. Some people need supervision or reminders to accomplish ADLs, such as using the toilet, eating, bathing, dressing, and so forth.

  • About half of all long term care expense is paid by state Medicaid programs. About one-third is paid out of pocket by individuals and their families. Medicare only provides for some skilled care in some limited situations. Neither Medicare supplemental insurance nor major medical coverage provided by most companies pays for long term care. This leaves approximately one-sixth of the total cost to be covered by other government programs and private insurance.

  • Anyone who is age 45 or older should consider long term care insurance when planning his or her insurance needs. "Consider" does not necessarily mean "purchase". Depending upon a person's particular insurance budget, there may be other insurance needs that deserve priority. Certainly, the purchase of long term care insurance should never create a financial hardship.

  • It is difficult to know in advance who among us is going to need long term care. Also, it is difficult to predict who will develop a medical condition between the ages of 45 and 60 that would preclude the purchase of long term care insurance -- when the potential need for assistance with ADLs is just a few years away. Another consideration is the premium, which is generally lower when purchased at a younger age. Early purchase can make long term care coverage affordable later on, particularly after retirement.

  • Income and assets will decide whether to consider insurance for Long Term Care as well as how much is appropriate. If you have two-thirds of the cash flow needed to pay for the costs of a worst case scenario nursing care situation, you would only need the other third to be provided by Long Term Care insurance. If you could produce one-third of the costs from income and interest on assets, the other two-thirds could come from Long Term Care insurance.

  • Medicare will only provide for some skilled care in very limited situations. It was not designed to cover activities of daily living. Rather, it was designed to cover acute care or skilled care such as that provided during a short hospital stay.

  • Yes, but in very limited situations. Medicaid will generally apply only to those with very low income and very few assets. Even then, there is only limited choice of what benefits will be provided, and where those benefits may be received. For example, there might be limited choice of physician and facility, no control over the number of people sharing a room, or no ability for the family to pay for any extras.

  • Although medical insurance has some aspects of long term care, they are not the same thing. For example, some medical plans may pay for the services of a nurse while you are recovering from an illness or an injury that requires medical attention. This medical benefit is very limited. Once you are better or reach the maximum benefit for nursing services, this benefit would cease to be available. Medical insurance is not designed to cover activities of daily living. Long term care is designed to cover activities of daily living.

  • Nursing home insurance is generally thought of as the predecessor of long term care insurance. Today it is possible to purchase a long term care insurance policy that only provides benefits when the insured is confined in a nursing home. It’s important to consider, however, if that is where the policyholder would want to be if he or she were well enough to stay at home and receive care.

  • The daily cost of staying in a nursing facility varies widely from one city to another. Also, the physical setting, ratio of care givers to patients, and the credentials of the staff members may also vary from nursing home to nursing home, even within the same city.

Life Insurance Questions

  • Life insurance is a contract, often called a “policy,” between you and an insurance company to provide money to a person you designate, in the event that you die during the time the contract is in force. In essence, during your lifetime you pay money, known as the insurance “premium,” to the insurance company. It promises to pay money to the persons you name, the “beneficiaries,” at your death. Some types of life insurance also give the policy owner the right to “borrow” a portion of the “cash value” within a policy, or to receive an “accelerated death benefit” if you become terminally ill or require confinement in a long term care facility.

  • If you can afford it, there are several reasons why you may need life insurance. The most important reason is to have enough money to provide for dependents such as young children, non-working spouses or elderly parents, should you die and no longer be able to provide for them. Also, your survivors may need funds to pay for extra expenses that may arise due to your death, such as funeral expenses, or other expenses to pay off bills and debts.

    If you have no dependents or have adequate financial resources, you may not have an actual need to purchase life insurance. However, some people who do not “need” life insurance still purchase it anyway. This can be a means to leave money to a beneficiary or beneficiaries while minimizing tax consequences.

    Another category of people who might want life insurance are business owners or people with substantial estates. Since these people have needs that require more planning, they should usually consult with professionals or specialists in insurance-related law, accounting or estate planning because legal business agreements or trust documents may need to be drawn up.

  • Some reasons to buy life insurance are:

    • Income Replacement

    • Funeral Expenses

    • Pay Off Debts

    • Pay Off Medical Bills

    • Mortgage life insurance

Affordable Care Act & Individual Health Questions

  • Health Insurance Marketplaces (also known as Exchanges) are markets for buying health insurance that will offer a choice of different health insurance plans, provide information to help consumers better understand their options, and they also certify the plans that participate. Through the Marketplace, individuals and families will be able to shop for coverage if they need to buy health insurance on their own. Premium and cost sharing subsidies will be available through the Marketplace to reduce the cost of coverage for individuals and families, based on their income. The most commonly referred to marketplace is accessed through healthcare.gov.

  • The exchange can be used by any individual or family that would like to buy health insurance within the state that the exchange operates. If you qualify for a subsidy or cost sharing reduction, and you would like to utilize it, you must buy your health insurance plan through the exchange (healthcare.gov).

  • Your employer should have notified you by October 1st of your coverage options. Regardless of your coverage, you are able to shop in and out of the exchange, but keep in mind you may not qualify for subsidies and cost sharing options. Please consult your HR department for questions on your employer coverage to determine if it is deemed affordable and if you qualify for extra help in the form of premium subsidies and cost sharing reductions for your health insurance plan should you purchase a plan through the exchange (healthcare.gov).

  • Starting in 2014, there are 10 essential benefits that must be covered. They are:

    • ambulatory patient services

    • emergency services

    • hospitalization

    • maternity and newborn care

    • mental health and substance use disorder services, including behavioral health treatment

    • prescription drugs

    • rehabilitative and habilitative services and devices

    • laboratory services

    • preventive and wellness services and chronic disease management

    • pediatric services, including oral and vision care

  • Yes. You cannot be denied coverage for a pre-existing condition with any health insurance plan that meets the minimum standards of the Affordable Care Act. You also will not be charged more based on your health history (with the exception of tobacco use).

  • The Open Enrollment Period begins November 1 and will run until December 15. If you sign up for health insurance coverage before December 15, your coverage starts on January 1. Outside of the Open Enrollment Period, you will need a qualifying event to sign up for health insurance coverage. These events are:

    • Loss of eligibility for other coverage (not including loss due to unpaid premiums)

    • Gaining a dependent (for example, if you get married or give birth to or adopt a child).

    • Divorce or legal separation

    • Loss of dependent status

    • Moving to another state or within a state if you move outside of your health plan service area

    • Exhaustion of COBRA coverage

    • Losing eligibility for Medicaid or the Children’s Health Insurance Program

    • For people enrolled in a Marketplace plan, income increases or decreases enough to change your eligibility for subsidies

    • Change in immigration status

    • Enrollment or eligibility error made by the Marketplace or another government agency or somebody, such as an assister, acting on their behalf

    Your special enrollment opportunity will last 60 days from the date of that triggering event.