Health Insurance in Special Situations (Medicare, Long-Term Care, Dental and Vision)
Medicare
Part A covers inpatient hospital, skilled nursing (after a qualifying stay), hospice, and some home health; most people get it premium-free with 40 quarters of work. Part B covers physician and outpatient services and requires a premium. Part C is Medicare Advantage, which delivers Parts A and B through private plans. Part D covers prescription drugs. Enrollment: the initial window spans the seven months around the 65th birthday month; the general enrollment period runs January 1–March 31; the annual election period runs October 15–December 7.
Medigap (Medicare Supplement) plans are standardized A–N. The six-month Medigap open enrollment gives guaranteed issue. Medigap cannot be used with Medicare Advantage and generally excludes drug coverage. Medicaid is income-based and may cover long-term custodial care.
Long-term care
LTC insurance pays for custodial care, not acute medical treatment. Tax-qualified policies trigger benefits when the insured cannot perform two of six activities of daily living for at least 90 days or has a cognitive impairment. Key features: elimination period, benefit amount and period, inflation protection, nonforfeiture, and home care coverage. Partnership programs allow asset protection.
Dental and vision
Standalone or group plans use deductibles, annual maximums, and waiting periods for major services; UCR and network rules apply. Vision plans cover exams and hardware with frequency limits. Discount plans are not insurance.
Traps
Medicare does not pay for custodial long-term care; Medigap does not include drug coverage; ADL triggers require two of six, not three.
Rule of thumb
Part A = hospital, B = doctor, C = bundle, D = drugs.
Worked example
A client on Medicare Advantage wants drug coverage - confirm the MA plan includes Part D or enroll in a standalone PDP; buying Medigap is not the answer.