Medicare can be perplexing, all the more so when you combine complex health issues and the need for medical aids such as oxygen or hospital beds. While the insurance maze can be difficult to traverse, an estimated 47.5 million people received this program in 2010, which is more than a sixth of the nation’s population.
Here is a brief overview and some answers to some commonly asked questions regarding Medicare and home health care.
1. Who qualifies?
Medicare is a national health insurance program provided by the U.S. government for those who are:
- 65 and older
- Under 65 with certain disabilities
- Diagnosed with End Stage Renal Disease (ESRD), a form of permanent kidney failure requiring dialysis or a kidney transplant
2. What types of services does Medicare cover?
Medicare has four different coverage sections: Part A, B, C, and D. “Original Medicare” consists of Part A & B, while Part C is known as “Medicare Advantage Plan”. These four parts are summarized briefly:
- Medicare Part A: Hospital Insurance
* Part A covers care while in hospital as well as health care in skilled nursing facilities, home health care, and hospice.
- Medicare Part B: Medical Insurance
* Part B covers doctor’s visits as well as visits to other health care providers. Additionally, Part B covers hospital outpatient care, durable medical equipment (like intravenous infusion devices), and home health care services. Part B also covers specific types of preventative services, such as getting certain vaccinations.
- Medicare Part C: Medicare Advantage
* Part C combines health plan options you purchase from other private insurance companies approved by Medicare. Part C also integrates Medicare Prescription drug coverage (Part D) and can be tailored to include extra benefits at an extra cost.
- Medicare Part D: Medicare Prescription Drug Coverage
* Part D covers the prescription of Medicare-approved prescription drugs and can lower the cost of other medications. Similar to Part C, Medicare-approved private insurance companies also run Part D.
3. Why do I need to choose between Medicare plans?
The choice of “Original Medicare” (Parts A & B) entails payment of monthly premiums for part B and may necessitate additional coverage to pay deductibles and coinsurance to see physicians, hospitals, and other providers who accept Medicare. If you require Prescription drug coverage, you must pay a monthly premium to join the Medicare Prescription Drug Plan (Part D).
The “Medicare Advantage Plan” (Part C, which covers Part A & B), also requires the payment of monthly premiums in addition to the Part B premium & a copayment for in-plan doctors, hospitals. If prescription medications are not covered by your supplemental coverage, you have the option of joining the Medicare Prescription Drug Plan (Part D).
As with prescription medications, you can purchase supplemental coverage to cover services not covered by Medicare. The “Original Medicare” plan allows for the option of buying Medicare Supplement Insurance (Medigap), while the “Medicare Advantage Plan” does not.
It is prudent to always check if you can take advantage of other additional coverage through your employer or union, military, or Veteran’s benefits.
4. Is home health care covered by Medicare?
The Medicare website states, “Medicare only covers home health care on a limited basis as ordered by your doctor”. As reviewed earlier, Parts A & B are the Medicare options which cover the home health care services specified by Medicare.
Coverage of home health care by Medicare in New Mexico stipulates you must meet the following criteria:
- You are currently receiving regular services from a physician. This physician must also maintain a care plan unique to you, which is reviewed regularly.
- Your physician must certify a “need” for specific medical services such as requirements for intravenous medication therapy, physical therapy, occupational therapy, respiratory therapy, or speech-language pathology services.
- The home health care agency providing you services must be Medicare-certified (for more details see below).
- Your physician must certify your health status as homebound, which is indicated by the following:
* Your health condition limits you from leaving the house.
* You are unable travel from home without help (i.e. transportation assistance such as aids or individuals).
* Leaving your home takes considerable effort and may be detrimental to your health condition.
5. My home health company does not take Medicare, why is this?
The Medicare-approval process is lengthy and costly, so while it may appear that many companies may not take Medicare, they may actually be in the process of becoming Medicare certified.
Furthermore, the Medicare criteria for individual qualifying to receive home health care are very strict; the reality is that many people who may apply for coverage by Medicare for their approved home health company services will not actually receive coverage. Currently, Medicare pays only about half of all health care costs to seniors. Medicare very often denies payment due to not meeting criteria, so it is essential to be aware if you meet these criteria prior to restricting yourself exclusively to Medicare-approved home health care companies.