Q & A
Q: MY MOTHER WAS RECENTLY HOSPITALIZED AND REQUIRES RECUPERATIVE CARE IN A SKILLED NURSING FACILITY BEFORE SHE CAN RETURN HOME. SHE HAS MEDICARE PART A. WE WERE TOLD THAT AFTER THE FIRST 20 DAYS, MEDICARE ONLY PAYS FOR 80%. SHE CAN'T AFFORD THE DIFFERENCE. WILL SHE HAVE TO LEAVE AFTER 20 DAYS?
A: No. The good news is that the nursing home or skilled nursing facility by law cannot discharge a patient who is unable to pay the coinsurance after 20 days.
Q: MY INSURANCE POLICY HAS A $1000 MAXIMUM ANNUAL CAP ON "DME." WHAT DOES THAT MEAN?
A: DME stands for Durable Medical Equipment. This includes the rental and/or purchase of equipment deemed necessary in the care of your particular clinical condition, especially in the home, when prescribed by your doctor.
It includes a hospital bed, cane, walker or wheelchair, oxygen and/or oxygen tubing, mask, concentrator, portable commode, pumps for intravenous drug or nutrition administration, pulse oximeter.
Most plans' membership handbooks specify very clearly what is and what is not covered. There is often an annual deductible which must be met first (an amount you pay out-of-pocket), and an annual cap (dollar limit on amount of benefit per year). This benefit becomes critical when determining whether or not care can be provided at home, e.g. hemodialysis for a bed-bound person, or chemotherapy. It should be noted, however, that intravenous home infusion is sometimes provided as a stand-alone benefit and is not included under "DME."
Q: HOW DO I KNOW IF I AM ENTITLED TO HOME CARE SERVICES AND WHAT ARE THEY?
A: Your home care benefits are mostly included under the "hospital benefit" of your insurance policy. They are listed as "intermittent" skilled care and are generally capped at a certain number of visits per (calendar) year. Some policies require a previous hospital stay. Home care would include visits by a registered professional nurse (R.N.), licensed physical/occupational/ or speech therapist, (P.T.,O.T., S.T.), and medical social worker. They may also include paraprofessional care by a home health attendant, but only if there is an on-going need for one of the professional providers (R.N., P.T., O.T., S.T.). That means that when the professional care has met its goals, which are by definition for short-term, not long-term or chronic care, then the paraprofessional services are discontinued too. Of course, you can always hire privately for non-professional services.
Q: MY ELDERLY PARENT WISHES TO REMAIN AT HOME, BUT NEEDS HELP WITH SHOWERING, GETTING MEALS AND ERRANDS WHILE WE ARE AT WORK. HOW DO WE GO ABOUT GETTING HELP AND IS IT COVERED BY INSURANCE?
A: The care needs you described are generally classified by insurers as "personal care needs" or "custodial" care needs. These are not typically covered by health insurance or Medicare, unless there are concurrent clinical care needs as well (see previous question). You can private hire at the "companion" level or certified "home health attendant" level. A companion is just that: someone who can run some errands, put together a light meal, escort outside, run a wash. A certified home health attendant has received training in health care basics and can monitor for adverse symptoms, assist in carrying out a home exercise program, and appropriately position and transfer a client. It is very important to hire help that is bonded and insured; that is why you want to use a state-licensed or certified agency.
Q: WE HAD PURCHASED AN INSURANCE POLICY WHICH HAS A $5000 ANNUAL CAP (LIMIT) ON PRESCRIPTION DRUGS. DOES THIS INCLUDE DRUGS FOR CHEMOTHERAPY AND, IF IT DOES, WILL IT BE SUFFICIENT COVERAGE IF WE NEED IT?
A: Although it seems like a lot of money, $5000 is a minimal drug benefit, especially if it is extended to include chemotherapy. Check your certificate of insurance (member handbook) to see if out-patient chemotherapy is listed as a separate benefit. If it is, it should not then be paid out of your prescription drug benefit with that $5000 limit. Call your insurer to check.
If you do not see a separate listing for out-patient chemotherapy and now need chemotherapy treatment, there are two possible options: 1) admission for chemotherapy as an in-patient in a hospital or skilled nursing facility or 2) a negotiated trade-off to increase your drug benefit coverage. Some insurers allow trade off of chiropractic and DME benefit for increased drug benefit, for example.
Q: WHAT OTHER FEATURES OF AN INSURANCE POLICY SHOULD I EXAMINE WHEN CARING FOR SOMEONE WITH CANCER?
A: Although it's become fairly standard now, check to confirm coverage for "ambulatory" procedures, which may also be termed "ambulatory or day surgery," or "ambulatory (out-patient) admissions." This is included under the hospital benefits section of the insurance policy. Many surgical procedures, including biopsies and chemotherapy, can be handled via admission to an ambulatory or "day" hospital department. As noted previously, such an admission can be a way to access covered chemotherapy benefits, when there is a minimal drug benefit.
Also check for radiation treatment coverage. This should be listed as a separate, out-patient policy benefit, which would include radiologic procedures in a doctor's office, an out-patient clinic, or a radiation therapy facility.
Verify transfusion benefit also. These are not done in the home; confirm coverage on an out-patient basis.