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By Joan Carrature

Ms. Carrature is a Registered Nurse, CCM (Certified Case Manager) and a HIAA certified Managed Care Professional. She also holds a BA and a BSN and an MA. She has been employed for the last six years as a complex care case manager for a not-for-profit health insurer.

It is so very important that you review your present health care coverage options periodically. Circumstances change as do we as we get older, and the covered benefits that seemed adequate for a healthy 30 year old may not provide even a modicum of protection after just one episode of accident or illness. To learn more, there are a few excellent sites on the Web that you can access at home or your local library. An excellent one for information about Medicare and Medicaid, continually updated, including comparisons of plans offered to Medicare recipients by all insurers, is http://questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std_alp.php?p_sid=9W6Bh*Ni.

Also visit http://data.georgetown.edu/research/ihrcp/hipaa for current information relating to the Health Insurance Portability and Accountability Act (HIPAA). There are links to state-by-state consumer's guides that review the ways to get and keep insurance in your state, as well as addresses and contact numbers for your state's Department of Insurance for further information. As always, the best protection is good information. We hope that we have started you on that path to learning.

Different Kinds of Coverage

Here is a brief review of the basic terms that describe health insurance coverage.

    A Managed Care Disclosure Document is a plan description that, since 1997, the insurer is required to provide by law. It is a general information summary; more detailed benefit info is located in the "certificate of insurance," the document or booklet that is provided and approved by the State Insurance Department. The Human Resources staff at your place of employment can provide these.

    HMO stands for Health Maintenance Organization. This is a plan that provides both coverage and services and is essentially pre-paid by the employer (or jointly by employer and employee). It can exist as a full-service clinic or as a network of physicians/nurse practitioners who operate out of their own offices. Many of these plans still require your primary care provider (PCP), who is your general medical doctor, to refer you to a specialist physician, and to actually write the order for any prescriptions or laboratory tests. HMOs generally cover any services that may be required, with the exception of dentistry and sometimes mental health. A small co-pay is also required in some plans. No claim forms need to be filed by the subscriber.

    PPO stands for Preferred Provider Organization. In this type of arrangement, there have been rate negotiations with a panel of physicians and facilities, the "preferred" providers. If these providers are used, the services are usually covered 100%, with perhaps a small co-pay.

    POS stands for Point of Service. A blend of HMO and PPO, the PCP provides general medical care, controls access to specialists, and refers to those specialists in the plan. However, for a higher co-payment and perhaps a deductible (amount the subscriber has to pay out-of pocket), a person may obtain medical care from someone outside the network for covered services.

    Medicare stands for the federal program targeted at people age 65 and over, based on an employment history of 40 working quarters qualifying for Social Security benefits. If a person becomes Social Security-eligible before 65 due to a disability for 2 years, or has irreversible kidney failure requiring dialysis for 30 months, that person is also Medicare eligible. If a person does not meet the requisite number of working quarters, he or she may enroll in Part A Medicare for a monthly premium.

      Part A Medicare pays for all hospitalization charges, less a $760 deductible, for the first 60 days of hospitalization in a benefit period (usually the year beginning with the month one turns 65). Part A also pays for Skilled Nursing Facilities (SNF's) for subacute or recuperative or rehabilitation care, as well as hospice care and home health care.

      Part B Medicare pays for physicians, laboratory fees, and other types of out-patient services. In 1997, the monthly charge was $43.70 and there is a $100 deductible per benefit year. Medicare pays physicians based on a Medicare fee schedule at 80% of the schedule allowance. The patient is responsible for the remaining 20%. Some doctors accept the Medicare fee allowance as payment in full; others do not accept the Medicare rates and may charge up to 15% more than the fee-schedule.

    MediGap refers to a privately purchased insurance plan designed to cover what Medicare does not. At the minimum, this type of plan covers the 20% of the doctor's fees as per the Medicare schedule allowance and the co-payment for the hospital charges, should the patient be confined beyond 60 days (up to 90 days).

For additional information about Medicare and Medigap, call the Department of Health and Human Services at 1-800-638-6833.

Seeking Treatment Out of the Country

More often than not, insurance benefits do not apply to services provided outside of the country. If you have an HMO (Health Maintenance Organization) plan, you are restricted to designated, local facilities for care, unless there is an approved emergency. If you are insured through Medicare or Medicaid, care outside of the U.S. is not covered. If your certificate of insurance contains language that allows care "anywhere," call to verify. Care must be consistent with U.S.-accepted standards of care to be covered. Also, the insurer may not make payment to the foreign provider(s), but rather to you. So you need to be prepared to pay for services, usually cash-only, up-front.

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.

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