Medicare & Home Health Care: A Quick Overview

Medicare can be confusing. Throw in complex health issues and the need for medical aids such as oxygen or hospital beds and the insurance maze can be even more difficult to traverse. Nevertheless, 47.5 million people received Medicare in 2010, which is more than a sixth of the nation’s population.

Nurses With Heart Home Care is frequently asked a variety of questions about Medicare. We would like to provide a brief overview of information related to some common questions about how Medicare and home health care work together.

 

1. What is Medicare?

Medicare is health insurance for those who are:

– 65 or older

– Under 65 with certain disabilities

– Diagnosed with End Stage Renal Disease (ESRD) which is permanent kidney failure requiring dialysis or a kidney transplant

 

 

2. How does Medicare work?

Medicare has four different components: Part A, B, C, and D. Part A & B are known as “Original Medicare” while Part C is known as “Medicare Advantage Plan”. The four parts are outlined as follows:

– Medicare Part A: Hospital Insurance

  • Part A covers care while hospitalized as well as care in skilled nursing facilities, hospice, and home health care.

– Medicare Part B: Medical Insurance

  • Part B covers visit to your doctor and other health care providers in addition to outpatient care at the hospital, durable medical equipment (like oxygen machines), and home health services. Part B also covers a limited amount of preventative services, such as getting a yearly flu shot.

– Medicare Part C: Medicare Advantage

  • Part C integrates health plan options provided by other private insurance companies approved by Medicare. Part C also covers Medicare Prescription drug coverage (Part D) and can include extra benefits at an extra cost.

– Medicare Part D: Medicare Prescription Drug Coverage

  • Part D covers the cost of Medicare-approved prescription drugs. Part D can also lower the cost of other prescription drugs. Like Part C, Part D is also run by Medicare-approved private insurance companies.

 

 

3. What are the differences in Medicare option choices?

If you choose “Original Medicare” (Parts A & B), you pay monthly premiums for part B and may require supplemental coverage to pay deductibles and coinsurance to see doctors, hospitals, and other providers who accept Medicare. If you want Prescription drug coverage, you must join the Medicare Prescription Drug Plan (Part D) and pay a monthly premium.

If you choose “Medicare Advantage Plan” (Part C, which covers Part A & B), you pay a monthly premium in addition to the Part B premium & a co-payment for plan doctors, hospitals. If your supplemental coverage does not cover prescription drugs, you can join the Medicare Prescription Drug Plan (Part D).

You may choose to obtain supplemental coverage to cover services, which Medicare does not cover. The “Original Medicare” plan allows you to buy Medicare Supplement Insurance (Medigap) while the “Medicare Advantage Plan” does not.

Always be sure to check if you can take advantage of other coverage through your employer or union, military, or Veteran’s benefits.

 

 

4. Does Medicare cover home health care?

According to the Medicare website, “Medicare only covers home health care on a limited basis as ordered by your doctor”. As discussed above, Part A & Part B covers the home health care components of Medicare.

 

To receive home health care coverage by Medicare in New Mexico, you must meet the following criteria:

– You must be receiving regular services from a doctor and have a care plan reviewed regularly by your physician.

– Your doctor must certify a “need” for medical services such as intravenous medication therapy, physical therapy, speech-language pathology services, or occupational therapy.

– Your home health agency must be Medicare-certified (see more on this below).

– Your doctor must certify you are home bound, meaning: your condition limits you from leaving the house, you cannot travel without help (i.e. transportation assistance), and leaving the home takes a considerable effort.

 

 

5. Why doesn’t my home health company take Medicare?

The process of becoming Medicare-approved is lengthy and costly, so while many companies may not take Medicare, they may be in the process of working towards Medicare coverage.

Additionally, Medicare criteria for receiving home health care are very stringent; many people who may want to use a Medicare-approved home health company will not actually receive coverage. In fact, Medicare pays only about half of all health care costs to seniors. Medicare frequently denies payment due to not meeting criteria, so it is important to know if you meet these criteria prior to limiting yourself to only Medicare-approved home health companies.

 

It is important not to get overwhelmed by the complexities of Medicare, as there is a wealth of information on the Internet, including the official U.S. government site for Medicare.

For further information about your Medicare options, see “Your Medicare Coverage Choices“.

To see if Medicare covers your services or tests, click here.

Find out about Medicare costs at”2012 Medicare Costs“.

 

In closing, keep in mind that while Medicare only covers home health for the home bound, home health care is NOT just for the home bound. Nurses With Heart Home Care offers a variety of services at competitive prices, which not only benefits those not covered by Medicare, but those who are home bound or otherwise.