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The Importance of Your Health Care

Health insurance plans are complicated. This used to be the problem of the Human Resources department. However, today more Americans then ever are sharing the responsibility of making decisions for their employer based health care coverage. Millions more are on their own, purchasing health insurance in the private market. While many decisions are centered on the monthly premium, the level of your health insurance deductible can greatly impact the overall cost of your plan and even your level of care.

What Is A Deductible?

A deductible is the amount of health care that the insured must pay before the health plan provider begins to make payments. The deductible applies only to medical care that has been billed directly through the insurance provider. It does not apply to any medical care paid for outside of the health plan.

Deductibles can vary widely from just a few hundred dollars to over $10,000 a year. Some will vary based on in-network versus out-of-network medical care. The deductible is wiped clear once a year, usually on January 1st.

Growing Influence

Most people have typically received health care coverage through their employer. Under such plans, the worker generally paid very little for actual medical care used. There might be a co-pay for a visit to the doctor and perhaps a small yearly deductible, but for the most part, benefits meant you did not pay much, if at all, for the health care you used.

But that’s often no longer the case. The reality is that health care costs have been on a steady, high growth rate over the past two decades. The cost for an employer to provide health benefits has reached a critically high level, in many cases well over five figures. In response, many employers have pushed some of the costs back on the employee. This is often seen directly in an increased share of the monthly premium paid by the employee, but also an increase in plans with high deductibles, most or all of which will be the responsibility of the employee.

High or Low?

When selecting a health care plan, many people focus on the monthly premium. When it comes to budgeting, many people think in month-to-month terms. Low premium, high deductible plans can look attractive. However, with such plans, the insured will have to spend a lot of money out of pocket, in addition to the premium, in the event that they use medical care. Plans such as these are best paired with a health savings account, so that money can be saved tax-free towards the deductible. Otherwise you may be stuck with a very large medical bill you are unprepared to pay.

Many people are used to low-deductible plans, and often prefer them. Its nice to know your medical care has been largely taken care of in a standard monthly payment. Part of why people have insurance is to have predictable costs. However, the cost of high premium plans has risen dramatically over the years, often beyond what a car payment is and in some cases rivaling a house payment. This has made high premium plans less attractive.

What Is Best For You?

In general, a high deductible plan will have a lower total yearly cost then a high premium plan. This is because many people do not use as much medical care as they think over the course of a year. What they have to pay towards a deductible is often offset by their monthly savings with the lower premium.

If you are someone who uses a lot of health care year in and year out, a high premium plan may be a better solution. High premium plans can also be a good decision for people who have a hard time saving. A high deductible plan can be a major hardship for people who do not have much in savings and who typically do not save a lot of money. A high premium plan is somewhat like a forced savings plan.

Health Care Reform

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To stir emotions the health care reform debate doesn’t have to peel the onion back very far. There are those who could always afford health insurance and are worried that their costs will significantly rise in the attempt to cover the cost of care for those who have gone without. There are those with numerous and expensive to treat medical problems, who have no health insurance or inadequate health insurance coverage and they need relief, now! And there are those who are healthy, have chosen not to have health insurance, and resent a mandate requiring them to “buy-in” or face monetary penalties.

How to provide health care.

The Health Care Affordability Act of 2010 is wide in its scope and goals. First, it moves us to a place where most Americans will be covered by health insurance. This will remove “the” key impediment to “routine” health care services for millions of Americans. Subsidies will insure health care insurance regardless of an ability to pay and just because you have pre-existing medical conditions you will still be eligible for “reasonably priced” coverage. Stated another way, insurers will not be able to reject you or drastically increase your premiums if you suffer from chronic illnesses that generate a high level of claims, nor will they be allowed to set dollar limits on health insurance coverage.

To fund these objectives the Health Care Affordability Act requires all Americans to purchase health insurance. There will be subsidies if you are in a low income category and if you have no ability to pay anything you will be eligible for Medicaid as these state level programs will be more accommodating and act as the ultimate safety net. Through its mandates, the law requires millions of healthy individuals to pay into the system. The idea here is that those of us who are not in need of health care will fund those who draw from it. Since any of us can succumb to a health emergency at any time and thus become in need of potentially costly health care interventions those who support the mandate feel that this is fair – we are simply looking out for each other. Next, there are numerous plans in testing phases that are designed to make the delivery of health care more efficient and more cost effective. These pilot programs are being managed by the Center for Medicare and Medicaid Services (CMS) and include the cooperation of health systems throughout the country. These are complex to say the least and in early development stages and until proven, which is years from now, it is not known what their effect will be.

I support the attempt by the Obama administration and others to get something done on this pressing national issue. But there is a lack of candor about the cost, where the funds will come from, what treatments and medical technologies will be restricted due to very high costs and how the demand of millions of newly insured patients will be managed in terms of timely access to care and treatments. I have spent forty-one years of my life in a medical technology career that focused on global health economics and reimbursement issues and believe me, something will have to give. In every country outside of America, health care budgets are limited and capped. Fees to hospitals and physicians are set, annually reviewed and kept in check and new medical technology prices and access to them are restricted in subtle and not so subtle ways. And if you think that these policies won’t happen in America – think again, as spending limits are being set and will be set and we will have to live within them!

Having said that, let’s continue on with the reforms, some government mandated, some driven by the market place as conservative health policies propose. Just know that we will be dealing with health care reform for a very long time and there are going to be a lot of disillusioned folks along the way, newly enfranchised and otherwise. The emerging health care system will be “more just” but it will require real and noticeable sacrifice from the majority of Americans who heretofore never much worried about the fairness of it all.

Australian Health Care Benefits

Moving to Australia is an exciting prospect. However inevitably the question of health care is raised. No one wants to become ill or injured while living in Australia and then be left with an enormous bill to pay.

Does Australia have free health care?

Medicare is Australia’s publicly funded health care system however it does not provide 100% coverage. Medicare provides eligible individuals access to free or subsidised medical, optometrical (eye care) and public hospital care. Medicare does not pay towards ambulance costs, physiotherapy, spectacles, podiatry, chiropractic services, or private hospital accommodation.

Medicare also does not cover dental costs, with some exceptions for low-income earners. A nationwide Denticare Australia program may be extended in the next government budget, however the specific details are yet to be announced. Some dental organisations provide interest free payment plans, member discounted services that attract an annual fee, or discounts for regular patients to help manage costs.

Individuals can also choose to access private health services that charge for their services, and may choose to take out private health insurance to cover these types of costs.

Will I be eligible for a Reciprocal Health Care Agreement?

The Australian Government also has Reciprocal Health Care Agreements with some countries that provide ‘restricted access’ to public health care while in Australia. Restricted access usually limits care to ‘medically necessary’ treatments eg. Ill health or injury which occurs while you are in Australia and which requires treatment through a public hospital before you return home.

Individuals from New Zealand and Ireland do not get issued with a Medicare card and instead present their passport at public hospitals or pharmacies. Non-hospital care, such as attending a local GP doctor, is not covered. Other reciprocal agreements will pay Medicare benefits for out-of-pocket medical treatment provided by doctors through private surgeries and community health centres. All agreements cover subsidised medicines under the Pharmaceutical Benefits Scheme (PBS).

Note: Reciprocal agreements technically only cover individuals if they have come directly from the reciprocal country eg. If you were previously living in another foreign country prior to coming to Australia you may not be eligible, as you have not been recently been part of the health system for your country of nationality. However application of this requirement varies between Medicare staff.

Medicare Information Kits for migrants are available in 19 different languages.

What amount is subsidised by the government?

The benefit (or refund) that you receive back from Medicare is based on the Medicare Benefits Schedule (MBS) for that specific service which is set by the government. Doctors and other health service professionals can choose to charge over the schedule fee or bulk bill. Bulk billing is when doctors bill Medicare directly, accepting the Medicare benefits as full payment for the service. If doctors charge a higher amount the patient wears the extra costs.

Many doctors now offer to process Medicare claims electronically at the end of the appointment. Alternatively you can lodge most claims online, visit a Medicare office or post in your claims. Refer also to How does Medicare work?

Patients may also be required to pay for additional tests or vaccinations that their doctor requests as part of their treatment.

Some benefit examples based on the current schedule (1 Nov 2011) are below:

Standard doctor Level B consultation for less than 20 minutes with a GP (General Practitioner) in their consulting rooms: Fee = $35.60 and Benefit = 100% so you receive a $35.60 rebate. Therefore if the doctor charges $65.00 for an appointment you will be out of pocket by $29.40. If the doctor bulk bills they would charge the $35.60 fee direct to Medicare resulting in no out of pocket costs for the bulk billed patient.

Specialist doctor consultation initial appointment in a hospital or their consulting rooms: Fee = $83.95 and Benefit = 75% (hospital in-patient) or 85% (out-of-hospital) so you would receive either a $63.00 or $71.40 rebate. Therefore if the doctor charges $130.00 for an appointment you will be out of pocket by $67.00 or $58.60. You will need a referral letter from a GP to see a specialist so will need to budget for both out of pocket costs. Specialist fees can also vary considerably with some charging several hundreds of dollars if they are highly specialised and sought after. It is worth checking fees prior to making appointments so you are prepared for any out of pocket costs.

Comprehensive dental oral examination, limited to 1 per provider every 2 years: Note: Any preventive services like removal of plaque and/or stains, or any fillings etc are billed separately and can quickly add up to a sizeable bill even with the rebates: Benefit = $40.50 so if the dentist charges $95 for this item you will be out of pocket by $54.50

Medicare concession card holders will usually be charged a lesser rate or receive some services for free.

Note: If you are not eligible for Medicare you will have to pay the full appointment fees. However you are also exempt from paying the Medicare Levy and any surcharges (see below for more information on these).

The Pharmaceutical Benefits Scheme (PBS) details the medicines subsidised by the government, which must be purchased through a pharmacy. Non-PBS medications will be charged at full price.

The government also protects high users of medical services from big out-of-pocket costs through the Medicare Safety Net, and provides pension and health care concessions for pensioners and low income earners. The PBS Safety Net is available for individuals who need a lot of medicines in any year.

Individuals may also be able to claim a tax offset of 20% for net medical expenses over the threshold, currently $1,500 for the tax year for eligible expenses.

Note: The above protections may only apply to individuals on full Medicare so check further with Medicare before applying.

Are there any costs when I use an ambulance?

Ambulance cover varies between the different Australian States & Territories.

In Queensland and Tasmania, ambulance services are provided free for local residents.

In all other States & Territories, fees may be charged. The fees can vary depending on: how far individuals travel by ambulance, the type of transport eg. helicopter, the nature of the illness, whether an emergency or not, and any concession eligibilities.

Residents living outside Queensland or Tasmania can insure against ambulance costs, either through membership schemes provided by the relevant ambulance service (in the Northern Territory, South Australia, Victoria and country areas of Western Australia) or through a private health insurance fund (in the Australian Capital Territory, New South Wales and metropolitan Western Australia).

Note: Check the details of any ambulance cover provided by private health insurers carefully as it may only be limited to ’emergency’ transportation eg. not covering trips between hospitals or non-critical call outs. Membership with ambulance services may be more comprehensive.

In most cases, local holiday or business visitors to other States & Territories will be covered if they were covered in their home State or Territory due to reciprocal arrangements. However it is worth checking this before travelling to other States or Territories.

Do I have to pay anything towards Medicare?

Medicare is funded by a Medicare Levy tax deduction taken from your income with the contribution level based on how much you earn. The Medicare Levy is currently 1.5% of taxable income.

In addition, the Medicare Levy Surcharge of 1% is levied on high-income earners who do not have private hospital cover. The income threshold for 2011-12 year is $80,000 for singles and 160,000 for couples / families increasing by $1,500 for second and subsequent dependents. The surcharge is designed to encourage individuals to take out private cover and therefore reduce the demand on the public Medicare system.

If you are not eligible for Medicare then you may qualify for a Medicare Levy exemption and will not have to pay the Medicare Levy or Medicare Levy Surcharge. You must however complete a Medicare Levy Exemption Form in order to be exempt from the tax.

Home Health Care With Medicare

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.

A Pound of Primary Health Care

Health care. Very few phrases envelope so many different aspects of an area of discipline. It can be confusing to know where to go to and when, and this issue has led to a cascade of health problems for our population and our population’s health care system. Emergency room or primary care? And where does preventative care fit in? Here’s an overview of a few facets of the system, and how they differ from each other.

Why Not Just Visit Emergency?

Most emergency departments offer a wide range of services available at all hours, without the requirement of an appointment. However, many ER visits are avoidable as patients are seeking non-urgent care or care that could have been treated and even prevented by primary health care. These avoidable visits result in higher costs, longer emergency department waits, and fewer resources available to the patients who actually require emergency services. Interestingly enough, misuse of the emergency department is equally committed across all ages, regardless of whether or not they are insured. This population-spanning issue has even spurred an “Urgency or Emergency” ad campaign in New Mexico coordinated by the Albuquerque Coalition for Healthcare Quality and funded by the Robert Wood Johnson Foundation.

It is essential to provide and spread education about appropriate times to facilitate emergency services, walk-in to an urgent care clinic, or wait to make an appointment with your general practitioner.

So when do you visit the emergency room?

Examples are incidences of:

– Difficulty breathing

– Uncontrolled bleeding

– Loss of consciousness

– Severe burns

– Chest pains

– Broken bones

When do you visit urgent care?

Any time that you experience a change in your health status which needs attention, but will not be an immediate threat to your health.

Examples of these incidents are:

– Migraines

– Back pain

– Earaches

– Sprains

– Rising fever

– Minor lacerations

Primary Health Care / Primary Care: The Same But Not!

Primary health care is an extensive and broad model designed to cater not only to the individual and their family but to their community as well. Primary health care is meant to be an accessible community based system, responding to the to social issues of the population it is serving.

Primary health care works to:

– Prevent illness and be promotive of health (as opposed to working solely in a curative manner as seen in primary care)

– Focus on maximizing individual and community involvement in the planning and operation of services as well as in the integration of health development with social and economic development

– Integrate rehabilitative and therapeutic care into patient’s daily lives

The presence of primary health care is essential to building healthy public policy and strengthening community action. This also allows for an equal distribution of care available to the local public. Individual and community involvement can also be seen through their participation through building beneficial public policy, creating supportive environments (such as in programs at community centers), and strengthening community action. It is the action of the local individuals as a group, which encourages increased community participation and support for each other, furthering positive health habits at the local level. Not only can primary health care’s focus on health promotion be seen on an external level through community action and public policy, this can also be seen on an internal level via the promotion of personal skills through education by medical professionals.

Primary care emphasizes the curative focus of medicine and mostly occurs in the clinical setting (i.e. your GP’s office, the local walk-in urgent care clinic, or the emergency department).

Primary care:

– Often is the initial point of contact between individual and medical personnel when the individual experiences a change in health status.

– Is not as comprehensive as primary care due to the acute nature of clinical visits

– Refers individuals to the services available through primary care as well as to home health care

The Take-Home, Part 1

There is a time and a place for preventative care, just as there is a time and a place for emergency medicine. The bottom line is that health statuses will always change. And when they do, stop and think. Is this something which requires long term care in my home? Can I wait until tomorrow to make an appointment at my doctor’s office? Can I drive to a walk-in urgent care clinic? Or should I call 911 and go straight to emergency? Your decision impacts not only you, but your community as well.

Telemedicine in the Affordable Health Care

Telemedicine is an important component of the robust and technology driven Affordable Care Act system (Obama care) and provides avenues for reducing costs in the new healthcare structure, because it offers options in how to access healthcare services.

The Affordable Care Act is the most comprehensive overhaul of the nation’s health care system in decades and it’s implementation and sign-ups will all be processed through marketplace exchanges.

What is the Meaning of Telemedicine?

Telemedicine is the use of telecommunication and information technology to provide clinical health care without a traditional face-to face consultation. It helps eliminate distance barriers and can improve access to supplementary medical services for people with:

  • Basic or No Insurance
  • High Deductible (HDHP) Insurance
  • Traditional Insurance

Tele-health Vs Telemedicine

‘Tele-health’ is an older, broader term for services such as health education and is not limited to clinical services, while ‘Telemedicine’ narrowly focuses on the actual curative aspect between the patient and healthcare professional. Examples of Tele-health are health professionals discussing a case over the telephone or conducting robotic surgery between facilities at different ends of the world.

Tele-Health has a broader scope than telemedicine and is sometimes called e-health, e-medicine, or telemedicine. Health care professional use tools like e-mails, e-visits, e-prescribing, after-hours care, e-reminders, health assessments, self-management tools, health coaching etc.

The State of the Market

The Affordable Care Act (Obama Care) Health Insurance Exchange (HIX) opens on Oct 1st, 2013. and goes into operation on Jan 1st, 2014. The Obama Care exchanges, are State, Federal or joint-run online marketplaces for health insurance. Americans can use their State’s “Affordable” Insurance Exchange marketplace to get coverage from competing private health care providers.

Steps to Sign up for Health Care Plans

  • Participants enter personal information into a web portal
  • Learn their eligibility for subsidies based on income, state-determined criteria or employer-based options.
  • Use a price calculator to shop, compare and choose a best benefit health plan.

Several major health companies have programs like TelaDoc in Aetna, KP-OnCall in Kaiser etc, trying to set up footholds in a market that is widely expected to grow rapidly. All participants have to do is research for telemedicine benefits through their health insurance plans or sign up for independent programs.

How Health Care Professionals Administer Telemedicine

Doctors can treat most everyday health needs by phone or a scheduled video consultation. A study by the American Medical Association shows that 4 out of 5 visits to a primary care doctor could have been treated over the phone instead. After each consultation, patients will receive a clinical report which can be emailed to a primary care physician.

Registered Nurses manage triage calls and act as health coaches. For some specific symptoms, they give guidance for the most appropriate care, and over 32% of the time will offer self-care options so patients avoid a visit to the doctor, ER or Urgent Care facility entirely.

Common symptoms often treated through Telemedicine

Respiratory Infections, Cold/Flu Symptoms, Urinary Tract Infections, Sore Throats, Headaches/Migraines, Sinusitis, Allergies, Insect bites, Certain Rashes, Sprains/Strains, Arthritic Pain, Stomach Aches/Diarrhea, Gastroenteritis, Minor Burns and many non-emergency medical conditions

By 2014, the law mandates that all non-exempt Americans have health insurance or face a tax penalty. The Affordable Care Act has far-reaching advantages such as prohibiting insurance companies from dropping a clients’ coverage if they get sick or discrimination against anyone with a pre-existing condition and extending children’s eligibility on parent’s plans.

For entrepreneurs, who will most likely be responsible for their own health insurance, knowing how telemedicine can supplement their health insurance plans, means they can take full advantage of the options, savings and benefits.

How to Choose The Right Health Care

With Health Care Courses around, there are many who update their knowledge and skills to be highly qualified so that they can work across a wide range of healthcare needs and environments. There are courses and training colleges or institutes which are specific and some that are customized, especially for health care assistants and nurses. With such a course in hand, professionals gain more information and knowledge over health care, caring needs, nursing skills, physical and mental health, illness and injury treatment too.

How it is designed

The main structure of the courses would be for professionals, so that they remain up to date with their skills and knowledge, which in turn would be a boon for patients who need qualified and professional help. Workers and assistants with the health care industry now have a range of courses to study and gain more information from, customized well according to the work nature they belong to. Degrees and qualifications are of many types and levels, with certificates that help the individuals prove their levels of professional development.

What it covers are;

  1. Home and community care
  2. Aged Care
  3. Disability Care
  4. Mental health
  5. Palliative care
  6. Studying how complementary or alternative medication can help

As a health care professional, one can choose or pick the best study manners which suit their nature of work. There are short healthcare courses and in house ones too, which are specific to the individual’s nature of work. If one would like to enroll with distance learning, they can do so and continue with their work and study at the same time too.

Social and health care training courses

Such health care courses help those who work for health and social care, where the training helps individuals with knowledge and skills that help treat patients and care for them. The training also helps the individuals grab a hold on other services, which helps patients get independent and self reliant, helping them make their own choices and have a control over their lives too.

Health care services

There are plenty of services through such courses which can help one promote preventive and curative health needs, palliative interventions too. One also would learn how to help patients who have suffered from abuse, at home or by society, neglect and trauma too. Individuals would work on the solutions, and also learn about the impacts working in teams through these courses.

Social work and care courses

These courses also help with social care learning and understanding the social care system too. There are courses for social carers and workers across the nation, which are of great help. Through such courses, one can care for patients, especially the elderly, the neglected and those who suffer from disabilities too. Such courses even have provisions for professionals to update their knowledge on child care and senior citizen care too. Finally, a course in health and social care would also empower the individual to specialize in counseling and caring, theories and law, also practices too.

Healthy and lifestyle courses

Amongst the many denominations of Health Care Courses, professionals can also update themselves on health and lifestyle courses. Right from Yoga to Acupuncture, making good health choices and lifestyle management, there is so much to learn from.

Health Care Reporting Requirements

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Smart business owners know the importance of keeping good records. The Affordable Care Act has created one more incentive for employers to keep abreast of sometimes complicated reporting requirements, by requiring them to provide information about company-provided health care to both their employees and the government.

How to choose the right health care ?

Not all of the law’s employer responsibility provisions have been implemented yet. Nevertheless, it makes good business sense to establish effective systems to meet obligations that are likely to be rolled out soon. Acting early will give business owners more time to iron out any wrinkles before the law comes to bear.

Reporting to Employees

The Affordable Care Act requires most employers to report the cost of any employer-sponsored group health care plan on employee Forms W-2. This requirement applies to all employers who provide what the government defines as “applicable coverage,” even if the employers are religious organizations or are not subject to Consolidated Omnibus Budget Reconciliation Act (COBRA) requirements. Small businesses issuing fewer than 250 Forms W-2 total are exempt from the reporting requirement until further guidance is issued.

For businesses subject to the rules, the amount reported in Box 12 of Form W-2 must include both the employer and employee portions of the plan’s cost. Certain forms of coverage must be reported, while other forms are either optional or excluded. For more information, see the IRS’ full chart of reporting requirements. (1)

Affected employers are not required to issue Forms W-2 to workers who would not normally receive one, such as retirees, simply to fulfill the requirement. For terminated employees, employers may use any reasonable method to report partial-year coverage, as long as the method is applied consistently. For employees who voluntarily leave and request Forms W-2 in writing prior to year-end, employers must provide the forms within 30 days of the request, but are not required to report the health benefit amounts.

Proposed Section 6056 regulations from the Internal Revenue Service would mainly affect reporting to the Service, though they would also require employers to notify employees in writing of any employee-related information shared with the IRS. These statements will need to be provided annually by January 31. Note that these regulations are still under discussion, and that there is a chance Form W-2 reporting alone could satisfy the requirement. Nevertheless, employers should pay attention to how the final regulations are worded.

Employers subject to the Fair Labor Standards Act have a responsibility to provide all new employees, both part- and full-time, with a written notice pertaining to the Health Insurance Marketplace. These employers include federal, state and local government agencies; hospitals and institutions engaged primarily in the care of the sick, the aged or the developmentally disabled who live on the premises; preschools, elementary and secondary schools, postsecondary institutions of higher learning and schools for gifted children; and companies or organizations with annual sales of receipts over $500,000.

The Health Insurance Marketplace, often referred to as the exchanges, may provide alternatives that cost less than the employer-provided health care plan, if any. Employers must make clear that employer contributions, if any, may be lost if the new employee chooses to pursue private insurance instead. Employers may satisfy the notice requirement through third-party entities, such as insurers or multiemployer health plans, as long as every new employee receives such a notice regardless of whether he or she plans to enroll in the company health care plan.

Finally, any employer providing a health care option must also furnish employees with a standard Summary of Benefits and Coverage (SBC) form. This form explains what services and care the plan does and does not cover. It also lays out the plan’s cost clearly.

Reporting to the IRS

As previously mentioned, the Affordable Care Act introduced new reporting guidelines for employers, known as Section 6056 rules, which mainly affect how employers will report to the IRS. Last September, the Treasury issued proposed regulations to provide further guidance on how businesses should observe the rules; the final regulations were released in mid-February. For the most part, these regulations only apply to employers that had 50 or more full-time employees (or full-time equivalent employees) for the prior year.

Affected large employers must file a return with the IRS reporting certain information for every employee who was full-time for at least one month during the calendar year, including:

  • The employee’s name
  • The employee’s address
  • The employee’s Taxpayer Identification Number (TIN)
  • Information about the health care coverage offered to each employee by month, including
    • What coverage was available
    • The employee’s share of the lowest-cost, self-only premium
    • Which months, if any, the employee was actually covered under the plan

The return will also specify how many employees the business had each month in the calendar year. These requirements are currently scheduled to take effect in 2015.

In addition to Section 6056 rules, certain employers may also fall subject to Section 6055 rules, regardless of size. These rules mainly apply to institutions providing health insurance, such as insurers. However, businesses that self-insure may also need to follow these rules. Affected businesses must provide information for each individual enrolled in minimum essential coverage, including the individual’s name, taxpayer ID number and the months in which the individual received coverage.

The IRS is currently considering allowing Section 6055 and Section 6056 reporting to be submitted together for organizations subject to both sets of rules. However, this concession has not yet been granted. Like Section 6056 rules, Section 6055 rules are scheduled to become mandatory in 2015, but are optional in 2014.

Employers that self-insure may also fall subject to the Patient-Centered Outcomes Research Trust Fund fee (the PCORI fee). The fee applies to policy years ending after September 30, 2012 and before October 1, 2019, and is equal to the product of the average number of individuals covered for the year and the applicable dollar amount. Organizations subject to the fee will need to file Form 720 annually to report and pay the fee.

If any of a business’ employees are liable for the Additional Medicare Tax, employers will also need to withhold the tax, set at 0.9 percent, and report the withholding. The threshold earnings amount to determine the tax liability is $200,000 for single filers and $250,000 for married taxpayers filing jointly. This tax should not be confused with the Net Investment Income Tax (NIIT), which is also sometimes called the Medicare surtax. The NIIT does not affect wages and is not the employer’s responsibility.

While small businesses are largely exempt from these mandatory reporting requirements, businesses with fewer than 25 full-time employees may wish to secure a tax credit for voluntarily providing health care coverage to their workers. Qualifying businesses will need to apply for the credit using Form 8941.

Self-employed individuals may also be eligible for a tax deduction for the cost of their health care. However, the Affordable Care Act has made this deduction solely applicable to income taxes, whereas in the past a deduction against self-employment taxes was available. Eligibility for this deduction is determined on a month-by-month basis.

Reporting to States

Certain states may have their own health care reporting requirements. For example, Massachusetts-based employers with 11 or more employees must file an Employer Health Insurance Responsibility Disclosure and an Employee Health Insurance Responsibility Disclosure for each employee. While these rules are not a product of the Affordable Care Act, employers should take care to comply with all state-specific reporting requirements as well as with federal rules.

As with most parts of the Affordable Care Act, reporting requirements will remain a moving target for some time. As a result, satisfying all of the rules may be a challenge for some employers, at least in the near term. However, the sooner you begin, the sooner you will be able to identify the more difficult rules to follow and develop adequate systems to address them, regardless of whether regulators extend leniency for what is technically required.

Choose The Right Health Care

A Health care practitioner is the one who is given the license or authority by the state to provide health care services. Anyone starting from a doctor of medicine, a dentist, pediatrician and chiropractor to a nurse practitioner, clinical psychologist and even a clinical social worker can be defined as a health care practitioner. In case a health maintenance provider does anything to violate the regulations and limitations determined by the state law, the health care entity has the right to review and judge their actions, thereby seizing their medical license if required. In such cases the health care entity is bound to provide the Board of Medical Examiners with the name of the concerned health maintenance provider and the details of their action for taking accurate review action.

There are various types of health care providers. Some of them are:

Primary Care Providers (PCP): The first person you visit for a health check-up serves as your primary care provider. On the basis of your health maintenance plan and the type of health problem you are having, you have to decide who can be the best PCP for you.

  • You can appoint a general practitioner as your PCP. A general practitioner involves doctors of medicine or osteopathy specialized in internal medicine and family practice.
  • Obstetrician and Gynecologists, specializing in women’s health and prenatal care, can also be appointed as your PCP.
  • Nurse practitioners with graduate degrees can serve as primary care providers in the field of family medicine, pediatrics, adult care, women’s health, etc. They are authorized to provide services for regular checkups and general concerns.
  • Physician assistants are licensed to provide a various services in association with a general practitioner.

Nursing Care: There are various categories in the nursing division.

  • Registered Nurse (RN): RN is licensed by the state to provide health maintenance services. They have to pass a state board examination and obtain a graduate degree from a nursing program.
  • Licensed Practical Nurse (LPN): LPN is a trained nurse, who is authorized by the state to provide health maintenance.
  • Advanced Practice Registered Nurse (APRN): APRNs obtain special degrees and advanced training, which is beyond and above the normal nursing care trainings. APRNs include clinical nurse specialists, nurse practitioners, certified registered nurse anesthetists and licensed nurse midwives.

Licensed Pharmacists: Licensed pharmacists hold a graduate degree from pharmaceutical colleges. They provide health maintenance by preparing prescription drugs that have been prescribed to you by your primary or specialty care provider. Pharmacists also provide adequate information to patients regarding medicines, and explain to them the dosages and side effects of medicines after discussing with the doctor.

How Freedomland Became A Health Care

My parents were in their early 40s in 1969, the year we moved to the massive Co-op City housing development in the Bronx. My brother and I were preteens.

When it was completed a few years later, Co-op City had more than 15,000 apartments, most of them in high-rises scattered across 300 formerly swampy acres that had once been the Freedomland amusement park. Within a few years, the community’s schools and shopping centers appeared. Most of Co-op City’s occupants were working-class laborers and civil servants, drawn mostly from elsewhere in the borough. Direct and indirect subsidies made their new apartments affordable.

My brother and I both left for college within a decade. Our parents stayed until 1990, when they retired, departed for the suburbs of central New Jersey and rebuilt their lives around the activities of the local senior citizens’ center. But many of their peers stayed in Co-op City, and quite a few of the kids my brother and I grew up with ended up staying with their parents, or inheriting apartments when their parents died.

For thousands of people like my parents, Co-op City became a “naturally occurring retirement community,” also known as a NORC. The survivors of their generation who have stayed put, now advanced far into old age, have had the benefit of family, friends, familiar neighborhood institutions and a host of social services to sustain them. The phenomenon of this open-air retirement home that came into being quite by accident has been apparent for more than a decade. The New York Times wrote about it as far back as 2002. (1)

In New York, Medicaid pays for a lot of the services these people need. To the extent that Medicaid is a low-income health care program, this is not necessarily surprising. Yet what makes New York’s situation different is that Medicaid often covers even those services that don’t have much to do with health care as most people understand it. In literature about the “Health Homes” initiative, introduced in 2012, the state’s Medicaid administrators described the function of a “care manager,” an individual who coordinates those seeing to an individual’s medical, behavioral health and social service needs. The theory is that by making sure people can live independently in their own homes, Medicaid saves money on hospital costs, ambulance rides, repetitive doctor visits and, most of all, nursing home care.

The same thing is happening in the mental health arena. Several years ago, New York expanded Medicaid coverage to provide housing for individuals with mental illness. In addition to the Health Homes program, New York also offers “supportive” housing that combines subsidized housing with a host of services, including medical, but also legal, career and educational, among others. Keep people off the streets and make sure they take their meds and get regular meals, the theory goes, and you’ll ultimately save money on emergency room and other acute-care costs.

Brenda Rosen, the director of the organization Common Ground, which runs a supportive housing building called The Brook, told NPR, “You know, we as a society are paying for somebody to be on the streets.” (2) And the outgoing New York State commissioner of health published an article in December 2013 arguing that housing and support services are integral to health, so Medicaid should help support the costs.

The state may be on board, but the arguments in favor of these programs haven’t made much headway with the federal government, which normally shares Medicaid expenses with the states. The feds won’t pay for these housing services, on the grounds that housing is not health care. Bruce Vladeck, who formerly administered the federal Medicaid (and Medicare) programs, said, “Medicaid is supposed to be health insurance, and not every problem somebody has is a health care problem.” (2)

That’s true. Not all care that leads to better health is health care. Good nutrition, having the time and place to get a full night’s sleep, and access to clean air and water are all essential for health, but we do not expect health insurance to pay for these things. Providing housing to people who need it is what we used to call social work, and most people don’t view social workers as health care providers.

But it is easier to gain political support for providing health care – with its image of flashing ambulance lights and skilled professionals dressed in white – than for subsidized housing for the aging or the disabled, especially the mentally disabled. So it is easier for Gov. Andrew Cuomo’s administration to organize these services under the label of Medicaid Health Homes. They are not homes at all in any traditional sense. Care managers are typically not doctors or nurses, but they are trained in social services or health care administration. Health Homes is a potentially worthwhile initiative that comes with clever, voter-ready branding.

The approach itself is not nearly as novel as the marketing. We have known for decades that good community support, including safe housing and close supervision for people who need it, is a lot less expensive than parking people in hospitals, nursing homes and other institutions. As New York State Medicaid Director Jason Helgerson pointed out when arguing in favor of Medicaid-funded housing support, Medicaid (and taxpayers) bear the cost of long, expensive hospital and nursing home stays. Giving people support to stay in their own homes is also a lot more humane in many, if not most, cases.

The challenge is to develop and market these programs in ways that sustain public support in the face of their predictable abuse. People misusing a service does not make it bad, but it does make it harder for politicians to defend. Disability insurance is also a good thing, but the Social Security disability program is just a couple of years away from going broke, in large part because of the wave of malingering that accompanied and followed the recent recession. Offer a benefit and people will want to use it, even if they are not genuinely part of the target population.

Well-supported housing with an effective array of social services for people who need them can do a lot of good, and can save society significant money as long as we are not prepared to make people in need survive on their own. NORCs can make excellent places for the elderly to live out their days, and housing for mentally ill and developmentally disabled people can keep them safely off the streets and out of the ERs.

But the feds are right that efforts to do so are not health care. It’s human care. If we don’t manage it effectively – keeping the malingerers out and holding costs at sustainable levels – some humans are going to be left on their own, no matter what we call it.