Tag Archives: New Mexico

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.