It has been a long time since I've written. I've been fighting health care issues one on one instead of taking on the world but it is time to get back.
How would you like to be one in a million? or maybe one in almost 6 million. You may be and not know it.
Nearly 24 million adults and children in the United States have Diabetes.
It is called the “silent killer” because nearly one fourth of those with the disease
- 5.7 million- do not know they have it.
For many, diagnosis may come seven to ten years after the onset of the disease. Early diagnosis is critical to successful treatment and delaying or preventing some of its complications such as heart disease, blindness, kidney disease, stroke, amputation and death.
So lets celebrate :
American Diabetes Alert Day
March 24th 2009
What is American Diabetes Alert Day?
It is a wake up call to inform the American public about the seriousness of diabetes especially when it is undiagnosed or treated.
Who is at risk?
Older Americans- Half of all diabetes cases occur in people over 45 years of age.
High risk ethnic populations: African Americans, Hispanic/Latino Americans, Native Americans, Asian Americans and Pacific Islanders
Over weight and Sedentary Americans
Lets look at the numbers:
65% of the US population are overweight or obese.
Childhood obesity has more than doubled in the last 20 years.
39% of Americans are over 45 years of age.
It is time to look at our risks. Please take the American Diabetes Risk Test, now.
The good news is that the recently completed Diabetes Prevention Program study conclusively showed that people with pre-diabetes can prevent the development of type 2 diabetes by making changes in their diet and increasing their level of physical activity. They may even be able to return their blood glucose levels to the normal range.
If you are at risk and want to prevent all the complications of diabetes it is as easy as losing a few pounds and increasing your activity.
Check now.
The American Diabetes Risk test is free and available in English and Spanish
by calling 1-800-DIABTES (342-2383) or by visiting the web at diabetes.org/alert
Tuesday, March 10, 2009
Thursday, February 7, 2008
Consolidated Omnibus Budget Reconciliation Act
The Consolidated Omnibus Budget Reconciliation Act of 1985, or COBRA, is a law passed by the U. S. Congress and signed by President Reagan that mandates an insurance program giving some employees the ability to continue health insurance coverage after leaving their employment.
This is a federal act which requires each group health plan to temporarily allow employees and certain dependents to continue the group coverage that had been provided by their employer for a stated period of time following a qualifying event that causes the loss of group health coverage. This coverage, however, is only available in specific instances.
Qualifying events listed in the statute are loss of benefits coverage due to:
- reduced work hours
- death or divorce of a covered employee
- termination of employment
- a dependent child reaching the age at which he or she is no longer covered
- covered employee's becoming entitled to Medicare
COBRA also allows for longer periods of extended coverage in some cases, such as disability or divorce, than others, such as termination of employment or a reduction in hours.
Unlike other federal statutes such as the Family and Medical Leave Act (FMLA) which require the employer to pay for the cost of providing continuation coverage, COBRA instead allows employees and their dependents to continue coverage at their own expense by paying the full cost of the premium that the employer previously paid, plus up to a 2% administrative charge (150% for the disability extension). Employees and dependents lose coverage if they fail to make timely payments of these premiums.
Employers are required to inform employees and dependents upon loss of coverage, in writing, by at least fifteen days before the coverage ceases.
Participation in COBRA is voluntary and requires payment by the former employee in order to receive continued health plan benefits. With a lost of employment or family member serious consideration should be made as to weather continuing coverage is feasible or necessary.
COBRA contains provisions giving certain former employees, retirees, spouses and dependent children the right to temporary continuation of health coverage at group rates.. Group health coverage for COBRA participants is usually more expensive than health coverage for active employees, since usually the employer formerly paid a part of the premium. Despite the fact that COBRA is generally less expensive than individual health coverage the cost to a retired or unemployed person or a spouse and dependant children can still be expensive.
There are however times when one should seriously evaluate the need for continuing health care coverage such as:
- If you or your dependants have had recent health problems, are undergoing treatment or may require surgery. Some policies do not cover pre existing conditions.
- If you or your dependants have had ongoing or chronic health problems.
- If you or your dependants are taking expensive medications.
- If you or your dependants have been declined for private insurance recently.
- If you or your dependants have a history of medical problems.
- If you have had an accident within the 60 day window of enrollment.
If you or your spouse are pregnant or planning to get that way. - If you got a job and your new employer does not offer a health plan.
- If you have had comprehensive benefits and don't mind paying more for them.
- If you want continual, guaranteed coverage despite a higher cost.
Additional information can be obtained from the Centers for Medicare and Medicaid
http://www.cms.hhs.gov/COBRAContinuationofCov/
or the Department of Labor site
http://www.dol.gov/ebsa/faqs/faq_consumer_cobra.html
Tuesday, January 22, 2008
Health Insurance Terminology Part II
In order for you to better understand health insurance terminology I have continued to define many of the terms found on health insurance policies.
Managed Care
Ways to manage costs, use, and quality of the health care system. All HMOs and PPOs, and many fee-for-service plans, have managed care.
Pre-existing Condition
A health problem that existed before the date your health insurance became effective.
Primary Care Physician PCP
This is often a family physician or internist, but some women use their gynecologist. The A PCP monitors your health and diagnoses and treats minor health problems, and refers you to specialists if another level of care is needed. In many health insurance plans, care by specialists is only paid for if you are referred by your primary care doctor. An HMO or a POS plan will provide you with a list of doctors from which you will choose your primary care doctor (usually a family physician, internists, obstetrician-gynecologist, or pediatrician). This could mean you might have to choose a new primary care doctor if your current one does not belong to the plan. PPOs allow members to use primary care doctors outside the PPO network (at a higher cost). Indemnity plans allow any doctor to be used.
Case Management
This is a process of identifying plan members with special healthcare needs, developing a health-care strategy that meets those needs, and coordinating and monitoring the care, with the ultimate goal of achieving the optimum healthcare outcome in an efficient and cost-effective manner. It is a utilization management technique that addresses the medical necessity of care as well as alternative treatments or solutions, especially when the patient is likely to require very expensive treatment case management.
Emergency Care
Most plans cover emergency care in a hospital emergency room if it is an extremely urgent medical emergency, even if the hospital you are taken to is not in the plan's network. It is possible, however, that after your condition has been stabilized, you would be transferred to a participating plan hospital.
Formulary Drugs
These are medications that generally have a lower copay. Formulary drugs are medications that have been reviewed by a team of expert pharmacists and physicians and have been identified as safe and effective but lower in cost.
Generic medications
When a new drug is put on the market, the pharmaceutical company patents it under a brand name. The company has the exclusive right to sell the drug under this name, but once its patent expires, other companies can sell the same drug under its chemical, or generic, name. Generic drugs are typically cheaper than brand-name drugs, but the Food and Drug Administration requires generic drug manufacturers to show that a generic drug "delivers the same amount of active ingredient in the same time frame as the original product."
Non-Formulary Drugs
Non-formulary drugs often require a higher copayment. Non-formulary drugs are those that have not yet been reviewed or have been denied formulary status, typically because they offer no extra benefit over the drugs already on a plan's formulary list.
Generic Substitution
The dispensing of a drug that is the generic equivalent of a drug listed on a pharmacy benefit management plan's formulary. In most cases, generic substitution can be performed without physician approval.
Gatekeeper
This is a term used to describe the primary care physician's role in a managed care plan; The PCP’s role is to authorize all services delivered to the insured by other physicians or health care providers. Thus, whenever you wish to see a physician other than your primary care physician, you must first obtain his or her permission (via a referral).
Health Care Provider
This is anyone who delivers medical or health-related care such as a doctor, hospital, laboratory, or nurse.
Home Health Care
Skilled medical care and other health care services that you receive in your home for the treatment of an illness or injury. Some insurance plans don't provide this kind of coverage, or provide it only for a limited amount of time.
Mental Health - inpatient
Inpatient mental health care is generally reserved for severe mental health problems, such a schizophrenia and severe depression. State laws vary widely on the degree to which insurance companies must cover mental illness. Most plans do provide some coverage, though there may be limitations such as the severity or nature of the illness and the duration of care.
Outpatient Surgery
This is surgery that does not involve an overnight stay in a hospital
Skilled Nursing
A level of care for patients who need intensive, 24-hour nursing supervision. This can take place in the home or in skilled nursing facilities, which offer services such as rehabilitation and specialized nutrition.
Urgent Care
Urgent care is appropriate when a medical urgency arises which necessitates immediate care, but has not reached the level of extreme emergency. Most managed care plans require you to seek urgent care at a participating urgent care facility or hospital.
Well Baby Care
The goals of well baby care are 1) to immunize; 2) to provide parents with reassurance and counseling on safety, nutrition and behavioral problems; and 3) to identify and treat physical and developmental problems.
Ambulatory Care Facility ACF
This is a medical care center that provides a wide range of healthcare services, including preventive care, acute care, surgery, and outpatient care, in a centralized facility.
Ancillary Services
Auxiliary or supplemental services, such as diagnostic services, home health services, physical therapy, and occupational therapy, used to support diagnosis and treatment of a patient's condition.
Appropriate Care
A diagnostic or treatment measure whose expected health benefits exceed its expected health risks by a wide enough margin to justify the measure.
Behavioral Healthcare.
The provision of mental health and substance abuse services.
Capitation
This is a method of paying for healthcare services on the basis of the number of patients who are covered for specific services over a specified period of time rather than the cost or number of services that are actually provided. For example one hospital may receive S10.000/yr for 500 people to get chest x-rays rather than the 451 chest x-rays that cost $10, 125.
Disease Management
A coordinated system of preventive, diagnostic, and therapeutic measures intended to provide cost-effective, quality healthcare for a patient population who have or are at risk for a specific chronic illness or medical condition.
Drug Utilization Review DUR
A review program that evaluates whether drugs are being used safely, effectively, and appropriately.
Managed Care
Ways to manage costs, use, and quality of the health care system. All HMOs and PPOs, and many fee-for-service plans, have managed care.
Pre-existing Condition
A health problem that existed before the date your health insurance became effective.
Primary Care Physician PCP
This is often a family physician or internist, but some women use their gynecologist. The A PCP monitors your health and diagnoses and treats minor health problems, and refers you to specialists if another level of care is needed. In many health insurance plans, care by specialists is only paid for if you are referred by your primary care doctor. An HMO or a POS plan will provide you with a list of doctors from which you will choose your primary care doctor (usually a family physician, internists, obstetrician-gynecologist, or pediatrician). This could mean you might have to choose a new primary care doctor if your current one does not belong to the plan. PPOs allow members to use primary care doctors outside the PPO network (at a higher cost). Indemnity plans allow any doctor to be used.
Case Management
This is a process of identifying plan members with special healthcare needs, developing a health-care strategy that meets those needs, and coordinating and monitoring the care, with the ultimate goal of achieving the optimum healthcare outcome in an efficient and cost-effective manner. It is a utilization management technique that addresses the medical necessity of care as well as alternative treatments or solutions, especially when the patient is likely to require very expensive treatment case management.
Emergency Care
Most plans cover emergency care in a hospital emergency room if it is an extremely urgent medical emergency, even if the hospital you are taken to is not in the plan's network. It is possible, however, that after your condition has been stabilized, you would be transferred to a participating plan hospital.
Formulary Drugs
These are medications that generally have a lower copay. Formulary drugs are medications that have been reviewed by a team of expert pharmacists and physicians and have been identified as safe and effective but lower in cost.
Generic medications
When a new drug is put on the market, the pharmaceutical company patents it under a brand name. The company has the exclusive right to sell the drug under this name, but once its patent expires, other companies can sell the same drug under its chemical, or generic, name. Generic drugs are typically cheaper than brand-name drugs, but the Food and Drug Administration requires generic drug manufacturers to show that a generic drug "delivers the same amount of active ingredient in the same time frame as the original product."
Non-Formulary Drugs
Non-formulary drugs often require a higher copayment. Non-formulary drugs are those that have not yet been reviewed or have been denied formulary status, typically because they offer no extra benefit over the drugs already on a plan's formulary list.
Generic Substitution
The dispensing of a drug that is the generic equivalent of a drug listed on a pharmacy benefit management plan's formulary. In most cases, generic substitution can be performed without physician approval.
Gatekeeper
This is a term used to describe the primary care physician's role in a managed care plan; The PCP’s role is to authorize all services delivered to the insured by other physicians or health care providers. Thus, whenever you wish to see a physician other than your primary care physician, you must first obtain his or her permission (via a referral).
Health Care Provider
This is anyone who delivers medical or health-related care such as a doctor, hospital, laboratory, or nurse.
Home Health Care
Skilled medical care and other health care services that you receive in your home for the treatment of an illness or injury. Some insurance plans don't provide this kind of coverage, or provide it only for a limited amount of time.
Mental Health - inpatient
Inpatient mental health care is generally reserved for severe mental health problems, such a schizophrenia and severe depression. State laws vary widely on the degree to which insurance companies must cover mental illness. Most plans do provide some coverage, though there may be limitations such as the severity or nature of the illness and the duration of care.
Outpatient Surgery
This is surgery that does not involve an overnight stay in a hospital
Skilled Nursing
A level of care for patients who need intensive, 24-hour nursing supervision. This can take place in the home or in skilled nursing facilities, which offer services such as rehabilitation and specialized nutrition.
Urgent Care
Urgent care is appropriate when a medical urgency arises which necessitates immediate care, but has not reached the level of extreme emergency. Most managed care plans require you to seek urgent care at a participating urgent care facility or hospital.
Well Baby Care
The goals of well baby care are 1) to immunize; 2) to provide parents with reassurance and counseling on safety, nutrition and behavioral problems; and 3) to identify and treat physical and developmental problems.
Ambulatory Care Facility ACF
This is a medical care center that provides a wide range of healthcare services, including preventive care, acute care, surgery, and outpatient care, in a centralized facility.
Ancillary Services
Auxiliary or supplemental services, such as diagnostic services, home health services, physical therapy, and occupational therapy, used to support diagnosis and treatment of a patient's condition.
Appropriate Care
A diagnostic or treatment measure whose expected health benefits exceed its expected health risks by a wide enough margin to justify the measure.
Behavioral Healthcare.
The provision of mental health and substance abuse services.
Capitation
This is a method of paying for healthcare services on the basis of the number of patients who are covered for specific services over a specified period of time rather than the cost or number of services that are actually provided. For example one hospital may receive S10.000/yr for 500 people to get chest x-rays rather than the 451 chest x-rays that cost $10, 125.
Disease Management
A coordinated system of preventive, diagnostic, and therapeutic measures intended to provide cost-effective, quality healthcare for a patient population who have or are at risk for a specific chronic illness or medical condition.
Drug Utilization Review DUR
A review program that evaluates whether drugs are being used safely, effectively, and appropriately.
Friday, January 18, 2008
Understanding Health Insurance Terms
In addition to the various types of health care coverage health insurance has its own unique terminology which can be very difficult to understand.
I will try to explain some of the terminology to make it easier to understand your policies.
Coinsurance
This is the amount you are required to pay for medical care in a fee-for-service plan after you have met your deductible. The coinsurance rate is usually expressed as a percentage. For example, if your health insurance company pays 80 percent of the claim, you pay 20 percent.
Coordination of Benefits
This is a system to eliminate duplication of benefits when you are covered under more than one group plan. For example if a husband and wife have family coverage at work they can not bill both polices for the full fee and receive additional funds in excess of the charge. Benefits under the two plans usually are limited to no more than 100 percent of the claim.
Co-payment
This is another way of sharing medical costs in addition to the insurance covered by your employer or under a basic policy. You pay a flat fee every time you receive a medical service (for example, $5 for every visit to the doctor). The health insurance company pays the rest.
Covered Expenses
Most health insurance plans, whether they are fee-for-service, HMOs, or PPOs, do not pay for all services. Some may not pay for prescription drugs. Others may not pay for mental health care. Covered services are those medical procedures the insurer agrees to pay for. They are listed in the health insurance policy.
Customary Fee
Most health insurance plans will pay only what they call a reasonable and customary fee for a particular service. If your doctor charges $1,000 for a hernia repair while most doctors in your area charge only $600, you will be billed for the $400 difference. This is in addition to the deductible and coinsurance you would be expected to pay. To avoid this additional cost, ask your doctor to accept your health insurance company's payment as full payment. Or shop around to find a doctor who will. Otherwise you will have to pay the rest yourself.
Deductible
The amount of money you must pay each year to cover your medical care expenses before your health insurance policy starts paying for covered eligible expenses.
Dependant
A person for whom the insured has some legal obligation to. For most plans, it is the insured's spouse and/or children. Some plans also allow non-traditional spousal relationships (significant other, life-partner, etc.) to be considered a dependent with some additional certifying paperwork.
Exclusions
Specific conditions or circumstances for which the policy will not provide benefits.
Maximum Out-of-Pocket Expenses
The most money you will be required pay a year for deductibles and coinsurance. It is a stated dollar amount set by the health insurance company, in addition to regular premiums.
Non-cancelable Policy
A policy that guarantees you can receive health insurance, as long as you pay the premium. It is also called a guaranteed renewable policy.
Premium
The amount you or your employer pays in exchange for health insurance coverage.
Provider
Any person (doctor, nurse, dentist) or institution (hospital or clinic) that provides medical care.
Third-Party Payer
Any payer for health care services other than you. This can be an insurance company, an HMO, a PPO, or the Federal Government.
Claim
This is a request for payment for medical services under the terms of an insurance policy.
Exclusions and Limitations
Conditions, situations and services that are not covered by the health plan.
Health Care Provider
This is anyone who delivers medical or health-related care such as a doctor, hospital, laboratory, or nurse.
Health Savings Account HAS
The newest choice in health insurance for the self-employed, also called Medical Savings Accounts (MSAs) allow you to build up a tax-free savings account to pay for routine medical expenses You must have a high deductible medical plan (catastrophic health plan) that includes a tax deferred savings account. A HDHP is an inexpensive health insurance plan that generally doesn’t pay for the first several thousand dollars of health care expenses but will generally cover you after that. Your HSA is available to help you pay for the expenses your plan does not cover. The money from the HAS savings account can be used to help meet the deductible, help pay early hospitalization/medical expenses or used towards personal retirement savings.
Indemnity plan
This is also called a fee-for-service plan. It is a health insurance plan that allows the insured to use any medical provider that he or she chooses. As such, there are no networks to utilize.
Insured
This is the person whose health is insured under an insurance policy. This person may also be referred to as a member.
Major Medical Insurance Plan
This is a type of traditional medical expense coverage that provides substantial benefits for hospital surgical expenses and physicians' fees.
Network
A group of doctors, hospitals and other health-care providers contracting with a health plan, usually to provide care at special rates and to handle paperwork with the health plan.
Out-of-Network
Health care services received outside the group of health –care providers affiliated with the HMO, POS or PPO network.
Out-of-Pocket expense
This is any medical care costs that is not covered by insurance or which must be paid by the insured.
Preferred Provider Organization PPO
This is an organization where providers are under contract to an insurance company or health plan to provide care at a discounted or negotiated rate. Typically, you can see any doctor in the PPO network without requiring special approval, and you usually do not need to choose a primary care physician. Most PPOs will also allow you to seek care outside of the PPO network; however, the benefits are usually reduced and the insured has a greater out-of-pocket expense.
Pre-admission certification
This is a component of utilization review under which the utilization review organization determines whether an insured's proposed non-emergency hospital stay or some other type of care is most appropriate and what the length of an approved hospital stay may be.
Pre-existing Condition
According to most individual health insurance policies, this is an injury that occurred or a illness that first appeared or manifested itself before the policy was issued and that was not disclosed on the application for insurance. According to most group health insurance policies, this is a condition for which an individual received medical care during the three months immediately prior to the effective date of his coverage.
Short-term Disability
This type of coverage pays a percentage of your salary if you become temporarily disabled, meaning that you are not able to work for a short period of time due to sickness or injury (excluding on-the-job injuries, which are covered by workers compensation). The per-week amount is usually 50, 60 or 66 2/3 percent of your weekly salary, and lasts for a period of time specified by the plan.
Usual, Customary and Reasonable Fee
This is the maximum dollar amount of a covered expense that is considered eligible for reimbursement under a major medical policy. In other words if the average cost for a doctor’s visit across the country is $ 50. If your doctor charges $100 per visit only $ 50 is covered as the usual, customary and reasonable fee.
I will try to explain some of the terminology to make it easier to understand your policies.
Coinsurance
This is the amount you are required to pay for medical care in a fee-for-service plan after you have met your deductible. The coinsurance rate is usually expressed as a percentage. For example, if your health insurance company pays 80 percent of the claim, you pay 20 percent.
Coordination of Benefits
This is a system to eliminate duplication of benefits when you are covered under more than one group plan. For example if a husband and wife have family coverage at work they can not bill both polices for the full fee and receive additional funds in excess of the charge. Benefits under the two plans usually are limited to no more than 100 percent of the claim.
Co-payment
This is another way of sharing medical costs in addition to the insurance covered by your employer or under a basic policy. You pay a flat fee every time you receive a medical service (for example, $5 for every visit to the doctor). The health insurance company pays the rest.
Covered Expenses
Most health insurance plans, whether they are fee-for-service, HMOs, or PPOs, do not pay for all services. Some may not pay for prescription drugs. Others may not pay for mental health care. Covered services are those medical procedures the insurer agrees to pay for. They are listed in the health insurance policy.
Customary Fee
Most health insurance plans will pay only what they call a reasonable and customary fee for a particular service. If your doctor charges $1,000 for a hernia repair while most doctors in your area charge only $600, you will be billed for the $400 difference. This is in addition to the deductible and coinsurance you would be expected to pay. To avoid this additional cost, ask your doctor to accept your health insurance company's payment as full payment. Or shop around to find a doctor who will. Otherwise you will have to pay the rest yourself.
Deductible
The amount of money you must pay each year to cover your medical care expenses before your health insurance policy starts paying for covered eligible expenses.
Dependant
A person for whom the insured has some legal obligation to. For most plans, it is the insured's spouse and/or children. Some plans also allow non-traditional spousal relationships (significant other, life-partner, etc.) to be considered a dependent with some additional certifying paperwork.
Exclusions
Specific conditions or circumstances for which the policy will not provide benefits.
Maximum Out-of-Pocket Expenses
The most money you will be required pay a year for deductibles and coinsurance. It is a stated dollar amount set by the health insurance company, in addition to regular premiums.
Non-cancelable Policy
A policy that guarantees you can receive health insurance, as long as you pay the premium. It is also called a guaranteed renewable policy.
Premium
The amount you or your employer pays in exchange for health insurance coverage.
Provider
Any person (doctor, nurse, dentist) or institution (hospital or clinic) that provides medical care.
Third-Party Payer
Any payer for health care services other than you. This can be an insurance company, an HMO, a PPO, or the Federal Government.
Claim
This is a request for payment for medical services under the terms of an insurance policy.
Exclusions and Limitations
Conditions, situations and services that are not covered by the health plan.
Health Care Provider
This is anyone who delivers medical or health-related care such as a doctor, hospital, laboratory, or nurse.
Health Savings Account HAS
The newest choice in health insurance for the self-employed, also called Medical Savings Accounts (MSAs) allow you to build up a tax-free savings account to pay for routine medical expenses You must have a high deductible medical plan (catastrophic health plan) that includes a tax deferred savings account. A HDHP is an inexpensive health insurance plan that generally doesn’t pay for the first several thousand dollars of health care expenses but will generally cover you after that. Your HSA is available to help you pay for the expenses your plan does not cover. The money from the HAS savings account can be used to help meet the deductible, help pay early hospitalization/medical expenses or used towards personal retirement savings.
Indemnity plan
This is also called a fee-for-service plan. It is a health insurance plan that allows the insured to use any medical provider that he or she chooses. As such, there are no networks to utilize.
Insured
This is the person whose health is insured under an insurance policy. This person may also be referred to as a member.
Major Medical Insurance Plan
This is a type of traditional medical expense coverage that provides substantial benefits for hospital surgical expenses and physicians' fees.
Network
A group of doctors, hospitals and other health-care providers contracting with a health plan, usually to provide care at special rates and to handle paperwork with the health plan.
Out-of-Network
Health care services received outside the group of health –care providers affiliated with the HMO, POS or PPO network.
Out-of-Pocket expense
This is any medical care costs that is not covered by insurance or which must be paid by the insured.
Preferred Provider Organization PPO
This is an organization where providers are under contract to an insurance company or health plan to provide care at a discounted or negotiated rate. Typically, you can see any doctor in the PPO network without requiring special approval, and you usually do not need to choose a primary care physician. Most PPOs will also allow you to seek care outside of the PPO network; however, the benefits are usually reduced and the insured has a greater out-of-pocket expense.
Pre-admission certification
This is a component of utilization review under which the utilization review organization determines whether an insured's proposed non-emergency hospital stay or some other type of care is most appropriate and what the length of an approved hospital stay may be.
Pre-existing Condition
According to most individual health insurance policies, this is an injury that occurred or a illness that first appeared or manifested itself before the policy was issued and that was not disclosed on the application for insurance. According to most group health insurance policies, this is a condition for which an individual received medical care during the three months immediately prior to the effective date of his coverage.
Short-term Disability
This type of coverage pays a percentage of your salary if you become temporarily disabled, meaning that you are not able to work for a short period of time due to sickness or injury (excluding on-the-job injuries, which are covered by workers compensation). The per-week amount is usually 50, 60 or 66 2/3 percent of your weekly salary, and lasts for a period of time specified by the plan.
Usual, Customary and Reasonable Fee
This is the maximum dollar amount of a covered expense that is considered eligible for reimbursement under a major medical policy. In other words if the average cost for a doctor’s visit across the country is $ 50. If your doctor charges $100 per visit only $ 50 is covered as the usual, customary and reasonable fee.
Sunday, January 13, 2008
Health Care Coverage Basics
One of the main reasons I started this blog was because of the desperate cries of people lost in the health care system. Most people are unaware of what options are available or where to seek assistance.
There are a lot of resources out there to help you understand the health care system. But you need to take stock in what you have and what you need. I will try to address some of the main concerns in this and subsequent blogs.
Basics on Health Care coverage
Health insurance is insurance that pays for all or part of a person's health care bills. The purpose of health insurance is to help people cover their health care costs. Health care costs include doctor visits, hospital stays, surgery, procedures, tests, home care, and other treatments and services.
There are three basic plans available to cover the costs of health care:
Private Health Insurance- coverage by a health plan provided through an employer or union or purchased by an individual from a private health insurance company. ex. Blue Cross/Blue Shield, United Health Care, or Aetna.
Government Health Insurance- plans funded by the federal, state, or local government ex. Medicare, Medicaid, the State Children’s Health Insurance Program (SCHIP), military health care, state plans, and the Indian Health Service.
Worker’s Compensation Insurance- Insurance that covers medical and rehabilitation costs and lost wages for employees injured at work; required by law in all states.
Private Health Insurance
Many employers offer group health plans to employees and their dependents as a benefit of working with that particular employer (medical benefits). The employer may pay for part or all of the insurance cost (premium).Group and individual plans can be further classified as either fee-for-service or managed care.
Fee-for-service is traditional health insurance in which the insurance company reimburses the doctor, hospital, or other health care provider for all or part of the fees charged. Fee-for-service plans may be offered to groups or individuals. This type of plan gives people the highest level of freedom to choose a doctor, hospital, or other health care provider. A person may be able to receive medical care anywhere in the United States and, often, in the world.
Managed care plans are also sold to both groups and individuals. In these plans a person's health care is managed by the insurance company. Approvals are needed for some services, including visits to specialist doctors, medical tests, or surgical procedures. In order for people to receive the highest level of coverage they must obtain services from the doctors, hospitals, labs, imaging centers, and other providers affiliated with their managed care plan.
Types of Health Care Plans
Health Maintenance Organization (HMO)
An HMO is a type of managed care called a prepaid plan. This type of coverage was designed initially to help keep people healthy by covering the cost of preventive care, such as medical checkups. The patient selects a primary care doctor from a list of physicians participating in the HMO program. This doctor coordinates the patient's care and determines if referrals to specialist doctors are needed. People pay a premium, usually every month, and receive their health care services (doctor visits, hospital care, lab work, emergency services, etc.) when they pay a small fee called a co-payment. The HMO has arrangements with caregivers and hospitals and the co-payment only applies to those caregivers and facilities affiliated with the HMO. This type of coverage offers less freedom than fee-for-service, but out-of-pocket health care costs are generally lower and more predictable. A person's out-of-pocket costs will be much higher if he or she receives care outside of the HMO unless prior approval from the HMO is received.
Preferred Provider Organization (PPO)
A PPO combines the benefits of fee-for-service with the features of an HMO. If patients use health care providers (doctors, hospitals, etc.) who are part of the PPO network, they will receive coverage for most of their bills after a deductible and, perhaps a co-payment, is met. Some PPOs require people to choose a primary care physician who will coordinate care and arrange referrals to specialists when needed. Other PPOs allow patients to choose specialists on their own. A PPO may offer lower levels of coverage for care given by doctors and other professionals not affiliated with the PPO. In these cases the patient may have to fill out claim forms to receive coverage.
Point-of-Service Plans (POS)
Many HMOs offer an indemnity-type option known as a POS plan. The primary care doctors in a POS plan usually make referrals to other providers in the plan. But in a POS plan, members can refer themselves outside the plan and still get some coverage. If the doctor makes a referral out of the network, the plan pays all or most of the bill. If you refer yourself to a provider outside the network and the service is covered by the plan, you will have to pay coinsurance.
Government Health Plans
Medicare and Medicaid are the two main health plans offered by the U.S. government. They are available to individuals who meet certain age, income, or disability criteria. TRICARE Standard, formerly called CHAMPUS, is the health plan for U.S. military personnel.
Medicare
Medicare was created in 1965 under Title 18 of the Social Security Act and is available to people who are 65 years or older , or younger individuals who have disabilities or end-stage renal disease (permanent kidney failure)
Medicare is divided into four parts.
Part A is hospital insurance and helps cover the costs of inpatient hospital stays, skilled nursing centers, home health services, and hospice care.
Part B helps cover medical services such as doctors' bills, ambulances, outpatient therapy, and a host of other services, supplies, and equipment that Part A does not cover.
Part C provides the option to choose from a package of health care plans
Part D helps provide coverage for medication.
Enrolled individuals must pay deductibles and co-payments, but much of their medical costs are covered by the program. Medicare is less comprehensive than some other health care programs, but it is an important source of post-retirement health care.
Medicaid
Medicaid was created in 1965 under Title 19 of the Social Security Act and is a federally funded state run program of public assistance for persons regardless of age whose income and resources are insufficient to pay for health care.
This program covers hospitalization, doctors' visits, lab tests, and x rays. Some other services may be partially covered.
State Children’s Health Insurance Program Summary (SCHIP)
The State Children's Health Insurance Program was created as part of the Balanced Budget Act of 1997 title XXI, to address the growing problem of children without health insurance. SCHIP was designed as a Federal/State partnership, similar to Medicaid, with the goal of expanding health insurance to children whose families earn too much money to be eligible for Medicaid, but not enough money to purchase private insurance.
Tricare
Tricare is the United States military's health care plan for military personnel and their dependents. The Tricare program is managed by TRICARE Management Activity (TMA) under the authority of the Office of the Assistant Secretary of Defense for Health Affairs (OSD/HA). Eligible military families may enroll in Tricare Prime, which is an HMO; Tricare Extra, which offers an expanded choice of providers; or Tricare Standard, which is the new name for CHAMPUS.
Workers' Compensation
Workers' compensation covers health care costs only for an injury or illness related to a person's job. Medical conditions that are unrelated to work are not covered under this plan. In some cases an evaluation is done to determine whether or not the medical condition is truly related to a person's employment.
For additional information
http://www.cms.hhs.gov/default.asp?
There are a lot of resources out there to help you understand the health care system. But you need to take stock in what you have and what you need. I will try to address some of the main concerns in this and subsequent blogs.
Basics on Health Care coverage
Health insurance is insurance that pays for all or part of a person's health care bills. The purpose of health insurance is to help people cover their health care costs. Health care costs include doctor visits, hospital stays, surgery, procedures, tests, home care, and other treatments and services.
There are three basic plans available to cover the costs of health care:
Private Health Insurance- coverage by a health plan provided through an employer or union or purchased by an individual from a private health insurance company. ex. Blue Cross/Blue Shield, United Health Care, or Aetna.
Government Health Insurance- plans funded by the federal, state, or local government ex. Medicare, Medicaid, the State Children’s Health Insurance Program (SCHIP), military health care, state plans, and the Indian Health Service.
Worker’s Compensation Insurance- Insurance that covers medical and rehabilitation costs and lost wages for employees injured at work; required by law in all states.
Private Health Insurance
Many employers offer group health plans to employees and their dependents as a benefit of working with that particular employer (medical benefits). The employer may pay for part or all of the insurance cost (premium).Group and individual plans can be further classified as either fee-for-service or managed care.
Fee-for-service is traditional health insurance in which the insurance company reimburses the doctor, hospital, or other health care provider for all or part of the fees charged. Fee-for-service plans may be offered to groups or individuals. This type of plan gives people the highest level of freedom to choose a doctor, hospital, or other health care provider. A person may be able to receive medical care anywhere in the United States and, often, in the world.
Managed care plans are also sold to both groups and individuals. In these plans a person's health care is managed by the insurance company. Approvals are needed for some services, including visits to specialist doctors, medical tests, or surgical procedures. In order for people to receive the highest level of coverage they must obtain services from the doctors, hospitals, labs, imaging centers, and other providers affiliated with their managed care plan.
Types of Health Care Plans
Health Maintenance Organization (HMO)
An HMO is a type of managed care called a prepaid plan. This type of coverage was designed initially to help keep people healthy by covering the cost of preventive care, such as medical checkups. The patient selects a primary care doctor from a list of physicians participating in the HMO program. This doctor coordinates the patient's care and determines if referrals to specialist doctors are needed. People pay a premium, usually every month, and receive their health care services (doctor visits, hospital care, lab work, emergency services, etc.) when they pay a small fee called a co-payment. The HMO has arrangements with caregivers and hospitals and the co-payment only applies to those caregivers and facilities affiliated with the HMO. This type of coverage offers less freedom than fee-for-service, but out-of-pocket health care costs are generally lower and more predictable. A person's out-of-pocket costs will be much higher if he or she receives care outside of the HMO unless prior approval from the HMO is received.
Preferred Provider Organization (PPO)
A PPO combines the benefits of fee-for-service with the features of an HMO. If patients use health care providers (doctors, hospitals, etc.) who are part of the PPO network, they will receive coverage for most of their bills after a deductible and, perhaps a co-payment, is met. Some PPOs require people to choose a primary care physician who will coordinate care and arrange referrals to specialists when needed. Other PPOs allow patients to choose specialists on their own. A PPO may offer lower levels of coverage for care given by doctors and other professionals not affiliated with the PPO. In these cases the patient may have to fill out claim forms to receive coverage.
Point-of-Service Plans (POS)
Many HMOs offer an indemnity-type option known as a POS plan. The primary care doctors in a POS plan usually make referrals to other providers in the plan. But in a POS plan, members can refer themselves outside the plan and still get some coverage. If the doctor makes a referral out of the network, the plan pays all or most of the bill. If you refer yourself to a provider outside the network and the service is covered by the plan, you will have to pay coinsurance.
Government Health Plans
Medicare and Medicaid are the two main health plans offered by the U.S. government. They are available to individuals who meet certain age, income, or disability criteria. TRICARE Standard, formerly called CHAMPUS, is the health plan for U.S. military personnel.
Medicare
Medicare was created in 1965 under Title 18 of the Social Security Act and is available to people who are 65 years or older , or younger individuals who have disabilities or end-stage renal disease (permanent kidney failure)
Medicare is divided into four parts.
Part A is hospital insurance and helps cover the costs of inpatient hospital stays, skilled nursing centers, home health services, and hospice care.
Part B helps cover medical services such as doctors' bills, ambulances, outpatient therapy, and a host of other services, supplies, and equipment that Part A does not cover.
Part C provides the option to choose from a package of health care plans
Part D helps provide coverage for medication.
Enrolled individuals must pay deductibles and co-payments, but much of their medical costs are covered by the program. Medicare is less comprehensive than some other health care programs, but it is an important source of post-retirement health care.
Medicaid
Medicaid was created in 1965 under Title 19 of the Social Security Act and is a federally funded state run program of public assistance for persons regardless of age whose income and resources are insufficient to pay for health care.
This program covers hospitalization, doctors' visits, lab tests, and x rays. Some other services may be partially covered.
State Children’s Health Insurance Program Summary (SCHIP)
The State Children's Health Insurance Program was created as part of the Balanced Budget Act of 1997 title XXI, to address the growing problem of children without health insurance. SCHIP was designed as a Federal/State partnership, similar to Medicaid, with the goal of expanding health insurance to children whose families earn too much money to be eligible for Medicaid, but not enough money to purchase private insurance.
Tricare
Tricare is the United States military's health care plan for military personnel and their dependents. The Tricare program is managed by TRICARE Management Activity (TMA) under the authority of the Office of the Assistant Secretary of Defense for Health Affairs (OSD/HA). Eligible military families may enroll in Tricare Prime, which is an HMO; Tricare Extra, which offers an expanded choice of providers; or Tricare Standard, which is the new name for CHAMPUS.
Workers' Compensation
Workers' compensation covers health care costs only for an injury or illness related to a person's job. Medical conditions that are unrelated to work are not covered under this plan. In some cases an evaluation is done to determine whether or not the medical condition is truly related to a person's employment.
For additional information
http://www.cms.hhs.gov/default.asp?
Wednesday, January 9, 2008
Cancer and the Uninsured
According to a new American Cancer Society report examining the impact of health insurance status on cancer treatment and survival, uninsured Americans are less likely to get screened for cancer, more likely to be diagnosed with an advanced stage of the disease, and less likely to survive that diagnosis than their privately insured counterparts.
"This report clearly suggests that insurance and cost-related barriers to care are critical to address if we want to ensure that all Americans are able to share in the progress we have achieved by having access to high-quality cancer prevention, early detection, and treatment services," said Otis Brawley, MD chief medical officer of the American Cancer Society.
http://www.cancer.org/docroot/NWS/content/NWS_1_1x_Report_Links_Health_Insurance_Status_With_Cancer_Care.asp?sitearea=NWS&viewmode=print&
For all cancers combined, the ACS researchers found that uninsured patients were 1.6 times as likely to die within 5 years compared to individuals with private insurance.
An earlier article by the American Cancer Society reports” People without health insurance and those on Medicaid are more likely to be diagnosed with advanced stages of cancer than those with private health insurance,”
http://www.cancer.org/docroot/NWS/content/NWS_1_1x_Uninsured_More_Often_Diagnosed_with_Advanced_Cancer.asp
It's important to note that although variations in health insurance coverage likely contribute to racial and ethnic disparities in cancer outcomes, those disparities persist for several outcomes even when differences in insurance status are accounted for," said Elizabeth Ward, PhD.
People with lower incomes were less likely to have insurance, the report found. And those without insurance were less likely to use certain health services. About 54% of uninsured patients aged 18 to 64 did not have a usual source of health care. About 26% delayed care due to cost, while nearly 23% did not get care because of cost. An estimated 23% did not get prescription drugs because of the expense.
"For too many hardworking 'average Americans' paying for cancer treatment means not paying rent, mortgage (resulting in foreclosure or eviction), or utility bills, or even going hungry," wrote Elmer Huerta, MD, American Cancer Society president, in an accompanying editorial.
These statistics are true and uninsured and underinsured are more at risk than Americans with better health care coverage. However free and low cost services are available to assist the uninsured and underinsured.
It was mentioned in the article those uninsured or on Medicaid were more likely to be diagnosed in later stages. Yet Medicaid covers cancer screening and treatment and the Department of Health for each state has set up programs in conjunction with the Centers for Disease Control and Prevention for free or low cost screening.
The Centers for Disease Control and Prevention (CDC) initiated a nationwide program in 1990 aimed at reducing deaths from cancer through education, outreach, and screening.
http://www.cdc.gov/cancer/nbccedp/
http://www.cdc.gov/cancer/colorectal/basic_info/screening/
http://www.cdc.gov/cancer/screening.htm
http://apps.nccd.cdc.gov/cancercontacts/nbccedp/contacts.asp
Most of these programs are run by the Department of Health for each state such as in Pennsylvania by Adiago Health
http://www.fhcinc.org/pages/healthcare/cancer.htm
or Illonois
http://cancerscreening.illinois.gov/
California
http://www.dhs.ca.gov/cancerdetection/
Rhode Island
http://findarticles.com/p/articles/mi_qa4100/is_200309/ai_n9272104
New York
http://www.freecancerscreening.com/2007/07/manhattan-ny-free-cancer-screening.html
The American Academy of Dermatology also offers free skin cancer screening
http://www.aad.org/public/exams/screenings/index.html
The article also stated that the people with lower incomes were most likely to be uninsured due to the cost for health insurance and whereas this may be true assistance is available for treatment. There are many programs for low income people to receive free or low cost medication. Many of the individual drug manufacturers as well offer programs to cover their medications as well.
http://www.healthfinder.gov/news/newsstory.asp?docID=611094
http://www.health.gov/
http://www.freemedicinerevolution.com/?gclid=CMP0xo3Mt5ACFUWoGgodGnvnKg
https://www.pparx.org/Intro.php
http://www.needymeds.com/
http://www.merck.com/merckhelps/
http://www.themedicineprogram.com/
http://www.nami.org/Content/ContentGroups/Helpline1/Prescription_Drug_Patient_Assistance_Programs.htm
http://www.pharma.us.novartis.com/about-us/our-patient-caregiver-resources/pap-enrollment.jsp?usertrack.filter_applied=true&NovaId=2229644997704410576
http://www.edhayes.com/indigent.html
http://www.phrma.org/
http://www.qdrug.com/sf/
http://www.familiesusa.org/404.html
http://familiesusa.org/issues/uninsured/about-the-uninsured/
Cancer Care has programs to assist with financing treatment and care.
http://www.cancercare.org/get_help/assistance/index.php
I do agree with the American Cancer Society that the uninsured and underinsured do have higher incidents of advanced cancer and may not receive the proper treatment but I also feel that we need to explore and eliminate other causes as well.
As it has been mentioned earlier many people without insurance are low income or unemployed. Poor nutrition and bad health care habits such as smoking and sun exposure may be factors also. Many are poorly educated and maybe unaware of symptoms or uncertain of treatments. or not follow the prescribed treatment as ordered. Many immigrant groups may also have cultural or religious beliefs against treatments.
http://www.cbcrp.org/research/PageGrant.asp?grant_id=1803
http://jnci.oxfordjournals.org/cgi/reprint/jnci%3b96/1/10.pdf
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1618773
There are many options available for care no matter your income or coverage but I believe that education is necessary to let people know what is available and how they can help themselves.
Most importantly emphasis should be made to instruct on:
Good Health Habits to prevent cancer- No smoking, good nutrition, medical follow up
Instruction in warning signs and symptoms, treatment options
Free and low cost screening and treatment is available and where it can be obtained.
Additional resources
http://coloncancer.about.com/od/screening/a/Uninsured.htm
http://www.cancer.gov/cancertopics/factsheet/support/financial-assistance
"This report clearly suggests that insurance and cost-related barriers to care are critical to address if we want to ensure that all Americans are able to share in the progress we have achieved by having access to high-quality cancer prevention, early detection, and treatment services," said Otis Brawley, MD chief medical officer of the American Cancer Society.
http://www.cancer.org/docroot/NWS/content/NWS_1_1x_Report_Links_Health_Insurance_Status_With_Cancer_Care.asp?sitearea=NWS&viewmode=print&
For all cancers combined, the ACS researchers found that uninsured patients were 1.6 times as likely to die within 5 years compared to individuals with private insurance.
An earlier article by the American Cancer Society reports” People without health insurance and those on Medicaid are more likely to be diagnosed with advanced stages of cancer than those with private health insurance,”
http://www.cancer.org/docroot/NWS/content/NWS_1_1x_Uninsured_More_Often_Diagnosed_with_Advanced_Cancer.asp
It's important to note that although variations in health insurance coverage likely contribute to racial and ethnic disparities in cancer outcomes, those disparities persist for several outcomes even when differences in insurance status are accounted for," said Elizabeth Ward, PhD.
People with lower incomes were less likely to have insurance, the report found. And those without insurance were less likely to use certain health services. About 54% of uninsured patients aged 18 to 64 did not have a usual source of health care. About 26% delayed care due to cost, while nearly 23% did not get care because of cost. An estimated 23% did not get prescription drugs because of the expense.
"For too many hardworking 'average Americans' paying for cancer treatment means not paying rent, mortgage (resulting in foreclosure or eviction), or utility bills, or even going hungry," wrote Elmer Huerta, MD, American Cancer Society president, in an accompanying editorial.
These statistics are true and uninsured and underinsured are more at risk than Americans with better health care coverage. However free and low cost services are available to assist the uninsured and underinsured.
It was mentioned in the article those uninsured or on Medicaid were more likely to be diagnosed in later stages. Yet Medicaid covers cancer screening and treatment and the Department of Health for each state has set up programs in conjunction with the Centers for Disease Control and Prevention for free or low cost screening.
The Centers for Disease Control and Prevention (CDC) initiated a nationwide program in 1990 aimed at reducing deaths from cancer through education, outreach, and screening.
http://www.cdc.gov/cancer/nbccedp/
http://www.cdc.gov/cancer/colorectal/basic_info/screening/
http://www.cdc.gov/cancer/screening.htm
http://apps.nccd.cdc.gov/cancercontacts/nbccedp/contacts.asp
Most of these programs are run by the Department of Health for each state such as in Pennsylvania by Adiago Health
http://www.fhcinc.org/pages/healthcare/cancer.htm
or Illonois
http://cancerscreening.illinois.gov/
California
http://www.dhs.ca.gov/cancerdetection/
Rhode Island
http://findarticles.com/p/articles/mi_qa4100/is_200309/ai_n9272104
New York
http://www.freecancerscreening.com/2007/07/manhattan-ny-free-cancer-screening.html
The American Academy of Dermatology also offers free skin cancer screening
http://www.aad.org/public/exams/screenings/index.html
The article also stated that the people with lower incomes were most likely to be uninsured due to the cost for health insurance and whereas this may be true assistance is available for treatment. There are many programs for low income people to receive free or low cost medication. Many of the individual drug manufacturers as well offer programs to cover their medications as well.
http://www.healthfinder.gov/news/newsstory.asp?docID=611094
http://www.health.gov/
http://www.freemedicinerevolution.com/?gclid=CMP0xo3Mt5ACFUWoGgodGnvnKg
https://www.pparx.org/Intro.php
http://www.needymeds.com/
http://www.merck.com/merckhelps/
http://www.themedicineprogram.com/
http://www.nami.org/Content/ContentGroups/Helpline1/Prescription_Drug_Patient_Assistance_Programs.htm
http://www.pharma.us.novartis.com/about-us/our-patient-caregiver-resources/pap-enrollment.jsp?usertrack.filter_applied=true&NovaId=2229644997704410576
http://www.edhayes.com/indigent.html
http://www.phrma.org/
http://www.qdrug.com/sf/
http://www.familiesusa.org/404.html
http://familiesusa.org/issues/uninsured/about-the-uninsured/
Cancer Care has programs to assist with financing treatment and care.
http://www.cancercare.org/get_help/assistance/index.php
I do agree with the American Cancer Society that the uninsured and underinsured do have higher incidents of advanced cancer and may not receive the proper treatment but I also feel that we need to explore and eliminate other causes as well.
As it has been mentioned earlier many people without insurance are low income or unemployed. Poor nutrition and bad health care habits such as smoking and sun exposure may be factors also. Many are poorly educated and maybe unaware of symptoms or uncertain of treatments. or not follow the prescribed treatment as ordered. Many immigrant groups may also have cultural or religious beliefs against treatments.
http://www.cbcrp.org/research/PageGrant.asp?grant_id=1803
http://jnci.oxfordjournals.org/cgi/reprint/jnci%3b96/1/10.pdf
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1618773
There are many options available for care no matter your income or coverage but I believe that education is necessary to let people know what is available and how they can help themselves.
Most importantly emphasis should be made to instruct on:
Good Health Habits to prevent cancer- No smoking, good nutrition, medical follow up
Instruction in warning signs and symptoms, treatment options
Free and low cost screening and treatment is available and where it can be obtained.
Additional resources
http://coloncancer.about.com/od/screening/a/Uninsured.htm
http://www.cancer.gov/cancertopics/factsheet/support/financial-assistance
Friday, December 28, 2007
Long Term Health Care/Custodial care
As a follow up to my blog of November 15th, I would like to discuss custodial and long term care. As I had mentioned earlier the cost of providing basic care to meet the daily needs for yourself or a loved one can be quite exorbitant. Unless you have an involved family that is able and willing to provide care, or have enough financial resources available the cost of providing care for yourself or a loved one is very difficult indeed. This custodial care could include assistance at home with activities of daily living, bathing, dressing, meal preparation, housekeeping, laundry or shopping or attention to these same basic needs in a nursing home or assisted living facility.
This is particularly difficult because when you are disabled or older and income is limited the greatest need is for long term custodial care. Most long term care is provided by families but few families today can sustain the financial and emotional burden of long term care and contrary to popular belief Medicare does not cover all medical costs and only covers about 2% of long term care.
To determine the average cost for Medicare please check the Medicare Rights Center
http://www.medicarerights.org/newmedicarecosts.html
To be eligible for limited nursing home coverage from Medicare certain criteria must be met:
- You must be in an acute care hospital for 3 days prior to entering a Skilled Nursing Facility. An acute care hospital is licensed by the state to provide skilled care.
- The Skilled Nursing Facility must be Medicare certified to provide care by or under the supervision of licensed personnel.
- Your care under Medicare must be skilled care not custodial. Most nursing home care is custodial not requiring licensed personnel for skilled treatment such as intravenous infusion or skilled rehabilitation.
As indicated in my earlier blog the average yearly nursing home cost exceeds $77,000. The cost at average of $19 per hour for home health aide services added onto costs for medication, deductibles, medical supplies or equipment as well as costs to maintain a household can quickly deplete savings when living on a fixed income.
Medicaid, a national program for individuals and families with low incomes and resources is another alternative to paying for long term care. Medicaid is jointly funded by the states and federal government, and is managed by the states. Medicaid is the largest source of funding for medical and health-related services for people with limited income. While Congress and the Centers for Medicare and Medicaid Services set out the main rules under which Medicaid operates, each state runs its own program. As a result, the eligibility rules differ significantly from state to state, although all states must follow the same basic framework.
Over 42 million people a year receive assistance from Medicaid but Medicaid guidelines are based on the poverty levels and to qualify for Medicaid, you must meet income and asset limits set by your state. In most states, income must be below $851 a month (individuals) or $1,141 a month (couples). In some states, you can also qualify if health care costs reduce your income to the state limit. Call your State Health Insurance Assistance Program to find out the Medicaid rules for your state and to check eligibility.
Most people when they reach their 50s should consider adding a long-term care policy to their insurance coverage. Long term care insurance can be costly but can provide you with a payout to cover nursing home costs as well as a variety of in-home health care expenses.
It is however difficult to consider paying these high rates at 50 for insurance you may or may not need for another 25 or 30 years. However if purchased later you will face much higher premiums, as well as run the risk of being denied coverage if you have a pre-existing condition. We all look forward to our retirement and believe we will be able to continue to be healthy and independent well into our later lives. People don’t want to think of getting old and disabled. We buy car insurance on the chance of an accident when only one in 240 will use their car insurance, yet at least one in three will use their long term care insurance.
Many things need to be considered when buying long term insurance:
- Cover the catastrophic need. Lifetime coverage is most desirable, since you will not outlive the benefits.
- Know which policy benefits are important to you.
- Pick a long term care company that is financially strong enough and large enough to be around in 20 or 30 years when you need it.
- Consider Cost of Living Adjustment (COLA) Rider to allow your benefits to keep pace with inflation.
- Pick a premium you can afford and purchase a Long Term Care Insurance plan based on your budget. Remember 50% coverage is better than no coverage. It's important to select a policy where you will be comfortable paying the premium not just today but 20 or 30 years from today.
Long-term care insurance is meant to merely supplement your other income sources such as 401k’s, Social Security and retirement accounts.
For more information check AARP report on long term care.
http://www.aarp.org/research/longtermcare/costs/fs27r_ltc.html
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