HELP LINE: The nuances of insurance are complicated

BASED ON A lot of emails that I’ve received from a lot of you, there are a lot of good questions floating around that are really the same questions coming from different folks dealing with different situations.

Let’s see if we can make a few things easier, beginning with:

• Medicare: Medicare is health insurance.

Yes, it has all of its various “parts” (A, B, etc.) but it’s really no different than the health insurance a person may have had when they were employed. It covers medical stuff.

So, if Mom breaks a hip and goes into the hospital for surgery, Medicare covers most of that. (True, Mom might have a Medicare supplement plan that covers more of it, but Medicare is covering the lion’s share.)

Then, Mom goes into a nursing home for rehab.

That’s still medical stuff, because Mom is recovering from the surgery, get it?

So, Medicare covers up to 20 days in the facility. (True, under some circumstances, Medicare might cover some of more than 20, but let’s leave that alone, for now.)

As long as Mom is discharged within that 20 days, and assuming that she spent the obligatory three nights admitted to the hospital, Medicare pays the freight and that’s that for that.

Now, what if Mom was already headed down the dementia/Alzheimer’s path before she fell?

Now, with the surgery and what-not, everything has escalated, and it’s obvious that you just can’t care for her at home anymore, so she’s going to need to move into a facility, permanently.

Doesn’t Medicare cover that?

No. That brings us to:

• Medicaid: Medicaid is health insurance, too, but assuming that Mom qualifies for Medicaid, in terms of need, income and assets, Medicaid will pay for long-term care.

Medicare never pays for long-term care, so Mom might need to switch from Medicare coverage to Medicaid coverage (assuming she qualifies), even if she’s going to stay in the same facility.

So, what the heck is:

• Long-term care? It just means that Mom (or whoever) is going to need a substantial amount of care from other people, for a very long time; often, permanently.

Don’t make that too complicated.

Now, what if “we” have:

• Long-term care insurance? Great. I’m glad that you were able to afford it and good for you.

Hopefully, back when you realized that Mom was going to need care (long-term care?) after the Medicare-paid 20 days, you dug out that long-term care insurance policy and read it.

Then, read it again.

Then, contacted the agent with questions, because one thing you probably saw is a “waiting period” that has to occur before the policy starts paying anything.

Is it 90 days or 180 days?

So, you had time to think about how this care was going to get paid for until the long-term care policy kicks in.

But, wait a minute: What if you’re going to be able to care for Mom at home after that discharge from the rehab facility?

What then?

Well, hopefully, while Mom was in the facility (or even before the surgery), you talked to her physician about:

• Home health: What the heck is home health?

Think, nurses, physical therapists, speech therapists, occupational therapists, etc.

Home health can come to Mom at home, assuming that her getting to a medical clinic is “taxing and difficult,” and provide skilled medical services at home.

Yes, there might also be some other ancillary services that come along with it, such as a bath aide, but they aren’t going to vacuum or do the dishes.

Think skilled medical services.

And who pays for this:

Medicare — assuming that you’ve engaged (and the doctor ordered) a Medicare-certified home health agency.

Yes, there are licensed, completely legitimate home health agencies out there that are not Medicare-certified. Why? Is it deceptive advertising?

No. These are agencies that provide nurses, therapists, etc. for valuable in-home, skilled medical services to people who need/want it.

They just aren’t going to be paid for by Medicare, because they aren’t Medicare-certified.

They might be paid by other forms of insurance or privately, as in out-of-pocket.

Will they vacuum, do the dishes and do whatever else?

Well, I’m pretty sure that the nurses and therapists won’t, but staff from another part of that same agency might, which forces me to realize that I’m not going to get as far with this today as I’d hoped, so cut this one out and stick it on the fridge with that cute doggie magnet, and we’ll pick it up here, next week.

I agree: It is complicated.

No, you aren’t stupid.

Yes, it can be done.


Mark Harvey is director of Clallam/Jefferson Senior Information & Assistance, which operates through the Olympic Area Agency on Aging. He is also a member of the Community Advocates for Rural Elders partnership. He can be reached at 360-452-3221 (Port Angeles-Sequim), 360-385-2552 (Jefferson County) or 360-374-9496 (West End), or by emailing [email protected].

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