Q: I recently applied for my Medicare benefits and soon after received a form to complete asking for information about employer’s health plans that I might be entitled to. Why would Medicare need such information?
A: Medicare needs to know about other health care coverage to establish your benefits file and to determine whether or not Medicare will be your primary coverage.
Usually when a person becomes eligible for Medicare, Medicare serves as the primary health care payer. However, some people are entitled to other health care insurance which pre-empts Medicare as the primary health care provider shifting Medicare’s role to that of secondary payer.
The questionnaire you received asks if you have health care coverage under an employer’s health plan either through your or your spouse’s current employment. This initial enrollment questionnaire provides information for the establishment of your benefit file. Medicare needs to determine if they will be the primary or secondary payer for your health care costs. Without this information Medicare would not be able to pay your claims in a timely manner and you could be billed by your providers for services rendered.
If your employer or your spouse’s employer coverage is through an HMO you must also provide this information to that HMO. They will then coordinate payments between Medicare and the employer plan.
If you are 65 years old or older and continue to work or you are 65 or older and have a spouse, of any age who works, federal law protects you from discrimination in employer health care coverage. An employer of 20 or more employees who offers health care benefits must offer you and your spouse the same health care benefits under the same conditions as those offered to other employees.
You have the choice of accepting or rejecting the plan offered by your employer or your spouse’s employer. If you accept the plan it will be your primary health care coverage as long as you or your spouse continues that employment. Medicare, if you decide to enroll, would then become your secondary insurance and could assist with payment of Medicare covered services that are not covered under the employer plan.
If you decide to reject the employer’s plan, Medicare will be your primary plan.
It is very important that you let your health care providers know what plan is providing your primary coverage. If it is an employer’s plan providers of care will need the name and address of the employer’s plan and policy number. Providers should be instructed to bill that plan first for any services provided.
As soon as you are no longer covered by an employer’s plan it is very important that you enroll in Medicare Part B (Medical Coverage), if you have not previously done so. You should also notify the insurance carrier or HMO responsible for your Medicare claims that you are no longer covered by an employer’s plan and that Medicare will now be the primary payer. Make sure they know the effective date of this change.
Last, but not least, inform your health care providers of your change in primary coverage so they can direct their claims to the proper insurer for payment.
Q: Recently a neighbor returned home from the hospital and needed some assistance. I was surprised when I was told she had to pay for these services. Doesn’t Medicare pay for in-home care?
A: Although it sounds simple — care in the home is a complex subject and you are not alone in your thinking. Keep in mind that Medicare pays only for “medically necessary” services. Medicare does not pay for “custodial” care.
In-home care essentially is custodial care and covers the assistance with meeting the activities of daily living. It includes assistance with walking, getting in and out of bed, bathing, dressing, eating and toileting.
It could also include preparation of special diets and supervision of taking medication that can be self-administered. It does not require the services of trained medical or paramedical personnel.
In-home health care is skilled nursing care and certain other health care services received in the home for treatment of an illness or injury. Medicare does cover this type of care in the home if the patient meets the eligibility requirements.
To qualify for home health care the patient’s doctor must order such care and present a plan for that care. The plan must show that intermittent, not full time, skilled nursing care, physical, speech or occupational therapy is required.
The patient must be homebound. This means that the patient is normally unable to leave home and leaving home is a major effort and when leaving home it must be infrequent and for a short period of time. The last requirement is that the home health agency providing the care must be approved by the Medicare program.
Home health care can be covered under either Medicare Part A or Part B. There are no deductibles or coinsurance associated with home health care except for the durable medical equipment. In the case of durable medical equipment Medicare will pay 80 percent and the patient or other insurance is responsible for the remaining 20 percent.
While this is a very simple answer to a complex service I hope that it shows you the difference between two types of care in the home and explains when Medicare will or will not pay for the services.