Am I Covered? Undstanding Your Home Health Care Insurance Benefits

Selecting the best health insurance coverage for your family can be complicated. So many choices, so many considerations, and so expensive! Comparing deductibles, copays, annual limits, provider networks, covered services, and more, makes it challenging to choose a plan that best fits your current needs.  And then there’s the unknown; will someone in your family be diagnosed with a serious illness or suffer a traumatic injury? How can you plan for that? How will you pay for home health care?Melissa Burnside, division director of BAYADA Home Health Care, understands how difficult – yet critically important – it is to understand the ‘nitty gritty’ of health insurance coverage – especially when it comes to home health care.
“In the Insurance Confirmation Department at BAYADA, we talk to people every day about their health coverage,” says Melissa, “Some people are new clients who’ve never had to worry about home health care before, while others have been receiving services for years. We find that many clients often don’t fully understand the home health care coverage and eligibility requirements of their plan. Sometimes the benefit is much different than they expected.”
With all the changes from the Affordable Care Act affecting the way health care is managed, delivered, and paid, it’s safe to say that comparing plans and choosing the best coverage is more complicated than ever. Whether your insurance is through an employer or through the government Health Insurance Marketplace (The Exchange), Melissa recommends carefully evaluating your options.
Evaluate. Compare. Ask for help.
Stock-Insurance-Paperwork-250x200Your plan’s Summary of Benefits and Coverage, which every plan must provide, only provides a brief mention of home health care with no critical details such as visit limits, authorization policy, exclusions, or the definition of medical necessity. Tara Montague, a BAYADA employee and mother of a pediatric client, knows all too well how important those specifics are.
“I always tell people to ask their insurer for full disclosure documents and read them with a microscope,” cautions Tara, “And ask them to explain it if you don’t understand.”
Tara’s daughter, Mary, 16, has been receiving home health care private duty nursing since she was an infant. Mary was born with two congenital disorders: Spinal Muscular Atrophy (SMA) Type 1 and Cerebrocostomandibular Syndrome.
SMA is a motor neuron disease that severely affects a child’s muscular development. Mary has the most severe form and is unable to move or speak. Coupled with Cerebrocostomandibular Syndrome, an extremely rare inherited disorder characterized by an abnormally small jaw, malformations of the roof of the mouth, improper positioning of the tongue, and abnormal development of the ribs, Mary’s care requires round-the-clock attention.
“My husband and I both work during the day and could really use 24 hours of nursing care for Mary, but most insurances only provide 16 hours,” explains Tara. “Our insurance company said that overnight nursing wasn’t ‘necessary’. I guess they didn’t expect us to ever sleep.”
Melissa agrees that it’s very common for insurance companies – including Medicaid – to provide up to only 16 hours of private duty nursing.  Many families pay out of pocket for additional nursing care, but that can be very costly. Others have to make adjustments to their schedules to be the caregivers.
After a serious month-long hospitalization in the spring, Mary was discharged with a temporary four hour increase of home nursing care, bringing it to 20 hours a day. Once that increase expired, Tara appealed to extend it and won, but it’s still temporary.
“We have arranged Mary’s care schedule so that we have a night nurse and coverage during the day while we’re at work,” says Tara. “My husband and I fill in the gaps in the evening.”
Consider all your options
Both Tara and Melissa recommend that when evaluating and comparing health insurance plans during open enrollment or at any other time, people should make the effort to look at all the particulars.  Understand the out-of-pocket contribution versus the premium (at one point, Mary had an individual plan that had a very high premium, but it paid 100% of the nursing care), consider the coverage benefit for prescriptions, durable medical equipment, therapy, and more, and find out what is considered a “medical necessity.”
“Unfortunately, people make a lot of assumptions when it comes to home health care coverage. The benefit and eligibility can be vastly different than those for more commonly-covered services such as doctor visits,” says Melissa. “The good news is that there are a lot of plans out there and it’s a matter of finding out which one best fits your needs and budget. BAYADA is always happy to help our clients evaluate their options so that they can maximize their home health care benefit to get the coverage they need.”
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