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Understanding What Insurance Provides

Senior talking to an insurance agent about what her insurance provides
Discuss your loved one's discharge plan with an insurance representative, case manager or provincial services office.

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April 20, 2012

Understanding what health insurance covers is among the most difficult financial issues that family caregivers and their senior loved ones face. One of the most common ways to finance medical care and health services for seniors in the United States is through Medicare. Canada's national healthcare system for all ages—also called Medicare—which according to Health Canada is a national program composed of 13 interlocking provincial and territorial health insurance plans, also provides certain common features and basic standards of coverage for seniors.

U.S. Medicare is a federal health insurance program that covers almost all Americans over the age of 65 for a large share of their medical expenses including hospitalizations, doctors' bills, x-rays and therapies. Canadian Medicare provides universal coverage for medically necessary health care services, but depending on what province you live in, the coverage can vary. In both countries supplemental insurance is often needed for items beyond the certain basics.

Many seniors and their families do not know exactly what their insurance covers until they need it. The following steps will help family caregivers obtain the information they need to better understand their senior loved one's insurance policies and programs before they return home from the hospital.

Contact Insurance Representatives Before Bringing Your Loved One Home

Discuss your loved one's discharge plan with an insurance representative, case manager or provincial services office. Make sure the insurance provider understands all the services and equipment that your loved one needs and ask them to provide information on what they will approve, why and for how long.

Keep in mind that both the United States and Canadian Medicare programs generally do not pay for non-medical care, including long-term care and assistance with activities of daily living, except in a few instances.

Conduct Research and Build a Support Network

  • Discuss your loved one's insurance needs with a bank trust officer, financial planner or other investment advisor. While these individuals do not provide legal advice they can often help with insurance, retirement plans and many other issues on behalf of their clients.
  • Get to know your local pharmacist, who may be an excellent and readily available resource for information about insurance as it relates to prescription coverage.
  • Discuss insurance options and information with friends and acquaintances who have experienced similar health care situations.
  • Have family members help with sorting bills, reviewing current and potential supplemental insurance policies and conducting research. Review the Helping Seniors with Finances Family Caregiver Educational video series for additional helpful suggestions.

Make sure that you speak with official representatives at insurance companies and related federal, state and provincial/territorial insurance programs to understand what services will generally be covered. It is common for friends and others to say, "Medicare (or another insurance plan) won't pay for that," and it is your job as family caregiver to do your research as each health care situation can be unique. What might not be covered in one case is different in another.

Health Insurance Resources

There are many resources available to help family caregivers learn more about insurance. We have listed a few below.

  • State, Provincial/Territorial and Local Level:
    • State Health Insurance Assistance Programs
    • Provincial/Territorial government agencies
    • County or state departments of health and human services
    • Local and area social service agencies
  • U.S. Federal Government:
    • Medicare is health insurance for people 65 or older, people under 65 with certain disabilities, people of any age with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant).
    • Medicaid is a program often confused with Medicare because they are both health care programs. But Medicaid is a "means tested" welfare program designed to help the poor of all ages, including the elderly.
    • The Center for Medicare and Medicaid Services, is the government agency that administers the Medicare Program and works with the states to administer the Medicaid Program.
  • Independent U.S.-based Resources:
    • The Medicare Rights Center
    • The Patient Advocate Foundation is a liaison between patients and their insurer to resolve insurance and other matters relating to a patient's condition.
    • Benefits Check-up is a service of the National Council on the Aging, and helps people over the age of 55 find federal, state and local public and private programs that may pay for some of their medical and/or prescription drug costs.
    • Stages of Senior Care is a book written by Paul and Lori Hogan, co-founders of Home Instead Senior Care, that focuses on helping you understand your senior care options and how to pay for them.

Because of the complexity of health care insurance policies and programs it is important for family caregivers to plan ahead and obtain as much information as they can prior to having a senior loved one discharged from the hospital. Meeting with knowledgeable professionals will help families understand their options and how those options will impact themselves and their senior loved ones.

Download the Returning Home guide.

Download the Canadian Edition of the Returning Home: Transitional Care Guide

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Thoughts and stories from others
  1. April 8, 2015 at 11:40 am | Posted by Linda Sculley

    Thanks - very helpful information

    Reply

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