No matter what age group you fit into, one of the most important things to consider is your insurance coverage and that type of decision should be made on a ‘need to know’ basis.
“Insurance is a very broad category, and it’s really important that you know what your insurance covers. And as you’re choosing your insurance, you choose it based on your needs. And it’s important that you know that information, prior to when you’re going to need it,” Molly Quarles Bailey said during a recent Health, Wealth and Humor gathering hosted by First Tennessee Bank.
Her role as nurse manager over quality, case management and regulatory compliance at Morristown-Hamblen Healthcare System/Covenant Health, along with 26 years of experience in the nursing field, affords Bailey a unique perspective on the critical relationship between insurance coverage and quality of care.
She said she learned a great deal, as well, from helping her two sisters care for their late mother, Rachel Cate Quarles, who passed away in 2013.
“You think you’re prepared for everything, but you’re not. Hopefully, by the end of night, we’ll at least give you some idea of how to navigate that water, when you have a parent who’s sick or you get sick yourself, or you try to nativate that with your children,” Bailey said.
Bailey said her mother was very thoughtful, very good at planning, and, as she grew older, divided her future care among her three daughters according to their talents: one took over finance, one took over general care, like entertainment and buying groceries, and healthcare was tasked to Bailey — “It worked for us,” she said.
The advice for the women in attendance included the practical.
“Any nurse in any hospital is going to tell you this: have a medications list,” Bailey said. “Always know what your medications are. And make sure, even if you don’t choose someone who’s going to be your healthcare decision-maker, that somebody knows your medication list and is checking that list against your pill bottles and making sure it’s up-to-date and accurate. You don’t want to get into the hospital and have an inaccurate list because that’s just going to set you back when it comes to figuring out what’s wrong, what’s going on and what may make you better faster.”
“My mother was a very strong woman, a very intelligent woman and she did not loose her faculties; she was mentally stable the entire time she was sick. But, even being sick, you have moments. I would check and find that her medications were not quite right — so, if you’re the caregiver, make sure you’re checking on that at least once a week. Make sure the pills on the bottle and on the list match up. Always keep that list with you and keep that list with them (the patient). Because if you’re flying to the emergency room in the middle of the night, you will need that list. I still have my mother’s list on my computer at work. I can’t delete it; it’s just one of those things.
“Make sure you keep a list of conditions, surgeries, physicians, specialists. It’s really important for you to have that when you get into a hospital or illness situation. “The quicker you have that information, the quicker we can help you in the hospital,” Bailey added.
With regard to insurance coverage, Bailey said its critical to understand there are lot of different options.
“As healthcare changes, whether we healthcare providers like it or not, you don’t get to stay in the hospital very long at all. It’s very important that you go in prepared,” she said.
After an injury or illness that requires a hospital stay, there are different options for how a patient is cared for.
• Home Health: nurses will not stay in your home 24/7, but will visit every day; they can provide therapy, IV antibiotics, wound care, etc.
• Long Term Acute Care: The closest facilies are located in Knoxville and Bristol. Eligibility is being critically ill, but not necessarily meeting hospital-level care requirements — “Insurance and Medicare rules drive what we can do,” Bailey said.
• In-Patient Rehab: Patricia Neal is an example. There is restricted admission at that facility, just 13 diagnoses are considered. All facilities require three hours of therapy per day.
• Skilled nursing facility/nursing home: The rehab is short-term, requiring one hour of therapy per day.
Hospital and insurance case managers can help with information about the options and it’s important for patients to get to know them,” Bailey said.
“Hospital case managers are navigators, help patients decide which options are best on an individual basis, what insurance will cover, what the physician feels is best,” she said.
Joining in on the discussion was Cassie Carpenter, who has been with the hospital for more than eight years and is the care manager/coordinator there. She underscored the need for individuals to be knowledgeable about insurance options, especially with regard to Medicare — open enrollment ends Dec. 7
“In the world of insurance, you have someone knocking on your door, calling you, wanting you to purchase Humana, Blue Cross, every plan — they’re getting paid a commission off that. So be really wary, during this open enrollment period, what you choose. You might be healthy when you make that decision; that can change, when your’re in the hospital. That’s where we come in; we help you navigate that,” Carpenter said.
She used an example of a patient who had experienced a broken hip to share a few facts.
“Traditional Medicare will cover up to 20 days of rehab, that’s 20 days at 100 percent. Medicare says it will cover up to 100 days, but there’s a little of bit of fine detail in there. Any days after ‘Day 20’ will be a co-pay day. You or your secondary insurance will be responsible for what could be $160 per day. That’s expensive, even if you just need one extra week. That secondary plan can really make a difference in what your coverage is extending past day 20,” Carpenter said.
“After 100 days, you have to be healthy for 60 consecutive days in order for that to reset. If you needed to be in a nursing facility for 100 days, it’s really unlikely that you’re going to be well enough to take a 60-day break,” Carpenter said. “The requirement is that you not be admitted to a hospital at all during those 60 days.”
With regard to Medicaid applications for short term care vs. long term care, Carpenter said recovery from a broken hip would be considered short term care, unless the patient was already being treated for several illness and their family was having difficulty caring for them at home.
She warned the Medicaid application for long term care is very detailed and there are certain requirements the patient must meet for long term care.
“You have to be functionally limited, and in some cases cognitively limited, to qualify. With the VA, the only local facility is Jefferson City Health and Rehab. Typically, the VA will cover 100 percent, depending on the service connectivity,” Carpenter said.
“It’s good for you guys to be here tonight and thinking ‘OK, if I get to this point’ … just have that first facility in mind. Know your options,” she added.
Medicare sets a guideline for companies offering supplemental insurance.
“All those companies have to do is offer the bare minimum,” Carpenter said. “They reserve the right, when you come into the hospital after breaking your hip, to say ‘We’re only covering seven days. With some patients, they will only cover five days.”
A question from the audience: “How do you know that it’s a 7-day or a 5-day plan before you sign up? Do they tell you?”
“What they are doing, from an insurance standpoint, is when you say, ‘I want to go to Heritage for my rehab,’ they are looking at that physical therapy evaluation from the hospital,” Carpenter said. “They will ask about prior level of function and they will tell you a certain number of days, but it’s actually based on that exact moment of time.
Question: “So if they tell you something, it’s not 100 percent that you can count on that?” — “Right,” Carpenter said.
She added that a phone call to the insurance call might result in an answer of ‘X, Y or Z,’ but “What they say and what they do are two different things.”
“Just realize that if a good-looking guy comes to your door, saying ‘Hey, come to Humana,’ he will be talking in general terms. Notice that they are not coming to your door with a list of your medications, a list of your doctors, with all the local facilities, saying ‘Here’s what we can offer,” Carpenter said.
There is a 100-page document on Medicare.gov that provides detailed information.
“It’s ‘written in Greek,’ but it does have an index so that you can look up specific subjects,” Carpenter said. “Or you can call 1-800-Medicare.
There is another critical decision to be made before you get sick, Carpenter said.
“You need to have a designee who can talk to Medicare for you, if you can’t speak for yourself. That proxy has to be designated prior to the event. A lot of people think we have pull with Medicare/Medicaid – we do not. When you come into the hospital, you always have a choice. There are options,” she said.
Carpenter also advised attendees to consider purchasing long term care insurance, a project that is offered locally by First Tennesse Bank. The bank utilizes a variety of insurance companies.
Health, Wealth and Humor events are organized by an advisory board; its members chose the topics, food, venue and speakers with a mission to empower, educate and engage women. The board recently welcomed a new member, Rosemary Wigington, who retired as the bank’s market president.
The official host of the evening was Julie Rex, who has worked with First Tennesese for more than 13 years and in 2011 was named its private client banker. Her clients typically have $500,000 in investable assets; however, Rex said the bank’s mission is to extend that level of service out into the community.
“We want to build that kind of relationship with everyone, to be that partner in starting with savings, getting the first loan,” Rex said.
First Tennessee and Capital Bank merged in May 2018 and have decided on one brand for Tennessee, the Carolinas, Florida according to Rex. In October, the bank officially took on the title of First Horizon, which has been the parent company of First Tennessee for a number of years.
Emcee Cookie Larkin said in welcoming the group. “It’s wonderful to be together with this group again. I just want to thank Julie for all the hard work she does in making this happen, and her able assistant Karen Bolten — we can’t do anything without Karen — and the whole committee that tries to plan, from outing to outing, what people would like to hear about and bring in some folks who are really skilled in those fields to share the latest information with us.”
Catering was provided by Little City Catering/Jersey Girl Diner. Sommelier services were provided by Jill Bruce. Event space was provided by the The White Rose at Hidden Meadows Farm. The invocation was provided by advisory board member Sharon Hayes.
For more information about upcoming Health Wealth and Humor events, call Karen Bolten at 423-254-6205.