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Ssd Recipient On Medicaid Spendown Plan Moving To Medicare

Disability Insurance News & Discussion

Ssd Recipient On Medicaid Spendown Plan Moving To Medicare

Postby Derrold » Sun Aug 21, 2016 4:02 pm

I regularly assist a disabled person, in Westchester NY, with her benefits planning, and had managed to get her enrolled in medicaid and social security disability(I have power of attorney for helping her with this).

She is not in a managed plan. Her disability is mental health based. She is now being pushed towards medicare. This is a multi-part question/issue:

1) Her Medicaid is currently on a spend down plan. Her SSD benefit is 935 monthly, which is still less than her rent. Still medicaid says she is over their limit by $200 monthly, so she must pay them that amount or present unpaid medical bills in that amount. This has been fun. Is this appealable?

2) She just became Medicare eligible, they want her to enroll.

In NY state, how does that interact with her spend down Medicaid plan? Can she have both? What does that do to her medicaid coverage? Will Medicare want her to pay additional money she doesn't have?

At first glance, there appears to be managed and non-managed  

medicare. Can she conceivably have managed medicare and non managed medicaid? Would this be advisable, since maybe the two might stack and allow more flexible coverage? Is there a decent book on this topic, and reasonable NY resources that don't rely on the Dept. of Social Services? They seem mired in red tape.

Thanks !!  
Derrold
 
Posts: 54
Joined: Sat Jan 04, 2014 11:23 pm

Ssd Recipient On Medicaid Spendown Plan Moving To Medicare

Postby Brannen » Tue Aug 23, 2016 8:44 pm

I regularly assist a disabled person, in Westchester NY, with her benefits planning, and had managed to get her enrolled in medicaid and social security disability(I have power of attorney for helping her with this).

She is not in a managed plan. Her disability is mental health based. She is now being pushed towards medicare. This is a multi-part question/issue:

1) Her Medicaid is currently on a spend down plan. Her SSD benefit is 935 monthly, which is still less than her rent. Still medicaid says she is over their limit by $200 monthly, so she must pay them that amount or present unpaid medical bills in that amount. This has been fun. Is this appealable?

2) She just became Medicare eligible, they want her to enroll.

In NY state, how does that interact with her spend down Medicaid plan? Can she have both? What does that do to her medicaid coverage? Will Medicare want her to pay additional money she doesn't have?

At first glance, there appears to be managed and non-managed  

medicare. Can she conceivably have managed medicare and non managed medicaid? Would this be advisable, since maybe the two might stack and allow more flexible coverage? Is there a decent book on this topic, and reasonable NY resources that don't rely on the Dept. of Social Services? They seem mired in red tape.

Thanks !!  
Brannen
 
Posts: 58
Joined: Wed Jan 08, 2014 3:11 pm

Ssd Recipient On Medicaid Spendown Plan Moving To Medicare

Postby Mansell » Mon Aug 29, 2016 5:28 am

Ben,

First let me tell you how much I admire you for helping someone muddle through the mess of public benefits.  It can be quite a boondoggle, can't it?

I am going to address your questions in the order in which you asked.

1) Her Medicaid is currently on a spend down plan. Her SSD benefit is 935 monthly, which is still less than her rent. Still medicaid says she is over their limit by $200 monthly, so she must pay them that amount or present unpaid medical bills in that amount. This has been fun. Is this appealable?

I am a little confused by the inference that she must PAY Medicaid $200.00 monthly.  Is she on a buy in program? If it is standard spend down, she must incur medical expense in excess of $200.00 before they will kick in and pay on her medical bills.  This can be in the form of prescriptions, office visits, counseling sessions, whatever.  After the initial out of pocket expense, then Medicaid will pay.

2) She just became Medicare eligible, they want her to enroll.

In all instances, Medicare is primary payer when the patient is eligible for both.  Medicaid can REQUIRE her to enroll in Medicare since she is now eligible. 3)In NY state, how does that interact with her spend down Medicaid plan? Can she have both? What does that do to her medicaid coverage? Will Medicare want her to pay additional money she doesn't have?

Medicare will have a premium of about $93.50 that she will be expected to pay.  But with her disability benefit of $935.00 monthly, she will qualify for another Medicaid program called QMB-Qualified Medicare Beneficiary.  What this Medicaid program does is pay her premium for her(thus-no loss of income from her check) AND pay all of her deductibles for inpatient care(currently about $1000.00 per visit). Once she has Medicare, she may still be dually eligible for Medicaid, but as I said, Medicare is primary payer. She will also become eligible for Part D Medicare, the prescription drug plan, that will help her with her meds.  Medicare will also become the primary payer for prescriptions for your friend.  The only drawback to the Part D plan is the so claled "donut hole" where once she hits a certain benefit level for the year in prescriptions(about $3500--but it does vary slightly depending upon which Part D plan she chooses), then she will have to pay for her prescriptions until she meets a $5000.00 threshold, whereas, Medicare Part D will pick up again and pay 100% of her costs. This is where dual eligibility really helps, as Medicaid could foot the cost of her prescription drugs while she is in the "donut hole."

4)At first glance, there appears to be managed and non-managed medicare. Can she conceivably have managed medicare and non managed medicaid? Would this be advisable, since maybe the two might stack and allow more flexible coverage? My best advice is DO NOT ENROLL HER IN A MEDICARE ADVANTAGE PLAN.  She should choose traditional Medicare.  Many healthcare facilities will not accept the Advantage plans and the beneficiary usually, in the long run, pays far more out of pocket if they select an Advantage plan. Traditional Medicare is your best bet.  If she selects an Advantage plan, this will also disqualify her for the QMB program that will help her with her premium and deductibles. I suspect there might be a book somewhere, but the inherent problem with that is this:  States can opt into or out of many of the Medicaid provisions offered to them.  That virtually means there is very little "across the board" standardization, which would make it very difficult to write a book onthe topic.  Likewise, since this is legislation and government policy, and it changes so frequently, a published book might be obsolete before it could ever hit the market.

May I suggest the Kaiser website? www.kasierhealth.com

This is a very comprehensive website, that once you learn to navigate it, is very helpfull and useful in all sorts of ways.  They also update it frequently, so the information is relatively current.

I hope I have helped some.  It is a very complex subject.

Best regards,

Joy Payne  
Mansell
 
Posts: 52
Joined: Wed Jan 01, 2014 9:13 am


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