Insured Patients Delay Surgery Due to OOP Costs

[straightnochaser]

Some of the greatest teaching moments happen when you discover your knowledge was incomplete or just plain wrong . . .

First hand experience is the best teacher.

The irony of this comment...

 

[Millwood]

There is no mechanism where medicaid pays supplement premiums.. it just doesn't happen. Might wanna check on your clients

Maybe not in your area. Must be state specific. I see it all the time in Oklahoma with clients who go on Medicaid when in the nursing home. DHS social worker is the one who recommends it. State of Oklahoma DHS carves it out and pays Med Supp premium so state isn't responsible for what Medicare doesn't pay.

 

[straightnochaser]

Maybe not in your area. Must be state specific. I see it all the time in Oklahoma with clients who go on Medicaid when in the nursing home. DHS social worker is the one who recommends it. State of Oklahoma DHS carves it out and pays Med Supp premium so state isn't responsible for what Medicare doesn't pay.

What does medicare pay for a nursing home?

 

[Millwood]

What does medicare pay for a nursing home?

It doesn't. State Medicaid does. State Medicaid pays or allows hold out for client to continue paying supplement while on Medicaid.

 

[rmhaire]

Maybe not in your area. Must be state specific. I see it all the time in Oklahoma with clients who go on Medicaid when in the nursing home.

I've seen it more than a few times in the nursing home scenario. But the ones I'm talking about are not in nursing homes and not in spend down mode .... So obviously there is a mechanism.

 

[somarco]

I have a couple of clients who had OM and Med Supp and later got Medicaid. They wanted to keep their doctors so they kept the med Supp

The dual market is not on my radar, but I am under the impression that Medicare is primary, Medicaid secondary.

My interpretation is that a dual can use any provider that accepts Medicare, and also that Medicaid mimics a supplement plan and picks up the balance of Medicare approved claims.

This seems to bear that out . . .


People who have both Medicare and full Medicaid coverage are “dually eligible.” Medicare pays first when you’re a dual eligible and you get Medicare-covered services. Medicaid pays last, after Medicare and any other health insurance you have.

If you're dually eligible, you’ll automatically be enrolled in a Medicare drug plan that will cover your drug costs instead of Medicaid. With drug coverage, you'll never pay 100% of the cost for drugs covered by Medicare.

Medicaid

Medicaid is a joint federal and state program that helps cover medical costs for some people with limited income and resources. The rules around who’s eligible for Medicaid are different in each state.

www.medicare.gov

 

[somarco]

But the ones I'm talking about are not in nursing homes and not in spend down mode .... So obviously there is a mechanism.

Generally, you must meet your state’s rules for your income and resources, and other rules (like being a resident of the state).

You might be able to get Medicaid if you meet your state’s resource limit, but your income is too high to qualify. Some states let you “spend down” the amount of your income that’s above the state’s Medicaid limit. You do this by paying non-covered medical expenses and cost sharing (like Medicare premiums and deductibles) until your income is lowered to a level that qualifies you for Medicaid.

If you have Medicare and qualify for full Medicaid coverage:

Your state will pay your Medicare Part B (Medical Insurance) monthly premiums.

Covers certain doctors’ services, outpatient care, medical supplies, and preventive services.Part B (Medical Insurance)

Depending on the level of Medicaid you qualify for, your state might pay for:
Your share of Medicare costs, like deductibles, coinsurance, and copayments.

Part A (Hospital Insurance) premiums, if you have to pay a premium for that coverage.

You'll automatically get Extra Help with your drug costs. Learn more about Extra Help.

Medicaid may pay for other drugs and services that Medicare doesn't cover

Medicaid

Medicaid is a joint federal and state program that helps cover medical costs for some people with limited income and resources. The rules around who’s eligible for Medicaid are different in each state.

www.medicare.gov

I suspect that some folks know how to "sell" D-SNP but have nominal understanding of how M-M actually works.

Not surprising, since many likewise do not know how OM works either.

 

[straightnochaser]

Generally, you must meet your state’s rules for your income and resources, and other rules (like being a resident of the state).

You might be able to get Medicaid if you meet your state’s resource limit, but your income is too high to qualify. Some states let you “spend down” the amount of your income that’s above the state’s Medicaid limit. You do this by paying non-covered medical expenses and cost sharing (like Medicare premiums and deductibles) until your income is lowered to a level that qualifies you for Medicaid.

If you have Medicare and qualify for full Medicaid coverage:

Your state will pay your Medicare Part B (Medical Insurance) monthly premiums.

Covers certain doctors’ services, outpatient care, medical supplies, and preventive services.Part B (Medical Insurance)

Depending on the level of Medicaid you qualify for, your state might pay for:
Your share of Medicare costs, like deductibles, coinsurance, and copayments.

Part A (Hospital Insurance) premiums, if you have to pay a premium for that coverage.

You'll automatically get Extra Help with your drug costs. Learn more about Extra Help.

Medicaid may pay for other drugs and services that Medicare doesn't cover

Medicaid

Medicaid is a joint federal and state program that helps cover medical costs for some people with limited income and resources. The rules around who’s eligible for Medicaid are different in each state.

www.medicare.gov

I suspect that some folks know how to "sell" D-SNP but have nominal understanding of how M-M actually works.

Not surprising, since many likewise do not know how OM works either.

This dude literally copy and pastes shit and has the NERVE to tell us who do this day in day out that we don't know how it works... Sit down and stay in your lane man jfc

literally everything you just shared is basic shit that a week 1 agent would understand

 

[straightnochaser]

Exactly. I am on a first-name basis with some of the Medicaid and Social Security offices. I help people get Medicaid, conditional part a, and I do the extra help applications. He probably has to look up what conditional part a is. But you know once he does he will copy and paste like the "Medicare expert" he is.

You can pretty easily start an application for MSP by applying for LIS. Don't even need to go into an office. I am sure our resident medicare genius knew that though.

 

[Chazm]

The dual market is not on my radar, but I am under the impression that Medicare is primary, Medicaid secondary.

My interpretation is that a dual can use any provider that accepts Medicare, and also that Medicaid mimics a supplement plan and picks up the balance of Medicare approved claims.

This seems to bear that out . . .


People who have both Medicare and full Medicaid coverage are “dually eligible.” Medicare pays first when you’re a dual eligible and you get Medicare-covered services. Medicaid pays last, after Medicare and any other health insurance you have.

If you're dually eligible, you’ll automatically be enrolled in a Medicare drug plan that will cover your drug costs instead of Medicaid. With drug coverage, you'll never pay 100% of the cost for drugs covered by Medicare.

Medicaid

Medicaid is a joint federal and state program that helps cover medical costs for some people with limited income and resources. The rules around who’s eligible for Medicaid are different in each state.

www.medicare.gov

“Some” doctors, or a lot, don’t accept Medicaid. I don’t deal with much Medicaid but maybe you’re right.