MA Plans and Nursing Homes

Oct 6, 2008

  1. insurance0707
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    insurance0707 Guru

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    I have a client that has an MAPD plan and just went into a nursing home. They have 10 days of full coverage than the client has to pay $100 a day up to 100 days.

    The same company that I wrote him has another MAPD plan that will cover him at 100% for 100 days. The premium would go from $118 to $198 but they don't mind that.

    Can I upgrade him using the OEPI? This is the code for institutionalized nursing home patients that give them a continouse SEP. From what I read I should be able to upgrade his plan, the insurance company is telling me I have to wait until the AEP.

    Anyone had this problem?
     
  2. retread
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    My understanding that entry into a nursing home establishes an SEP, and as long as they are in admittance are pretty much continuous SEP status like Medicaid. I am not sure about this, but tend to agree with you. I think the insurance company may have a hidden agenda.
     
    retread, Oct 6, 2008
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  3. jdeasy
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    You are correct. It is now an SEP and will remain an SEP as long as the person is confined, meaning they could change every month if a new deal comes along.

    If enrolled now, or anytime during Oct., the new plan would be effective Nov. 1. The company may not like it, but, they don't have a choice, it's GI, unless the person is in a nursing home for ESRD.
     
    jdeasy, Oct 6, 2008
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  4. insurance0707
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    that's what I thought, the company wouldn't agree. I gave them the SEP code, I told them I was looking at Medicare's webiste...they finally said go ahead and submit it but it probably will get rejected. I guess you just have to send along the SEP list and documentation to back it up. thanks for your help jdeasy...i appreciate it.
     
  5. jdeasy
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    I've got a "cheat sheet" here someone and I can't find it. Anyway, it's gives the codes by number that CMS uses for the various SEP's available.

    It helps to give that number to company because they can enter into the system and see that you know what you are talking about.

    The comapny may decline it at first. I had Wellcare decline one twice in June of this year when the people had a legit SEP. I finally had to get Medicare involved directly to get Wellcare to process it.

    It will get processed if you stay with it. I do a lot of dual eligibles. I have to on guard all the time for poachers. People with continuous SEP's never go out of season.:D
     
    jdeasy, Oct 6, 2008
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