MAPD for young disabled client question

RunnerDude

Super Genius
181
I am a SC agent, and have an extended MAPD enrollment period until 12/31 due to an SEP for recent weather conditions. I have a 36 year old disabled client with Medicare parts A and B- who also has extra help through Medicaid fo medications and. Part B premiums. In addition to her local specialists, she also sees specialists in other states. I am currently contracted with Humana, WellCare no UNH. I am trying to sign her up for a MAPD plan, but am unsure which one will suit her needs best. I am concerned that she may not get coverage for out of state coverage if I change her from original Medicare to an MAPD. Does anyone have any advice?
 
It's VERY unlikely there is care out of the network. You didn't state if it's an HMO or PPO but since she's on Medicaid there is little need for any MA plan in his area. The out of network cost for a PPO would kill him.

I'm not sure if she's better off staying where he is and paying the 20% when he's out of state. Since he has Medicaid what benefit would any MA plan do for her.

As you should know, those with LIS and/or Medicaid have no enrollment period and have a year 'round SEP in or out of an MA.

If you want to discuss this send me your phone number via PM or email.

Rick
 
Actually, the client is not on full Medicaid- but does get extra help with prescriptions and Part B premiums (so does not qualify as dual eligible). The plan I was considering is WellCare PPO Prime.
 
Actually, the client is not on full Medicaid- but does get extra help with prescriptions and Part B premiums (so does not qualify as dual eligible). The plan I was considering is WellCare PPO Prime.

She still has a LIS so can change plans anytime. Will she pay more out of network than she is now?

There's more to this then just asking what the best plan might be. A more important question is will you be causing financial and medical harm moving her into an MA plan.

Rick
 
Yea- that's the point. For the most part she sees MD's in network - but I know she has at least one big surgery out of state. Maybe I should just advise her to stay with original Medicare until after the surgery - and look at it again then. The bill from the surgery might put her on full Medicaid anyway.
 
Yea- that's the point. For the most part she sees MD's in network - but I know she has at least one big surgery out of state. Maybe I should just advise her to stay with original Medicare until after the surgery - and look at it again then. The bill from the surgery might put her on full Medicaid anyway.



I believe in order for the bills for the surgery to count towards her share of cost she would have to use providers who accept medicaid in her resident state.
 
Good point- but it seems wrong to leave her with original Medicare- it is possible that the out of state hospital will bill WellCare for their money -she has medical issues and may need the coverage at home-
 
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