Medicare Part A Pickle

[somarco]

Client fighting adrenal cancer for probably 5 years . . . started before turning 65. The last 2 years she has spent more time in the hospital than out. Most of her care at NIH in Bethesda.

The last admission was 5+ months ago and the hospital told her she is running out of benefit. She has used up her most recent "per admission" and gone through most of her lifetime reserve.

I have not had a client go this far into their benefit and am at a loss.

It is my understanding when you get to this point your apply for Medicaid. I suggested talking to the hospital social worker only to be told the social worker quit and they do not have a replacement.

She is still listed as a GA resident and wants to come back home (air ambulance). I told her I don't think that will work since she would be admitted for the same thing and has not gone 60 consecutive days without readmission.

This is uncharted territory for me.

Even if she qualifies for Medicaid in MD, if she moves to GA she will have to requalify here.

Is there something I am missing?

I suppose she can enroll in an MAPD plan but that won't start until 1/1/2022 still leaving a gap due to expired Part A benefits.

She is not in hospice (even though she probably should be).

If she enrolls in an MAPD will they keep her or kick her back to original Medicare?

Looking for some guidance here. Any and all suggestions appreciated.

 

[Limozine]

As long as she has A&B she qualifies for MAPD, so I'm not aware of any reason that they would or could decline her or kick her back to original Medicare. If her county of residence offers a low MOOP MAPD (some of ours here in SC go as low as $3400) then that would be the direction I'd be looking, if she doesn't qualify for Medicaid. Good luck and I hope you can help her.

 

[Up In Smoke]

Low MOOP MAPD or SNP sounds like the way to go. But to qualify Medicaid she might have to go through a spend down process if she has "too much " resources or income? Don't know if there's a SEP you can use at this moment for her situation. Never thought about it so don't know if they let you use a SEP during AEP. I don't think they can deny her coverage for MAPD. The real questions are 1) how soon can you get her one and 2) how much is the MOOP.

 

[BibH]

Can't use a sep outside mov during aep that I'm aware of . Plus its almost to late as dec here so all effective dates will be 1/1 . Lowest mops in Ga $3400( WellCare assist ) and a Kaiser at under $4k .Both HMO's i wouldn't touch. Honestly the moop means little as she sounds terminal and it probably won't be paid . I'd go with a a Aetna or United ppo as there the most lenient on services.

 

[axeman462]

I dont see any reason why MAPD would kick her back to OM, unless hospice kicks in. But I'm not convinced that MAPD is the right choice for her.

I'm not super familiar with Medicaid, as its not my target market, but that does seem to be the best choice... but does Medicaid work across state lines?

Also I'm not cofident that Medicare, or even Medicaid would pay for an Air Ambulance, just because someone wants to go home. Those are rediculusly expensive...

You didn't mention anything about a supp... so is it safe to assume she has OM only?

If thats the case, then she is almost definitely bankrupt at this point, and should qualify for Medicaid. The only question here is which state? Again, definitely not an expert on Medicaid, but probably GA since its her home state?.. But again, does Medicaid work interstate?

I also want to stray away from any D-SNP unless its with a company that has a nationwide network, in case she wants to go back to that md hospital. Straight medi/medi may be the best choice here (depending on how GA or Md Medicaid works).

As for getting her home, you might have to throw her in the back of your van. I think these MAPD companies pay these non-emergency transportation shuttles around here something like 17 cents/mile. So you might be able to make a decent check there.

As for advice on Medicaid in Maryland, or Georgia, couldn't she just go to some County Health Department?

 

[somarco]

Thanks for the responses and information.

She had an HMO prior to 65 and will never have another one. PPO might be possible, but she is very stubborn (even worse since her health deteriorated).

Her care is specialized because of her rare form of cancer. Only a handful of adults have this and she has lived longer than any of them. The bulk of her care has been part of an experimental program handled by NIH.

I have told her the idea of an air ambulance is probably out of the question. Between the med's for pain and other regimens she is more docile but sometimes less lucid. The last conversation had to be terminated due to her faint voice and monitors beeping in the background. Since then we have communicated by email.

Medicaid is a combination state and federal program administered by the state. Medicaid seems to me to be the only option for continuity of care. Any MAPD will not go into effect until January, and yes, if she is admitted to hospice it is my understanding she will be kicked back to OM and no way to get back on a supplement plan. I could be wrong, but I don't think being booted off the MAPD due to hospice creates and GI to Medigap situation.

Hospital social workers normally handle these things but it seems that is not an option. Going to a local Medicaid office is also not an option and I don't believe they make house (hospital) calls.

Perhaps @Travis Price can shed some light.

Her health has deteriorated so raplidly in the last few months and our communication has been sporadic. She contacted me about a weeks ago, inquiring about what happens when you run out of Part A benefits. As indicated, I have never had anyone in this situation so I am scrambling to find answers.

Her income is meager. I don't know about assets but anything she has will most likely be recovered by Medicaid (if she can get into the program) via estate recovery.

I don't know if admission to a hospice facility will be covered since Part A benefits have run out.

 

[axeman462]

Thanks for the responses and information.

She had an HMO prior to 65 and will never have another one. PPO might be possible, but she is very stubborn (even worse since her health deteriorated).

Her care is specialized because of her rare form of cancer. Only a handful of adults have this and she has lived longer than any of them. The bulk of her care has been part of an experimental program handled by NIH.

I have told her the idea of an air ambulance is probably out of the question. Between the med's for pain and other regimens she is more docile but sometimes less lucid. The last conversation had to be terminated due to her faint voice and monitors beeping in the background. Since then we have communicated by email.

Medicaid is a combination state and federal program administered by the state. Medicaid seems to me to be the only option for continuity of care. Any MAPD will not go into effect until January, and yes, if she is admitted to hospice it is my understanding she will be kicked back to OM and no way to get back on a supplement plan. I could be wrong, but I don't think being booted off the MAPD due to hospice creates and GI to Medigap situation.

Hospital social workers normally handle these things but it seems that is not an option. Going to a local Medicaid office is also not an option and I don't believe they make house (hospital) calls.

Perhaps @Travis Price can shed some light.

Her health has deteriorated so raplidly in the last few months and our communication has been sporadic. She contacted me about a weeks ago, inquiring about what happens when you run out of Part A benefits. As indicated, I have never had anyone in this situation so I am scrambling to find answers.

Her income is meager. I don't know about assets but anything she has will most likely be recovered by Medicaid (if she can get into the program) via estate recovery.

I don't know if admission to a hospice facility will be covered since Part A benefits have run out.

sorry, forgot to answer the question about part A:

As I understand it, if you run out of days during your benefit period, Medicare simply stops paying. The patient then gets bills. But it can be reset if you leave the hospital for at least 60 days. This is regardless of lifetime reserve days.

Life time reserve days are simply to extend the ability to pay the hospital if you are in there longer than 90 days.

This all being said, you may want to ask her what MAPD plan she is on, and look into the evidence of coverage. I don't know how rich the benefits are in GA, but there are some plans here in Florida that specifically say the patient can have an "unlimited amount of days" [in the hospital]

 

[axeman462]

Just thinking about this case again..

If she contacted you specifically asking about Part A running out, then my guess is that she was recently informed by the MAPD that they will soon stop paying.

If thats the case, then theres litterally nothing you can do, except pay the bills for her, or push her to Medicaid.

At this point the hospital will just have to write her bills off as charity, or assist her getting Medicaid.

The more I think about it, the more Medicaid seems to be the answer for her.

 

[somarco]

@axeman462 she is on OM + Medigap. Never on MAPD. She was a KP client of mine for several years before T65. She has gone past 90 days in the hospital and is eating away at her lifetime reserve. Hospital and her docs (on staff at NIH) informed her she is almost out of benefit. She has been in ICU almost 5 months . . . no way she can stay out of the hospital long enough to reset Part A coverage.

 

[Up In Smoke]

I can confirm as well many MAPD that I see now specifically say they cover unlimited days of inpatient hospital stay. If not MAPD or SNP, then straight-up Medi/Medi can be the option? A few weeks ago I actually met a lady who has both Medicaid and Med Supp with Mutual of Omaha. I was baffled that she has both. I remember reading it on a GOV site where it says it is possible, but I really don't know how to go about that route.