Would share of cost medicaid pay in this situation?

[Special Agent]

MA member is in SNF and her MA is not approving beyond 11 days if she stays additional days without approval from MA would share of cost still pay? I know if it was approved and went beyond 20 days share of cost would apply on both original medicare and MA but didn't know if would apply in this situation.The facility takes medicaid and her SLMB share of cost is about 1400.00

 

[DonP]

No share cost won’t apply . Ma is only approving 11 days . Slmb is not cost sharing Medicaid . Basically slmb just pays her part B premium and allows her to get a better benefit plan with a food card and dental . The medical plan is no better than most mapd regular plans . After 11 days she’s on her own . If she had a med sup and orginal Medicare she’d pay nothing

 

[rmhaire]

MA member is in SNF and her MA is not approving beyond 11 days if she stays additional days without approval from MA would share of cost still pay? I know if it was approved and went beyond 20 days share of cost would apply on both original medicare and MA but didn't know if would apply in this situation.The facility takes medicaid and her SLMB share of cost is about 1400.00

The first thing to remember is that she is dealing with an insurance company and not Medicare.

The second thing is that she's dealing with SNF rules and not the hospital.

And third, you need to provide more information before we can help with your question.

Until then here's the short answer. She basically has two short term options. File an appeal, apply for Medicaid or both. Again either of these will only buy her a short period of time.

Nursing Home Surprise: Advantage Plans May Shorten Stays to Less Time Than Medicare Covers - KFF Health News

Private Medicare Advantage health plans are increasingly ending coverage for skilled nursing or rehab services before medical providers think patients are healthy enough to go home, doctors and patient advocates say.

kffhealthnews.org

 

[Special Agent]

The first thing to remember is that she is dealing with an insurance company and not Medicare.

The second thing is that she's dealing with SNF rules and not the hospital.

And third, you need to provide more information before we can help with your question.

Until then here's the short answer. She basically has two short term options. File an appeal, apply for Medicaid or both. Again either of these will only buy her a short period of time.

Nursing Home Surprise: Advantage Plans May Shorten Stays to Less Time Than Medicare Covers - KFF Health News

Private Medicare Advantage health plans are increasingly ending coverage for skilled nursing or rehab services before medical providers think patients are healthy enough to go home, doctors and patient advocates say.

kffhealthnews.org

she has medicaid that will pay everything IF her share of cost reaches 1400.00 within the calendar month-the SNF wants to start charging her the full 500 per day because her MA plan didn't authorize additional days so she would meet her share of cost in 3 days- the question is is there any reason why this couldn't be submitted to medicaid

I have personally helped SLMB people who had a share of cost ( all SLMBs have a dollar amount of share of cost which is roughly calculated by subtracting 200.00 from their income ie 1600 monthly income your share of cost is 1400 for the month) submit claims to medicaid and all was covered IF provider they used accepts medicaid.Just wondering in this case if there would be any pushback since the MA plan didn't authorize additional days of SNF.

 

[DonP]

The first thing to remember is that she is dealing with an insurance company and not Medicare.

The second thing is that she's dealing with SNF rules and not the hospital.

And third, you need to provide more information before we can help with your question.

Until then here's the short answer. She basically has two short term options. File an appeal, apply for Medicaid or both. Again either of these will only buy her a short period of time.

Nursing Home Surprise: Advantage Plans May Shorten Stays to Less Time Than Medicare Covers - KFF Health News

Private Medicare Advantage health plans are increasingly ending coverage for skilled nursing or rehab services before medical providers think patients are healthy enough to go home, doctors and patient advocates say.

kffhealthnews.org

she has medicaid that will pay everything IF her share of cost reaches 1400.00 within the calendar month-the SNF wants to start charging her the full 500 per day because her MA plan didn't authorize additional days so she would meet her share of cost in 3 days- the question is is there any reason why this couldn't be submitted to medicaid

I have personally helped SLMB people who had a share of cost ( all SLMBs have a dollar amount of share of cost which is roughly calculated by subtracting 200.00 from their income ie 1600 monthly income your share of cost is 1400 for the month) submit claims to medicaid and all was covered IF provider they used accepts medicaid.Just wondering in this case if there would be any pushback since the MA plan didn't authorize additional days of SNF.

Never heard of slmb clients ( which is partial Medicaid) having any cost sharing bills paid by Medicaid . That must be specific to your state . Anyway Medicaid to a mapd is like a med sup to orginal Medicare . The mapd carrier must approve the charges for Medicaid to pay any . No different than orginal Medicare must approve charges for a sup to pay any .

 

[Special Agent]

Never heard of slmb clients ( which is partial Medicaid) having any cost sharing bills paid by Medicaid . That must be specific to your state . Anyway Medicaid to a mapd is like a med sup to orginal Medicare . The mapd carrier must approve the charges for Medicaid to pay any . No different than orginal Medicare must approve charges for a sup to pay any .

it is actually called Medically Needy and in Fl ( and i believe most states have this) you can qualify if you have medicare or disabled no matter what your income is as long as your assets are under the limit.I have seen people who make over 3000 a month have medically needy status.

Fun fact if your state has medically needy program and you are verifying medicaid a person who has SLMB may show to have full medicaid if they have met their share of cost for the month on the day you verify but then that resets the beginning of the next month back to SLMB


Medically Needy (No Income Limit)Medically Needy Income Level (MNIL)Full Community Medicaid when Share of Cost is met Subtract $180 from gross income

https://training.floridashine.org/Website_Resources/SSI%20CHART.pdf

 

[rmhaire]

Never heard of slmb clients ( which is partial Medicaid) having any cost sharing bills paid by Medicaid . That must be specific to your state . Anyway Medicaid to a mapd is like a med sup to orginal Medicare . The mapd carrier must approve the charges for Medicaid to pay any . No different than orginal Medicare must approve charges for a sup to pay any .

Sounds like he's describing medicaid spend down. And that's never a good thing.

 

[Special Agent]

Sounds like he's describing medicaid spend down. And that's never a good thing.

How could it be a bad thing to have share of cost stop gap with original medicare or an MA plan? I am open to learning new things what am i missing?

BTW a medicaid spend down only refers to qualifying for Institutional Medicaid for nursing home

 

[DonP]

I’m not going down those roads . I’m not a social worker . My job is to find you the best plan based on your present situation. I already feel like a ping pong ball with people going back and forth between having Medicaid then losing it and then getting it

 

[Special Agent]

I’m not going down those roads . I’m not a social worker . My job is to find you the best plan based on your present situation. I already feel like a ping pong ball with people going back and forth between having Medicaid then losing it and then getting it

So if you have a client of 15 years who is already enrolled in plan and finds themselves in a situation and they reach out to you for help you won't explore whether or not their share of cost will help them?

I will call the the SNF and talk with the admin tomorrow ( they are always taking people on and off MA and applying for medicaid for patients so they may know answer) but kind of disappointed an agent can't come on this forum to get input on one off situations.You sell enough MA plans you are going to run in to situations.