Would share of cost medicaid pay in this situation?

[DonP]

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.

Yes if they came to me I would on long term client . Honestly I’ve not run into this yet . 95% of snf’s are pulling them off mapd to original Medicare if this happens

 

[rmhaire]

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

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

Sorry. Didn't see anything in your original post saying she was on medicaid. That may change things. I don't sell in FL so I don't keep up with the medicaid laws down there.

Medicaid spend down can apply to pretty much anything. Not just nursing homes. Such as monthly income and resources.

Since your client is already on medicaid, applying for it is obviously not the solution. But an appeal might be.

I'd suggest appealing both the medicare advantage decision and with medicaid. That might buy her enough time until she can get this sorted out.

Good luck

 

[AgentGeneral]

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's not always so black and white. Just an example here in Mi....medicare doesn't cover weight loss drugs like wegovy for weight loss, Medicaid here does. I have duals on Wegovy for only weight loss, no diabetes, it's covered by their Medicaid only.

I know this isn't the same thing as dealing with SNF, but theres that, and plenty of other examples, mostly to do with meds or DME.

 

[Chazm]

I’m in Fl and if a client of 15 years called me about this situation, I’d let them know they have two options.
Number 1 is to file and appeal. If that doesn’t work, they need to go back to OM and they’ll get up to day 20 for free. But, the plan won’t be dropped until the 1st.

 

[straightnochaser]

There is no cost share protection with SLMB -

It's not always so black and white. Just an example here in Mi....medicare doesn't cover weight loss drugs like wegovy for weight loss, Medicaid here does. I have duals on Wegovy for only weight loss, no diabetes, it's covered by their Medicaid only.

I know this isn't the same thing as dealing with SNF, but theres that, and plenty of other examples, mostly to do with meds or DME.

Med's/DME not covered by medicare can be covered by medicaid, if a service is covered by medicare, medicaid will only pay if medicare/mapd pays first.

 

[Special Agent]

I’m in Fl and if a client of 15 years called me about this situation, I’d let them know they have two options.
Number 1 is to file and appeal. If that doesn’t work, they need to go back to OM and they’ll get up to day 20 for free. But, the plan won’t be dropped until the 1st.

Yes going back to OM is in play for 4/1 and she has filed an appeal just wanted to see if anybody had any experience with a medicare beneficiary submitting claims to medicaid for medicare covered services that was not authorized by an MA plan.I was hoping to get some information here (are there other recommended medicare agent forums out there i should be checking?) because medicaid is impossible to reach on the phone and in Fl medicaid will not even allow an agent to be on a 3 way call with a beneficiary.

In theory it seems like it should be ok based on the Fl medicaid info

file:///C:/Users/allhe/Downloads/i165-70-adobe11.pdf


Submit any allowable unpaid or paid medical expenses to DCF to determine if the share of cost has been met. Once the allowable medical expenses equal the share of cost, the individuali s eligible for Medicaid for the rest of thatmonth.Example #1: Your share of cost is $800. You go to the hospital on May 10 and send us the bill for $1000. You have met yours hare of cost. If the provider accepts Medicaid, that bill will be paid and you will be eligible for Medicaid through the end ofMay.Example #2: Your share of cost is $800. You go to the hospital on May 10 and receive a bill for $750. On May 12 you go to the physician and receive a bill for $150. You send us both bills.Your share of cost was met on May 12th because the total of the two medical expenses were more than the amount of your share of cost. If the provider accepts Medicaid, the May 12thbill will be paid and you will be eligible for Medicaid through the end of May.