My 92-year old mother who has dementia has been approved for Medicaid Star-Plus Waiver to receive in-home care beginning Jan 1, 2019. However, her Medicare will also change to Medicare Advantage, which is an HMO, so she will lose her doctor. Is there a way to keep her regular Medicare and still receive in-home care paid by Medicare or Medicaid? I am at my wits end trying to get answers from Medicare and Medicaid, to no avail.
It sounds like Chynabelle's problem is her mother changed her Medicare plan and the current doctor won't take the new Medicare plan. Medicaid services in the home has nothing to do with it.
Depending on the state you live in rules may vary.
So, let's say the Dr charges 60 + a 10 co-pay normally, but if he/she accepts medicaid and medicaid will only pay 11 than the Dr only gets the 11 & the Dr can not charge you the difference or co-pay this is why some many Dr's don't accept medicaid!
Now, medicare pays 80% of the Dr's visit & can bill you the remaining 20% with the co-pay.
Bottom line: medicare gets billed first so, they pay 80%, than medicaid gets billed the rest of the 20%, but medicaid won't pay the full 20% and the Dr cannot charge you the remaining fee or a co-pay.
Therefore, your mom's Dr probably doesn't participate with her Medicare or Medicaid plan.
And if your mom has an HMO plan that just means your mom's Dr is not participate with HMO plan.
I hope I didn't confuse you to much. Feel free to call your mom's Dr's office someone their can answer your questions.
Good Luck.
"Waiver Description. This waiver allows elderly Texans, aged 65 or older, that require a nursing facility level of care, to reside at home or in assisted living residences and receive care services in those locations. Under STAR+PLUS, both medical care and non-medical long term care services as covered.Feb 1, 2018"
So from how I read this she is getting Medical which means she uses Medicaid doctors.
Chynabelle, why don't you call Medicaid and run by them that Mom would like to keep her present doctor. Is there a way that if she isn't allowed to pay, maybe you can.
The name is deceptive and it causes lots of confusion.
Why? ..... this is gonna be long, get a cup of coffee.....
To me, the “wits end” issue is your not speaking with the service provider for her new star plus waiver. It’s not MediCARE (CMS) or state of TX Medicaid per se but insurance contractor who is managing waiver she signed up to be on starting 1/1/19. Look to see if her new plan is with “Superior Health” (if not Superior it’s another group like them).
They are the big BIG player for Medicaid waivers in TX. Their HQ is in Austin. & they do all types of Medicaid waivers, like they have health providers and programs from kids on CHIP (medicaid for kids from low income families) to at home health services for elderly.
It runs on an “Advantage“ program model for Medicare in that in order for your mom to have coverage with no or low copay she MUST ONLY see the providers & facilities in the Superior network as they are under contract with Superior at predetermined rates of reimbursement. Advantage model is similar to an HMO but true HMOs (like Kaiser Permanente) requires you to be part of a group / employer in order to belong to the HMO; for Advantage anyone eligible for Medicare can enroll in the Advantage plan if available in your area. The vibe I’m getting for a Superior is they are using the Medicare hospice system for elder care in that there is an overall MD group that that evaluates and determines care needed or uses the state’s needs assessment on her to determine what level of in home services she’s requiring (like say she’s assessed at 23 hrs a week of caregiver). But the actual boots on ground (in your mom’s case boots in the house as it sounds like in home care) will be done by NP, or maybe PA, on the once or twice a week in home visit and all other care done by CNAs. Whatever service needed has to be done by the best way to contain costs within the existing network which means services only with providers under contract and an NP or PA is lots less $$ than an MD. If your mom is the type thats used (& likes) to going every mo or 8 weeks to her old MD office, those days are over. She only gets to get an MD appointment if the weekly NP/PA assessment shows need; and the MD will be at the clinic or health care system contracted with Superior.
Your mom seeing her old MD, if he’s not with the Advantage plan will be totally out of network AND cannot be at all billed to either MediCARE or Medicaid; it will be truly private pay. Unless her doc has moved to “concierge” model to bill, his office will be befuddled to even figure out how to bill to your mom. Plus this downstreams to payment on lab work done, therapist seen, RXs filled.....
Google Superior Health Plan, HQ on Ben White in Austin, they have a good website that gives an overview of how it runs. It’s pretty tight. Their all over TX. If she’s not with Superior again it’s going to be another Advantage plan like Superior. As an aside, I wouldn’t be surprised that they have a model to take over services at SNF & that will be the final nail for smaller NHs already struggling to stay open in TX.
My mom (dead a couple of years now), got a raft of letters from a bunch of her old old MDs at beginning of 2018, notifying her of new alignment with various MediCARE Advantage plans OR that they were leaving their old medical group effective 1/1/19. Letters literally sent to patients going back a decade.
Did you ask what her old MD participates in?
Your moms old MD might be affiliated with another Advantage plan, but not with Star Waiver. Or old MD might not do any advantage plan but only take original MediCARE & gap supplemental.
Out of curiosity, why go the in home waiver system?
Why not go for SNF / NH onto Medicaid placement for your mom?
We also had an Aging Life Specialist help our elderly parents go through their options for insurance. She was a big help because she was aware of all the ifs, buts and ands associated with the policies. She did not tell them which one to pick but she made sure they were aware of the benefits/deficiencies of each.
How are you not all fit to be tied?
How the heck does anyone in America ever know what doctor they're supposed to register with and to whom they're supposed to hand their wallets?
I suppose it's out of the question for Chynabelle's mother to retain this doctor privately, for old times' sake? - if the family were able to afford his fees, perhaps.
and it’s going to only get much worse when the tsunami of boomers start hitting needing care AND LTC facilities in big #s in about 5 years. It’s going to be beyond awful for Aging in America unless your really wealthy. Like top 25% on a NY, MA level. As a health planner last millennium I flat cannot believe we are abt to hit 2019 and folks in the US cannot understand what single payor is much less why it needs to be done. It’s not ideal but at least it’s a standard framework.
If I recollect correctly the maximum that SS will pay for ‘19 for folks who do FRA is $2,861 and about half new retirees will get paid the max as they worked during the boom years so have big SS entitlement due. So none of these will ever, ever, ever be able to be eligible for LTC NH Medicaid like our parents have been as our folks get $800-$1500 SS so under the Medicaid eligibility max of abt $2100 mo income.
Just where are the boomers supposed to go to live and get care?? Their not ever to be eligible for Medicaid. Care in their kids homes, yeah sure and I’m getting into my size 6 slacks again.
If you have a good employer sponsored plan in the US, it’s actually pretty straightforward if your in a big city to get care with somewhat manageable copay. Like for us in New Orleans, we have 3 competing health systems. But if you live out in the country, there’s no real options. When hubs had day surgery, waiting room filled with folks who had to drive in 2+ hours as no surgery center for what they needed that was covered by their plan. and those with experience knew to bring phone chargers, pillow, blanket and snacks. It was like a bad airport terminal situation.
We’ve been thinking Uruguay (you guys have a British hospital there with a expat plan that’s pretty great & comprehensive) ...... plus its young demographic country so probably won’t be quite so peeved with old foreign retirees as neighbors.
https://www.medicareresources.org/faqs/can-i-be-enrolled-in-medicare-and-medicaid-at-the-same-time/
I have seen so many instances of older people being forced to switch doctors (either for convenience sake or because of insurance) and EVERY time they wind up being healthier and (therefore happier). Often, no matter how well-intentioned and beloved a person's current doctor is, a fresh look from a new doctor can result in adjusting meds and re-evaluating diagnoses. American seniors are often over-treated and that means lower quality of life.
I really don't understand Medicare Advantages and have chosen to stay with BC Traditional as our suppliment. We get this thru my husbands former employer. My DH pays a small amt monthly for me. I rather do this then go thru some of the stories I have heard about MAs.
As I said before, my nephew has Medicare as his primary and medicaid as secondary. He signed up with a local clinic that handles medicaid. On full Medicaid, which he had bf SSD, he had to go to a medicaid doctor. Once he was on Medicare medicaid is now his supplimental. Nephew doesn't like the clinic, wait can be hours. He had a PCP he went to prior. Since he was now Medicare, the doctor agreed to see him. Nephew to pay any balances. So, far, nephew has paid nothing. Dr maybe eating the balance.
What I am saying here, call her doctor. See if he can work with the MA insurance. If not, then to get Mom help, you will need to switch. If she was in a NH on Medicaid you would have to do the same thing.
Also if you are on both Regular Medicare and Medicaid ( even Managed Care), then Medicaid IS your Secondary....so it is similar to Supplemental Insurance.
MEDICARE will pay for at Home OT, to determine need for assistance in bathing, services to train/ determine need for assistance with Toileting, Cooking, Cleaning.....then you get switched to self pay, private insurance, or Medicaid Waiver to cover ongoing in home services.
Regualar Medicaid, Medicare, or Supplemental Insurance won't pay for housecleaning, even if they determined you need that help. They won't cook, pay for Meals on Wheels, sit and play cards, etc.
Medicaid Waiver Services pay for these as is medically necessary to keep you at home, not in NH!!
If mom wants the Star + Plus waiver, she can only choose from those in the Star+Plus waiver group. There might not be many choices.
I’m concerned that if mom didn’t realize she cannot see her old MD if she goes onto the waiver, there might be a whole bunch of other things mom doesn’t realize happens by being on this waiver......
I’m guessing this waiver is approved as her mom has been assessed to need SNF aka a NH but instead of being in a NH, takes the waiver to get “in-home” care instead as mom wants to stay in her home. Chynabelle & her mom need to quickly figure out IF the care that the waiver will provide will actually give her mom the coverage needed in her home. Waiver is not ever going to be 24/7 oversight like living in a NH does but more likely 3 days a week CNA and within 1 of those days a NP or PA visit. MD at home or in office visit rarely. Family is totally responsible for caregiving all ALL all the rest of the time.
If they didn’t realize there’s required doctor changes, they might not realize the required by family coverage needed aspect of the waiver.
Where we are there’s a PACE Center nearby (the Benson Center), it’s a day care center waiver program for those assessed to need a NH but want to stay at home. Most go to the Benson 2 or 3 days a week & all health care has to be done within the provider network affiliated with this PACE. There are exemptions for true emergencies for out of network. If there’s stuff needed at a hospital, the PACE coordinates it. They do transportation too. Catholic Charities is the administrator for this PACE. Basically everything medical has to be done via PACE. If not, it’s totally out of network and not covered at all by either Medicare or Medicaid. Benson is lovely, folks & staff seem happy and often outside when I’ve driven by. But unless elder has family to do & be there for all the other nonPACE days, it flat cannot work & they need to be in a NH.
Dual Eligibility is the key terms here.
My suggestion:
As you live in Dallas, you can call the North Central Texas Area Agency on Aging and speak to someone in Information & Assistance or ask for a Benefits Counselor. They probably have a deeper understanding of how Medicare works with the Medicaid programs available in Texas.
I am in Iowa. I have Medicare, Medicaid went to MCO 5 days after I moved here. Got to top of list for Medicaid Waiver in April, started getting those services in late September.
Medicaid Waiver is not the same as Medicare Advantage!!! I was assigned to have Medicaid Waiver through my MCO ( Medicaid Managed Care Organization).
Many doctors offices think they won't get paid, or won't get co- pay if they are not in MCO group. Wrong!
I am disabled, 61, if Medicare doctor or Service provides Medicare Approved Service My Medicaid MCO will pay balance! They do not have to be in network.
Note: Medicare has strict limits on number of sessions of OT, PT, Speech, ect. In your lifetime. So at home care may have to go to Medicaid Waiver Assigned Provider....But that should not change PCP or Specialist, unless you chose to change to MEDICARE ADVANTAGE...which is different!
If you choose MEDICARE ADVANTAGE, you can switch back during Open Enrollment, or Jan 1 - Feb 14 of first year it I effect. Then hope her doctor still takes her on as a patient.
If you go on Medicaid because of low income alone... Don't have Medicare of any sort, and your state has Managed Care Medicaid, you would have to stick with in Group doctor.
Since you have MEDICARE.. regular...no need to change doctors. When I had private insurance NH tried to make me switch to their in house doctor. They couldn't require Me to switch. I had to take their can and see my doctor at her office. After hours ambulance to ER.. getting back to NH late was an issue.
I just looked this up on HHS.Texas.gov! Like me, she is Dual Eligible!!! So let me give concrete examples:
Medicare can cover:
- OT, PT, Speech/Swallow Therapy, RN, even going to a Chiropractor, your Specialist
Medicaide Waiver cover:
- light housekeeping
- Respite Care- Companionship
- Cooking - Running Errands
In IL
Medicaide will pay for Accupuncture
Medicare will cover
Chiropractor
Medicaide Waiver ( mine is with MCO) helps with
bath, clean and organize to make home safe, grocery shopping, take me to doctor, pick up RX.
I hope this helps!
Star + Plus will pay for family caregivers but not for spouse caregiver. There is a waiting list & current in a NH residents given priority to get the waiver.
The LTC room & board charge isn’t covered by Medicare; R&B is paid by Medicaid. But within this there is stuff in their room, like O2, ,pneumatic mattresses, wound care supplies, that are getting paid by the M&Ms.
Programs kinda need participants to be duals so they can be assured of getting paid AND vendors know how much to charge for supplies aAND also know what type of staffing is needed. Like right now the day centers & NH have likely already had extra NPs or PAs to get the over 65 flu shots done.
Btw for anyone reading this, if you’ve got family in AL MC, NH, please in addition to the flu shot get the pneumonia shot. And yeah the pneumonia is a total witch of a shot but it provides a safety herd immunity to both you, and your elder in the NH and all the residents there. It’s good for like 10 years! Also Target in my area is giving $5.00 gift cards if you get your flu shot there......