Client in SNF for Rehab, Will Go to Nursing Home, Change MAPD?

[yorkriver1]

Just had my first client go into SNF. The facility told client's family that Medicare pays better than the MAPD. That's true for days 8-20. About $600 total, at $50/day. Can't fix that now. Same rate as Medicare days 21-100. The bigger question for me is, what does the agent do when the person goes into a nursing home. I just read on Medicare.gov that the nursing home will have a long term care pharmacy contract, so find a plan that works with them. is that always true? My question is, would my client keep their current MAPD, which does mention the long term care pharmacy benefits, or need to switch to another MAPD, maybe a SNP for institutions. I am not aware of any that agents can write in my area. I had called to review their plans for 2015, and was told of the unfolding events. So far, they are planning on using assets, not applying for Medicaid. I understand that there is no coverage for custodial/LTC care costs on Medicare or Medicare Advantage, just to clarify. We are talking about the special medical and pharmacy benefits for the situation, and I know there is a SEP/Institution ongoing, like LIS, Medicaid, etc.

 

[Bob_The_Insurance_Guy]

Do yourself and the client a favor, and get them in touch with an Elder Care Attorney.

The water is only going to get murkier from here.

 

[yorkriver1]

Do yourself and the client a favor, and get them in touch with an Elder Care Attorney. The water is only going to get murkier from here.

Good point. They do have an attorney, who is helping with planning, and they have their reasoning worked out for what is happening. My concern now is to get the best fit for medical expenses. I just checked, and there are no I-SNP MAPD plans in the area. The choices will be, the current MAPD/HMO or another carrier's HMO, or return to Original Medicare and a drug plan. It occurs to me, since this is a new situation in my relatively new client base, how does their relationship with their current doctors and specialists change when entering a nursing home? That would be important to know when choosing a plan, are the docs they will be seeing in the network.

 

[bluediamond]

I don't see why they would have to change anything unless they were unhappy with the payments the first 20 days. No one cover's custodial care after 100 days unless they have a LTC policy.

I would not see any reason their relationship would change with current provider's just because they are in a nursing home.

 

[Bob_The_Insurance_Guy]

I don't see why they would have to change anything unless they were unhappy with the payments the first 20 days. No one cover's custodial care after 100 days unless they have a LTC policy.

I agree. Hopefully, when you went through the Summary of Benefits, you explained to them that, even though there are some benefits for facility care, this is NOT a Long Term Care insurance plan.

Though it may tug at your heart, as it would mine, I would leave them where they are. If there is a legal loophole for their situation, that is for the attorney to find, not you.

You have done as much as you can.

 

[midwestbroker]

I worked with numerous nursing homes when I was an agent with UHC selling Evercare Institutional plans. Here is what I discovered:

Nursing homes do not like, for the most part, MAPD plans. Their therapy payment / billing is different than Medicare's, and usually pays the facility less. Plus, the therapy department in most cases would rather just deal with Medicare direct and not a private insurance carrier.

Once a person is admitted into a nursing home for residential care, they are usually seen by the medical director for the facility, and not usually seeing their primary care physician any more. So, the doctor has to be in network as well.
Some states will allow someone on Medicaid to continue to use their Medicare supplement, and the billing office for the facility (if they are smart) will take the premium for the supplement and have it subsidized by the state Medicaid program. No facility wants to bill Medicaid, and Medicaid does not usually want the bill. So, they will have original Medicare, their supplement, and Medicaid, which never gets billed as Medicaid is always the last payer to be billed. So, after Medicare and the supp pay, there is nothing left for Medicaid to pay. This is not an option with MA plans.

As for the Medicaid spend-down and getting an estate lawyer involved, that is the best way to go. Each state has their own unique rules and regs for Medicaid, having a professional lawyer who specializes in Medicaid can save your clients lots of chaos. Plus, as an agent, they are a good person to network with.

Hope this helps...If you want to know what the facility really thinks of MA plans, talk to the business office manager or the admissions department. They are typically the ones who deal with the carriers the most.

 

[kstein]

I agree with Midwest 100%. I explain it like a glove on a hand. The mapd has preferred vendors for blood work, PT, medical care, rx refills, places/ways billing needs to be handled.

The nursing home has the same needs but often different preferred vendors and it is rare that they all match up perfectly. These friction points are the problem, not the "copay" aspect of the first 100 days. On mapd its rare that you get to 100 days anyways as they usually stop coverage before then.

With original medicare, they tend to allow the nursing home the flexibility to do what they want (as far as vendors and ease of billing).

If you try to argue the out of pocket side or coverage angle of mapd v original medicare (ie the oop max) you will lose and the nh will help facilitate the disenroll. Its better for you to be proactive about it and maintain the relationship. In fact admissions of ltc facilities are great referral sources.

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On a similar vein has anyone had success with people who are on original medicare only (BC they needed the 100 days and the mapd wouldn't allow it so the client went back to original medicare). Now the 100 days are up and the person is magically ready to leave. Many times the admissions will reenroll the client into the same mapd via med.gov.

Basically this is a nice sep niche as this happens through the year and if your in front of the LTC facility, you might get the call to find the best mapd plan rather than just assuming the previous plan is best. Thoughts? Also is you have a GI med sup (like omaha N of previous years) you are a god to ltc facilities.

 

[bluediamond]

While I agree with midwest for the most part and yes a medical director will partially be responsible for their care I have had two personal experiences in the past 4 years and both that were in nursing homes were taken by the nursing home to their regular doctor appointments.

MAPD plans (if in network) have to cover what Medicare cover's and pays ie, 100 days in SNF.

But to OP I would step away and let an attorney and family handle this situation.

 

[yogooglethis]

Just had my first client go into SNF. The facility told client's family that Medicare pays better than the MAPD. That's true for days 8-20. About $600 total, at $50/day. Can't fix that now. Same rate as Medicare days 21-100. The bigger question for me is, what does the agent do when the person goes into a nursing home. I just read on Medicare.gov that the nursing home will have a long term care pharmacy contract, so find a plan that works with them. is that always true? My question is, would my client keep their current MAPD, which does mention the long term care pharmacy benefits, or need to switch to another MAPD, maybe a SNP for institutions. I am not aware of any that agents can write in my area. I had called to review their plans for 2015, and was told of the unfolding events. So far, they are planning on using assets, not applying for Medicaid. I understand that there is no coverage for custodial/LTC care costs on Medicare or Medicare Advantage, just to clarify. We are talking about the special medical and pharmacy benefits for the situation, and I know there is a SEP/Institution ongoing, like LIS, Medicaid, etc.

"The facility told client's family that Medicare pays better than the MAPD. "


But what the SNF doesn't tell the patient or family is if the SNF is par with the ma plan, which it should be if they were sent there, is that the exposure under original medicare is 80 days at 150+ dollars or over 8500.00 whereas all ma moop must be 6700 or less.They also don't tell the family that sometimes SNF will game the system and find a way to readmit the patient to a hospital for 3 days so they can get medicare to pay 100% for the first 20 days all over again - this is something that may not be in the patients best interest but helps the bottom line line of the corporations that own these NH and SNF.Also nursing homes with SNF units have been known to " skill " their residents for dubious medical reasons if the facilities SNF patient to custodial care residents ratio falls below a certain level .This requires them to send the resident for a 3 day stay at local hospital first, so they can move them down the hall to the SNF wing so then they collect over 500.00 a day from medicare for SNF services for a resident they where receiving 100.00 a day from medicaid a custodial resident .The additional cost for the facility to provide the elevated level of care that is required of a SNF is very minimal above the fixed cost the NH is already spending on housing the resident under custodial care so it is a big profit center for these facilities...I bet you won't find very many nursing residents who come back from a hospital stay that were inpatient less then 3 days


Almost always when a ma member goes in a NH for custodial care they are going to be better off on original medicare because the majority of people who do go in NH will qualify for IP medicaid .As far as the LTC rx benefit i believe that is a non issue because all PDP plans have to make accommodations for that.

 

[Chazm]

SNF always tell them that IMO. Had a client call me last week. Her husband was in the hospital for 17 days, stroke, and was approaching day 20 in rehab. They suggested he go back to original medicare for days after 20 because UHC was going to cost him $152/day now. I informed her it's going to be the same with medicare as of now. They aren't that bright