Dual Eligible Question

[jmarkk1]

I met with a gentlemen today to discuss medicare options. I had met previously with his wife and her sister and enrolled them in a plan already.

He is under 65, dual eligible. Currently he has AARP Preferred PDP plan, and A and B, plus medicaid.

The plan I showed him had same RX coverage, but his doctor is out of network. I explained to him that he would have to pay a portion of the out of network dr. office copay, but he would have better options when it comes to other doctors, etc. The plan does have providers that accept medicaid as in network.

I took the app, but I haven't submitted yet. I'm having second thoughts. Should I call him and inform him that I think we need to hold off on changing things until it later on when it's needed?

What about other thoughts?

 

[Josh]

You have to submit that app. The client can cancel it once it's submitted so it doesn't go effective, but you as an agent are required to submit that app.

I'm not sure how it is in Texas, but in many states, as long as the doctor he is seeing currently takes Medicaid, even if it's out of network on the Medicare plan, Medicaid will still pay out and he'll have zero liability. My presumption is that if the doctor is taking what he has now and not collecting anything from the client, it's entirely possible nothing will change, but you could ask the doctor's billing department to confirm.

My other thought, and I apologize in advance, is that carriers/FMOs do a horrible job of educating their agents about how dual plans work.

Does that help?

 

[jon25304]

I would definitly make sure what you are selling him doesnt hurt his current benefits. Are you offering him a dual eligible plan or a regular medicare advantage plan. Selling him a regular medicare advantage plan would take away his benefits under Medicaid. I would do some research before you do something the cannot be fixed with this guy. People who are dual eligible have gone through a alot of work to get Medicare and Medicaid, therefore do your research make sure it is a dual eligible plan you are offering and all his doctors participate.

 

[jmarkk1]

You have to submit that app. The client can cancel it once it's submitted so it doesn't go effective, but you as an agent are required to submit that app.

I'm not sure how it is in Texas, but in many states, as long as the doctor he is seeing currently takes Medicaid, even if it's out of network on the Medicare plan, Medicaid will still pay out and he'll have zero liability. My presumption is that if the doctor is taking what he has now and not collecting anything from the client, it's entirely possible nothing will change, but you could ask the doctor's billing department to confirm.

My other thought, and I apologize in advance, is that carriers/FMOs do a horrible job of educating their agents about how dual plans work.

Does that help?

I was trained that with the MAPD plans, if you have a dual eligible, you need to do your best to present that network doctors will allow him to have better choice than medicaid and that the network would give him same benefits as medicaid. If he goes out of network he may have to pay the difference between what medicaid doesn't pay. He currently doesn't pay for anything in the Medicaid system, and so part of me assumes that he would still have very low liability even out of network because of income restrictions.
Also, one issue that I left out is that he is planning on spending some time out of state, and I don't imagine medicaid will give him a lot of coverage options. Which brings me to a question. With medicaid, what happens if individual goes to a provider that isn't in the medicaid network?
Also, I want him to be happy and eventhough we talked things through, if he's never paid a bill before with Medicaid, I'd hate to see him pay even a few bucks with the MA plan.
We kind of left it at its worth trying and he can always go back on medicaid as primary payer if needed. The main reason I did what I did was to give him better access to doctors and hospitals and to help him with rx costs.
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I would definitly make sure what you are selling him doesnt hurt his current benefits. Are you offering him a dual eligible plan or a regular medicare advantage plan. Selling him a regular medicare advantage plan would take away his benefits under Medicaid. I would do some research before you do something the cannot be fixed with this guy. People who are dual eligible have gone through a alot of work to get Medicare and Medicaid, therefore do your research make sure it is a dual eligible plan you are offering and all his doctors participate.

The plan is a regular MA plan. He doesn't live in the dual eligible SNP area.
I did my best to help him understand the differences between his current coverage and the newer coverage with the MA plan from Anthem.
I told him I would come back and walk him through everything again once he gets his card, etc. Part of me thinks I should just submit it and see if I can wait to get paid on it after we meet. That way I don't have to worry about a chargeback, and even more importantly, make sure he's secure with the plan.
Also, as it relates to payment, if he goes in network with Anthem and goes to hospitals that are in the medicaid network, would payment for claims be processed virtually the same? In other words, if medicaid would have paid everything, is it safe to assume that it would be the same with Anthem and Medicaid/Medicare paying?
Again, the guy is under 65, on disability, on parts A and B and full medicaid.
Thx.

 

[SportsNut]

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The plan is a regular MA plan. He doesn't live in the dual eligible SNP area.
I did my best to help him understand the differences between his current coverage and the newer coverage with the MA plan from Anthem.

My understanding from Anthem Senior Agent Support is that ALL their MA plans work as a Dual Eligible SNP. You will notice on the application there is a place to indicate whether they are receiving Medicaid, and if so their Medicaid number.

You may wish to discuss this specifically with ASAS in some detail to alleviate your concerns here. What I have seen in reviewing the plans is that Dual Elig SNP folks medical providers seems that more of them accept the Regional PPO than the HMO. If you are rural you are probably already presenting a Reg PPO plan... Of course Anthem will refer you back to the county Med offc for specific answers of how the benefits will co-ordinate. Also not a bad place to call to discuss the net result of the MA plan and M'caid.

 

[jmarkk1]

My understanding from Anthem Senior Agent Support is that ALL their MA plans work as a Dual Eligible SNP. You will notice on the application there is a place to indicate whether they are receiving Medicaid, and if so their Medicaid number.

You may wish to discuss this specifically with ASAS in some detail to alleviate your concerns here. What I have seen in reviewing the plans is that Dual Elig SNP folks medical providers seems that more of them accept the Regional PPO than the HMO. If you are rural you are probably already presenting a Reg PPO plan... Of course Anthem will refer you back to the county Med offc for specific answers of how the benefits will co-ordinate. Also not a bad place to call to discuss the net result of the MA plan and M'caid.

I called his provider and discussed the billing options. They said that they do bill out of network for Anthem MA plans. This is where things begin to be a little unclear, at least in my head. With Anthem's RPPO, PCP out of network is $30 copay. The lady said that they bill Anthem first and then Medicaid. I'm guessing that client would pay a $30 copay at the time of visit or would they be billed after the fact? If they do this billing, how likely would it be that he'd have more than a $10 or $15 charge on a regular visit? especially in his case, he's 100% full dual eligible because he's a workman's comp/disability guy, and low income.
In my mind, I need to figure out if I'm actually helping him. I think he'll have a better network of doctors, etc., but is it worth switching him?
I still plan on submitting app and then going over everything with him, once he gets his packet. I did find that Humana's MA plan covers his dr. but the premium is $44/month, when compared to the $0 premium plan. Would this be a justified option to present to him later on if Anthem wouldn't work?
Also, are you aware of any real "holes" in coverage with someone that is on Medicaid and Medicare Full Eligible without a MA plan?

 

[Josh]

You're golden if that's what the provider told you and they are correct.

Medicaid is the payor of last resort, so Anthem will pay and then what she told you is that they'll bill Medicaid for the balance. If they contract with Medicaid, they can't take a nickel from the client, so to the client, nothing will change. The provider might start getting paid a different amount (more or less depending on a few factors), but you're in good shape.

If they client goes to any provider that accepts Medicaid, whether or not provider takes the MA plan is irrelevant, the client still won't have to pay anything.

If you put the client on anything they'd have to pay for you're doing the client a disservice.

With respect to the "holes in coverage", Medicaid works like a medigap policy filling in wherever A&B don't. The difference here is that if the client goes on a MA plan, usually the Medicaid plan will pay for everything regardless of whether it's a Medicare A&B coverage, or the Medicare Advantage coverage, it will fill in the gaps for both. To put it another way, no matter what the client has, Medicaid will fill in the gaps, even if it's out of the Medicare network (as long as it's in the Medicaid network), Medicaid will still pay the bill and the client will not have to pay anything (virtually 100% of the time).

Obviously you should make sure the clients RX coverage on the new formulary still has all of the same prescriptions he needs covered, but other than that you should be good to go.

Also, on that Humana plan you that you think would cost him $44, it probably wouldn't. I'm going to pick numbers because I'm not looking at the plan, but if $44/month is what the plan is for a "normal" beneficiary, then a percentage of it is in effect for the part c coverage and a percentage of it is for the part d coverage, so for the sake of discussion let's say that the part d coverage was $24 and the plan coverage was $20, the part D plan (up to the benchmark, which is an entirely different conversation) would be subsidized and the client would only have to pay for the plan portion, so in this example the client would only have to pay $20/month for the $44/month plan because of the part D subsidy.

 

[jmarkk1]

You're golden if that's what the provider told you and they are correct.

Medicaid is the payor of last resort, so Anthem will pay and then what she told you is that they'll bill Medicaid for the balance. If they contract with Medicaid, they can't take a nickel from the client, so to the client, nothing will change. The provider might start getting paid a different amount (more or less depending on a few factors), but you're in good shape.

If they client goes to any provider that accepts Medicaid, whether or not provider takes the MA plan is irrelevant, the client still won't have to pay anything.

If you put the client on anything they'd have to pay for you're doing the client a disservice.

With respect to the "holes in coverage", Medicaid works like a medigap policy filling in wherever A&B don't. The difference here is that if the client goes on a MA plan, usually the Medicaid plan will pay for everything regardless of whether it's a Medicare A&B coverage, or the Medicare Advantage coverage, it will fill in the gaps for both. To put it another way, no matter what the client has, Medicaid will fill in the gaps, even if it's out of the Medicare network (as long as it's in the Medicaid network), Medicaid will still pay the bill and the client will not have to pay anything (virtually 100% of the time).

Obviously you should make sure the clients RX coverage on the new formulary still has all of the same prescriptions he needs covered, but other than that you should be good to go.

Also, on that Humana plan you that you think would cost him $44, it probably wouldn't. I'm going to pick numbers because I'm not looking at the plan, but if $44/month is what the plan is for a "normal" beneficiary, then a percentage of it is in effect for the part c coverage and a percentage of it is for the part d coverage, so for the sake of discussion let's say that the part d coverage was $24 and the plan coverage was $20, the part D plan (up to the benchmark, which is an entirely different conversation) would be subsidized and the client would only have to pay for the plan portion, so in this example the client would only have to pay $20/month for the $44/month plan because of the part D subsidy.

In reference to what you say about Medicaid virtually paying 100% of the time....
I'm still not sure I understand the whole out of network thing. I was told that the client might have extra out of pocket if they are out of network with MA even when they go with a medicaid provider. Is this wrong? or is it if they go to a non-medicaid provider that there may be a balance owed to doctor?

Also, after some research last night....I do see an advantage of getting him out of Medicaid....it seems that everything requires some type of referral and this is never a good thing for a client needing treatment. Plus, he's gaining a much better system for health care....when compared to Medicaid's limited coverage.

 

[SportsNut]

In reference to what you say about Medicaid virtually paying 100% of the time....
I'm still not sure I understand the whole out of network thing. I was told that the client might have extra out of pocket if they are out of network with MA even when they go with a medicaid provider. Is this wrong? or is it if they go to a non-medicaid provider that there may be a balance owed to doctor?

Also, after some research last night....I do see an advantage of getting him out of Medicaid....it seems that everything requires some type of referral and this is never a good thing for a client needing treatment. Plus, he's gaining a much better system for health care....when compared to Medicaid's limited coverage.

If you are enrolling client in MA plan that is SNP you are not "getting him out of medicaid". You are merely adding a plan that becomes his primary coverage and medicaid become and pays secondary coverage.

Medicaid isn't limited coverage... it may have some limitations, but doesn't every health care plan. Certainly you are not implying that MA do not have limitations... You are merely improving ones choices, if they choose to make them, by enrolling them in an MA plan - SNP. There may be some extras that might help with transportation or more choices for eye glasses, or other such extras. This choice does not come without some risk of fouling up their healthcare needs too, since most folks who are dual eligible might not take the time or have the ability to understand what they are obtaining for health ins with the MA plan... they must know how to use it or else they could be in worse shape; (possibly).

Again, suggest that you learn more about the M'caid program from your local county.

 

[jmarkk1]

If you are enrolling client in MA plan that is SNP you are not "getting him out of medicaid". You are merely adding a plan that becomes his primary coverage and medicaid become and pays secondary coverage.

Medicaid isn't limited coverage... it may have some limitations, but doesn't every health care plan. Certainly you are not implying that MA do not have limitations... You are merely improving ones choices, if they choose to make them, by enrolling them in an MA plan - SNP. There may be some extras that might help with transportation or more choices for eye glasses, or other such extras. This choice does not come without some risk of fouling up their healthcare needs too, since most folks who are dual eligible might not take the time or have the ability to understand what they are obtaining for health ins with the MA plan... they must know how to use it or else they could be in worse shape; (possibly).

Again, suggest that you learn more about the M'caid program from your local county.

I wasn't implying that he would be losing Medicaid, but rather he would have the MA plan as primary, which gives him a better system w/o referrals, etc.

I'll contact the county medicaid office. I'm just a little confused about the whole out of network thing. In his county, there aren't a ton of PCP's that are medicaid and in network, but when it comes to specialists, etc., there are really good options.

If he sticks with his current doctor, he'll be out of network, but everything else should be fine.

All in all, wouldn't it be safe to say that he has to apply the same thought process with the MA plan to his medicaid coverage? He knows that if wants medicaid to pay for everything, he has to stay in their system, and in theory, this is the same with the MA plan.