Dual MA Vs Medicaid

[midwestbroker]

From what I understand, a doctor can see a dual eligible beneficiary even if the doctor is not on the Medicaid network, they just cannot balance bill for the remaining balance after Medicare's payment. Does this happen? I know I have had dual clients who continued to use providers that were not on Medicaid's network, but how would Medicare know unless they started digging, and what does Medicare care if the provider is getting paid anything beyond the 80%...

 

[kennethbroyles]

FYI... In TN 2015 if your a "Duel," not on a DSNP, you will be auto-enrolled into one of the 3 MCO's for "TnCare." A lot more to be said on this subject but I'm taking some time off.

 

[aheff]

So the real question is, "what is the purpose of a dual eligible special needs plan?" There is none in my opinion other than the agent trying to get paid a commission.

I mean, maybe there will be some transportation benefits or a gym membership, or some dental if that state's Medicaid program doesn't cover dental, but you are giving that dual eligible a network of doctors.

However, the dual eligible can go in and out of plan as they wish, so I guess it is okay if the agent is looking to have lots of chargebacks.

Medicareguru- You really need to step outside of your bubble! Most duals are piss poor. Having a transportation benefit to some may mean the difference between seeing a doctor vs not seeing a doctor. Extra dental coverage may mean all the difference in the world to a dual (saving a tooth, reducing pain substantially). Coordinated care may very well save a dual's life. Having free OTC medicine may mean having cold medicine or other needed stuff or not having them. A dual plan may pay for a bathroom modification. To many of us, these may not seem like a lot; but to some duals, some of these benefits are incredibly important. To many duals, these lifelines far outweigh the negative of network. Lastly, I am an agent who has about 2% of its total book of Medicare business in dual plans. The commission I make off of duals do not come close to the many negatives that come along with this block. But, what do I know-I'm just chasing after this business just to earn a commission.

 

[medicareguru]

aheff-

Let me be the first to thank you for your contribution to our country. I now see the light.

I'll tell you, I really don't know how you have any clients especially after telling someone you do not know to "step outside of his bubble" lol.

 

[aheff]

Medicareguru-
You made two statements:
1. "what is the purpose of a dual eligible special needs plan?" There is none in my opinion."
Do you still stand by this statement?
2. "the agent trying to get paid a commission."
While I am not really in the dual market, i do know several agents that are, and that do well. Each of them do a great job working with this (what I believe) difficult market. I believe your insinuation is way off base.

 

[medicareguru]

aheff:

you are allowed to have your opinions just as I am. Why don't we agree to disagree. Have a nice Holiday and a Happy New Year.

 

[GordieHowe]

1. Dental vision hearing otc gym transportation medical alert systems,etc

What about states where transportation is supplied by Medicaid and coordinated with Medicaid/ state and MA?

And dental has limited benefits with MA that difference is picked up by Medicaid

Are there MA 's that picks up full dentures?
The few states I wrote in Medicaid covered way more then majority of cost of dentures.

High number of duals need new teeth in my experience.

MA's have less limited network , same DR's with multiply offices. Some in network some not.
Most duals have multiple Drs. And difficult to find all in network

Just my experience

 

[Chazm]

What about states where transportation is supplied by Medicaid and coordinated with Medicaid/ state and MA? And dental has limited benefits with MA that difference is picked up by Medicaid Are there MA 's that picks up full dentures? The few states I wrote in Medicaid covered way more then majority of cost of dentures. High number of duals need new teeth in my experience. MA's have less limited network , same DR's with multiply offices. Some in network some not. Most duals have multiple Drs. And difficult to find all in network Just my experience

No one said dual plans are best for every situation and in every state. He asked why would someone benefit over just straight Medicaid/Medicare and in FL there are plenty of plans that are better and worth it

 

[yorkriver1]

Humana training managers have said that it's best for the duals to go to Medicaid providers due to the reimbursement issues. That's all I know, except that QMB+ in our state is part of a demonstration plan that includes more services and does not work with agents. Agents may lose some clients to this system, and the Insurance Commish has put the kibosh on agents talking to clients to try to convince them to stay on their original (agent originated) plans. They have made examples out of a few agents suspected of interfering with client choice of original plan or the 3 QMB+ Medicare/Medicaid plan providers.

 

[midwestbroker]

Technically speaking, a provider can see any patient they want, it is just a matter of getting paid.

If a Medicare but not Medicaid doctor decides to see a DE, they can as long as the billing department (as most usually understand this) know not to send any balances to the DE.

In most cases that I have seen, this is what happens: DE goes to a specialists who is Medicare but not Medicaid. The office says we don't take Medicaid. The office manager steps in and makes a case by case judgement call. If it is a long term patient, they may just take the 80% that Medicare pays and write off the rest. If it is a newer patient, they send them down the road.