Medicare Advantage & Medicaid

[wehotex]

I have a few members on a Dual plan because they like the gym membership and it works nicely with their Medicare and full dual medicaid. Another of my Dual SNPs is dropping this gym benefit in 2013. :(
I don't have any other options except to put these ppl on a regular MA to keep a gym membership. If they enroll into one of these, can I count on each provider to waive the copay or coinsurance when they present their medicaid card along with the MA card? The PCP has already verified that they would, but I'm concerned about the other providers. What have been your experiences with this?

 

[kamp]

Each state if different with regards to that. Usually, depending on what level of LIS they qualify for would determine that.

In my own experience, if their part B premium is paid by the state then they wouldn't pay anything..

Where do you live?

 

[wehotex]

Each state if different with regards to that. Usually, depending on what level of LIS they qualify for would determine that.

In my own experience, if their part B premium is paid by the state then they wouldn't pay anything..

Where do you live?

LIS is NOT medicaid though. I am in San Antonio Tex. The individual is considered FULL DUAL if monthly income is less than $950 and less than $6,600 in liquid assets.

 

[kamp]

LIS is NOT medicaid though. I am in San Antonio Tex. The individual is considered FULL DUAL if monthly income is less than $950 and less than $6,600 in liquid assets.

Yeah, I'm not in Texas..hopefully someone here (from there) can help you.

Sorry.

 

[Josh]

Best thing to do is contact the provider and ask the billing office. As long as they're contracted with Medicaid then they can't take a penny from the prospect regardless of what other insurance they may or may not have. That can varie by state, but odds are you're fine. Just call the providers offices and double check. They may not follow what's going on, but they should be able to answer the question within a few calls or less.


Short answer: Odds are your fine as long as the provider is contracted with Medicaid.

 

[fleur]

I have a few full duals that chose regular MAPD plans because of gym benefit. We have many plans with few co-pays on services, but when there is, my clients have said the provider does make them pay, even if contracted with Medicaid.
I would check with the billing offices but also tell the clients that they may have co-pays. Does the no cost gym membership out weight the annual cost of co-pays?

 

[Josh]

I have a few full duals that chose regular MAPD plans because of gym benefit. We have many plans with few co-pays on services, but when there is, my clients have said the provider does make them pay, even if contracted with Medicaid.
I would check with the billing offices but also tell the clients that they may have co-pays. Does the no cost gym membership out weight the annual cost of co-pays?

In NY (and I believe most states), that is illegal. Part of their Medicaid contract states that they can't seek further payment other than whatever the copay is (Medicaid may have a copay).

 

[yaknow1]

Usually:
MAPD plan office visit copay $15
Medicaid office visit copay $3
Patient liability: $3

Danger: Just because Medicaid pays for Part B premiums doesn't mean Medicaid will cover Medicare co-insurance. Medicaid will pay part B premiums and nothing else under "SLMB" Specified Low-Income Medicare Beneficiaries" or QI-1 Qualified Individuals 1.

 

[jdeasy]

Usually:
MAPD plan office visit copay $15
Medicaid office visit copay $3
Patient liability: $3

Danger: Just because Medicaid pays for Part B premiums doesn't mean Medicaid will cover Medicare co-insurance. Medicaid will pay part B premiums and nothing else under "SLMB" Specified Low-Income Medicare Beneficiaries" or QI-1 Qualified Individuals 1.

Medicaid does not anyone's part B premium. The "extra help" program is federal. Medicaid is state.

 

[yaknow1]

My original example is wrong if the patient is QMB Medicaid recipient. Medicare and Medicaid's payments are considered to be payment in full.

As to LIS and extra help: that terminology is limited to drug plans. Medicaid does indeed pay part B premiums. The second page of this link makes a good explanation of this. /www.kff.org/medicare/upload/7912-04.pdf