HELP! I can't seem to get a straight answer about exactly what NYS Medicaid covers regarding Medigap and Rx's for Nursing Homes residents.

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Mom just went into a Nursing Home in upstate NY. She paid for the 1st month out-of-pocket (or they wouldn't have taken her), and will be Medicaid-pending starting Sept. 1st. I was told by the Medicaid Social Worker assigned to her case that she would NOT have to pay Medicare Supplemental Insurance. Only her Rx plan premium (Express Scripts). Her plan's $400 deductible was met right before she entered the NH, after that, her Rx co-pays cost anywhere between $0 and $4. This NH uses a special company, Pharmscript LLC. I just got a bill for $105.00 from them. Co-pays. I called Express Scripts, and they said Pharmscript is 'not' in their network - that's why the co-pays are so high. (I called Pharmscript to ask which companies they work with - rep said she isn't allowed to 'advise' me which company to use. What? I have a feeling, they are not in 'anyone's network'. So I call the Medicaid Caseworker to ask about this, and she is now singing a different tune. She has to ask her supervisor what Medicaid covers. I said I need to cancel mom's Medigap Insurance before they take it out of her bank account on 9/1. She says to 'wait on that'. So what is the point of being on Medicaid? Just to pay the Nursing Home? They'll also be getting her Social Security & Pension (but she get $50.00/mo. for the beauty parlor or vending machine...) No one seems to know the answer.....

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Dealing with the M&Ms is quite the maze! Medicaid is state specific on eligibility, benefits & regs, its hard to suggest a defined answer to.
But it’s Medicaid in the future unless elder has 250k-400k in assets to be able to pay the Room& Board costs of a NH (5k-15k mo).

The safest route to take no matter what state, in my experience is:
- from date Medicaid application done, do NOT spend a penny of their monthly income. Whether it’s just a SS of $900mo, or SS, pension & an annuity payment. All monthly income - minus smallish personal needs allowance- will inevitably be paid to the facility as the copay or SOC (share of cost) if they are a widow or widower on LTC Medicaid.
- If NH doesn’t require payment of the monthly income during the “Medicaid Pending” phase, it’s likely cause your state laws precludes that from happening as the terms Medicaid contract is not yet enforceable. But $ will all be due once Medicaid approved. Let $ build in their checking account, you don’t want to be caught out and short...
- keep a binder with current “awards Letters” and place any correspondence to any changes in monthly income in it. Their SOC is based on awards letters $ amount. But there will be a lag time on Medicaid adjusting the SOC. Again eventually $ will be due as copay & you don’t want to get caught out in billing drama over $28.47 increase x 8 mos NH wants. My mom was in IL & 2 NH, all had billing errors.
- try to make a definitive decision as to IF their monthly income is to be directly paid to facility OR if you as dpoa want that $ continuing to be direct deposit into your elders checking account and you as DPOA write NH a check to the penny of the required copay by date required as per admissions contract.
We did the latter, for us it made sense as mom continued to own her home and the bank acct would segueway to the estate account as probate was going to be done; AND I had a gut feeling that her 1st NH likely wasn’t going to be it. If you at all think they might move to another facility as you want them closer, or NH #1 is crappy, or their on a waiting list at a nicer NH, please please do NOT allow the NH to be their payee for any monthly income. Trying to get NH, or it’s corporate HQ, to release the direct deposit funds won’t be easy, plus changing representative payee at SS will be a nightmare as SS does not recognize DPOA and you can’t easily haul your elder down to the SS office to get this change done.
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rocketjcat Aug 22, 2018
100% agree with not letting the NH be the payee for her SS. Moms SS and pension get deposited into her checking account, the NH bills me once/mo, and I pay it online. My GF warned me...her moms SS and pension went right to the NH, but somehow SS thought she had passed away and stopped paying. GF didn’t know until the NH tracked her down and told her she owed $60K in back bills. It took months to get that fixed. For the 5 minutes a month it takes me, I know exactly what’s happening and can keep on top of the bill and her personal account.

JoAnn, regarding affording supplemental insurance, in NY if you do have supplemental health insurance while in a NH, all you have to do is tell Medicaid and they will lower your cost share by the monthly amount so you can pay for it. The advantage of the UHC plan is it gives the UHC members a full time on-site NP to augment the regular NH staff of RNs and the illussive DR. So scripts, tests, and proactive nursing are so much easier to get. Since the OP is also in upstate NY I hope she can look into it.
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I’m in upstate N.Y. as well, Syracuse area. I was so confused about Medicare vs Medicaid! Here’s how it was explained to me when Mom went into the N.H. Medicaid is just for the NH bill, Medicare (or some version of it) still is for health care. Mom had been on an Aetna advantage plan which covered medical and drugs and was $33/ mo, on top of her Medicare payment withheld from her SS check. Just like yours, my Medicaid caseworker couldn’t tell me for sure if she should keep Aetna, or just go with straight Medicare. But the NH advised me to check out UnitedHealth Care Nursing Home Plan. This covers everything that Aetna did, is zero $ per month, and also gave her a full time Nurse Practitioner on site for 60 residents. (This has proven invaluable). The UHC contact cancelled her Aetna and signed her up same day. I had to inform Medicaid that she was saving $33/ mo so they increased her cost of share by the $33 which was fine. I do nothing. There are 0 copays for labs or drugs or doctors bills, nada. I just get a statement monthly showing what they paid. You may want to check out UHC nursing home plan (hmo) if it’s available in your area.

As JoAnn said the bill will probably be covered by Medicaid. My caseworker at the Medicaid office told me not to pay anything while we were in the Pending status, and they will cover everything medical, therapy, transport and NH related from the application date And back in time 3 months. Dont even pay the NH bill. I had to keep all the bills and fax her copies of them as they came in. As soon as she was approved (4 months later) everything was accounted for in the final statement and all I had to pay was the 4 months cost of share to the NH.
Hope this helps a little.
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JoAnn29 Aug 21, 2018
Then ur Medicaid is different from NJ. Once on Medicaid here you need no other insurance. My nephew has been on it fully and partially. He pays nothing. Medicare stays in effect, Medicaid pays for the nursingcare and healthcare. You have no money, how can u afford healthcare.
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Once Mom starts on Medicaid she will not need her pharmacy insurance, dental, vision or her medical. Medicaid picks it all up. Like you said, she will have no money. Now the bill you have will need to be paid. But this is the only month that should happen. Medicaid will start Sept 1st.

You need to get someone at Medicaid who knows their job. There should have been no problem in answering your questions. These are not unusual questions. You can call and confirm what I have said. I am from NJ and this is how it works.

To tell you the truth, supplimentals only cover the 20% that Medicare doesn't. Moms tier of Medigap only paid 10% of the 20% she paid the other 10%. Its called cost sharing. If you have paperwork from Medicaid saying she starts the first then she does. Me, I would call now and have the Medigap stopped,

Just a thought. It has been discussed that when you go on medicaid there is a retro on medical bills. You may want to wait and see if Medicaid may pay for that 105. I think its not so much a copay but a higher cost because u didn't use express scripts. Lets see if a member confirms this.
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