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My father was diagnosed with ESRD and Congestive Heart Failure back in May, he currently has Original Medicare, part A and part B, he is enrolled in a prescription drug plan, and also receives extra care to help pay for prescriptions premiums, deductibles and I believe some of the copays for prescriptions. He is also receiving SSDI benefits and SLMB Medicaid which pays Medicare part B premiums. He was originally receiving FULL Medicaid benefits but had it terminated as of November 1st. We have been given different reasons as to why his full Medicaid was terminated but never a straight answer. His monthly SSDI check is $1222 and the income limit here in NM is $1387 I believe for Medicaid. He has no assets. The SSDI benefit is the ONLY income he receives monthly. How does he apply for and what are the qualifications for Dual eligibility? Does anyone know? Is he exempt because of the fact that he receives SSDI? If he meets income limit for FULL Medicaid here in NM why is he only receiving SLMB, which only covers Medicare part B premium? He cannot afford the 20% that Medicare does not cover, as well as dentist visits, eye exams, transportation to and from dialysis... I was recently his caregiver until Medicaid stopped and now that Medicare does not cover that we aren’t sure what to do. Does ANYONE have any helpful information? I have spent numerous amounts of hours on the phone, and in person, with Medicaid office, SSI office, income support, so many places and no one has helped us or given us any info. They only state that he is not eligible for full Medicaid. No reason given. I do not understand why, if he is below income limit for full Medicaid! NM does not have a spend down program so that is out of the question. I am extremely grateful that he even has these benefits now to help cover a lot of his medical expenses but it is confusing and frustrating that he “does not qualify” for full Medicaid that helped him pay for a lot of things Medicare won’t. He is only 43, I am only 21! We have delt with so much I hope someone can help or provide some more info as to what we can do. I am desperate at this point. I am not working because I am scared and fear him being left home alone because of the state he is in. I have given up so much to take care of him and I will continue to do so for as long as I possibly can but I just wish there was more that we could do. Why is it that people who should not be receiving Medicaid or assistance because they simply do not need it and are abusing the system are fully covered for insurance but my father who depends on these things does not qualify for help he should. Why do the people who really need it have to suffer! Ugh. Any advise would be gratefully appreciated..... thank you.

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Just a note to expand about dual eligibility for Medicare and Medicaid...if his medical needs are assessed and it is determined that he has issues that meet the standards for additional care he may qualify. That is probably done by a different part of the state agency that got him the Medicare Savings Program coverage. See if your agency has a division that handles Home and Community Services. Dealing with the big state bureaucracies is like shopping at the mall....if you want a Cinnabon you don't walk into Foot Locker. They are all under the same roof but probably don't interact with each other.
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I feel like I responded to this question on another thread, so here's just a few comments. If you are on SSDI for 24 months due to most diagnoses you become eligible for Medicare. Some diagnoses like ALS get you Medicare immediately. When you get Medicare you don't lose lose all other medical insurance. You could be purchasing insurance on your own or be covered under your working spouse's coverage (which is how I provided coverage for my disabled spouse for years). What you are going to lose is Medicaid, the state administered health coverage. The state is not going to cover you if you have Medicare. It's just cheaped for the state and Medicaid is always the payer of last resort anyhow. If your income is low enough you may qualify for one of the Medicare Savings Programs detailed in a post above. The state pays the Medicare premiums (and more on QMB) because that also is cheaper than providing full classic Medicaid. Your state may have a spend down or whatever it calls another program where it picks up some additional costs after you pay your spend down or deductible ...or you buy some Medicare gap ptogram, or Medicare Advantage Program from the private health insurance market. If you can't afford to pay what what regular Medicare doesn't cover look for a zero cost Medicare Advantage program in your area. You do that by looking at the Medicare guidebook that Medicare clients get every year. I just got my 2018 version about 2 weeks ago. Read it. The straight reason full Medicaid was cut off is because he has Medicare now. You don't need to pay a lawyer to understand this, just accept it and plan what to do next. And quit complaining about other people getting Medicaid...He did and now he gets his Medicare premium paid for too.
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Ask his dialysis social worker for information regarding supplemental plans. Check to see if NM has a state program that provides payment of his supplemental insurance premiums. Many states have these special funds as the dialysis company wants to assure the patient can pay the premium for the supplemental so they are guaranteed to be able to bill & receive reimbursement. It is more cost effective for the big dialysis companies. The dialysis companies get their reimbursement from Medicare, and from his supplemental policy. In Maryland, it is called the Maryland Kidney Fund. This program is funded by grants and donations.
Good luck & keep up the fight!
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Reyes, PLEASE see a disability advocate or lawyer. When a person receives disability and Medicare, the social security administration/federal rules are used by the State of New Mexico. They have no choice. You need to take all the documentation that Medicaid offices gave you and have a legal set of eyes look at it. Somewhere in the pages is the answer you don't have about why he is no longer eligible. Please note as I've copied below from New Mexico's Medicaid guidelines pamphlet that your father is above the income limits for full Medicaid since he receives $1220 per month and does not qualify for QMB status receiving Medicare.

"Reyes16 ON A DIFFERENT THREAD 5 days ago
I spent a good portion of my night in tears because of how stressful this is for us. Like I said I am grateful that he has some sort of coverage but what happens when he cannot afford to cover the 20% that is left over? It is easy for Medicaid reps to say, “well I’m sorry I wish there was more I could do” when they aren’t the ones in this situation. It is crazy to think that there are so many people milking the system receiving benifits that they should not and the people who genuinely need them to stay alive have to go without! Confusing indeed Shane, I find it so hard to grasp that Medicaid is an income based program, my dad fits the criteria of being “financially needy” being that his SS disability check is definitely under that income limit here in NM but “does not qualify” what is the point of dual eligibility then? I KNOW there are people out there who are receiving both so what’s so different about him! We are definitely going to be looking into a disability lawyer, as I do not believe that there’s nothing else that can be done. We were told that since he is receiving Medicare and Disabilty he cannot receive full Medicaid. That it “just doesn’t work that way” ugh.

In regards to 401k, he does have some put away from his previous job but nothing big what so ever. Maybe a couple of months worth and the last we were told was that it is not worth trying to use because more will be taxed than given back to him." ***

I found this info in July 2017 Medicaid eligibility docs released for New Mexico. http://www.hsd.state.nm.us/uploads/files/Looking%20For%20Information/General%20Information/Rules%20and%20Statutes/Medical%20Assistance%20Division/MAD%20NMAC%20Eligibility%20Program%20Manual/Eligibility%20Pamphlets/EP%20revised%206_17.pdf
Qualified Medicare Beneficiaries (QMBs)
Category 041(over 65) Category 044 (under 65) entitles individuals to payment of Medicare premiums as well as the deductible and coinsurance amounts on Medicare-covered services. To be eligible, the applicant must already have, or be conditionally eligible for Medicare Part A (Hospital Insurance). To be eligible, their income must be below 100% of the Federal Poverty Level Guidelines. Income limits are $1,005 for an individual and $1,354 for a married couple.
Specified Low-Income Medicare Beneficiaries (SLIMBs)/ Qualified Individuals 1 (QI1s)
Category 042 and Category 045 entitles individuals to payment of their Medicare Part B premiums, if their income is below 120% of the Federal Poverty Level Guidelines. Countable
monthly income must be at least $1,005 but no more than $1,206 for an individual and at least $1,354 but no more than $1,624 for an applicant with an ineligible spouse when income is deemed.
The SLIMB category was expanded to cover an additional group of individuals known as Qualified Individuals 1 (QI1's), if their income is between 120-135% of the Federal Poverty Level
Guidelines. Countable monthly income must be at least $1,206 but no more than $1,357 for an individual and at least $1,624 but no more than $1,827 for an applicant with an ineligible spouse when income is deemed.
The resource limit for QMB, SLIMB and QI1's is $8,890 for an individual and $15,320 for a couple inclusive of a $1,500 burial deduction per person. The applicant must be enrolled in Medicare Part A. Medicaid does not pay the Medicare Part A
premium. Since payment of the Medicare Part B premium is the only benefit, no Medicaid card is issued.
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The issue is probably going to revolve around rules for SSDI. SSDisability

SSDI (aka SSD) has its own system (even though it’s administered by SSA) which is based on your dads work credits & what he paid into FICA before he became disabled and on SSDI. Family, if they qualify, can get auxiliary benefits based on dads FICA; like a dependent of dads who is in school can themselves get a benefit based on their fathers work record. I think (but could be wrong) that the federal standard on SSDI is that AFTER 2 years they become fully MediCARE eligible, & so other insurance (even Medicaid) stops as they are Medicare only.

If so, dad is going to need to very carefully shop around for a gap/ advantage/ supplement or substitute to Medicare plan. I say carefully as most Medicare gap policies are all about the usual Medicare recipients who are relatively healthy over 65 retiree. At 43 & disabled, your dads health needs are going to be a lot different. It is open enrollment period right now for Medicare, so you need to help dad ASAP figure out which to go with or stay with original Medicare. It could be - & this is a guess on my part - is that Medicaid as his secondary insurance stopped right now as it’s open enrollment for Medicare gap plans and plus it was time limited to stop after 2 years. Medicaid is state program so perhaps NM does Medicaid for a period of time for SSDI & dad timed out.

The income ($ 1222) SSDI pays dad is based on his FICA based work history.

SSI is a totally different animal (from SSDI) as it’s a very strict means based at-need program so looks at both income & assets. SSI is low-income & cause it’s low income usually qualify for SNAP and Medicaid. Dad isn’t on SSI so cannot get SSI benefits.

If you think there’s a mistake in his SSDI, you’d probably be best off finding a disability rights advocate to review his situation. If your dad had a disability atty who did his SSDI application cycle, I’d suggest you call their office to ask what advocacy programs are in NM or if they will as a courtesy do a review.
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