Hep C Discussion Forum

Groupergetter · Guru

Medicare Supplemental Policy Enrollment.

wmlj1960 · Moderator

Groupergetter wrote:
Mike, each state administers it's Medicaid program differently. To qualify for benefits you must be a resident of that state. If Tennessee is your place of residence, you would need to meet criteria in Tennessee. If you are "visiting" Tennessee and Mississippi is your state of residence it will change things a bit.

I am a MS resident and have had that MS address for years where my cousin still lives. I only have this small 1 bedroom in Memphis rented as a temporarily location close to my HCV and HIV Dr.'s office to save transportation cost (108 miles per visit, 4-5 visits per month including HIV support services, HCV support group, labs, MRI's every 3 mo, Dr appointments). I initially had considered moving here permanently but I'm not happy with living in this crazy city and now plan to return home after my Tx is complete in 10 weeks and travel will be less frequent.

If you are already enrolled, do you know what your share of cost (similar to a deductible) is?

$20 per visit

Any unpaid and/or owed medical bills may be used one time to meet your "share of cost. Once you meet your share of cost you would be Medicaid eligible the balance of the month. It would be important to try and schedule any diagnostic imaging or other tests, labs, visits etc. as close to the first of the month as possible. Medicaid eligibility for the Medically Needy programs runs month-to month. I will PM you.

I have no idea about this subject so I'll wait for your PM smile

Groupergetter · Guru

Mike, each state administers it's Medicaid program differently. To qualify for benefits you must be a resident of that state. If Tennessee is your place of residence, you would need to meet criteria in Tennessee. If you are "visiting" Tennessee and Mississippi is your state of residence it will change things a bit. If I understand correctly it sounds as though you've pretty much got your meds covered. If you aren't already enrolled in the "Medically Needy" program, you should be. This would likely cover inpatient deductibles. If you are already enrolled, do you know what your share of cost (similar to a deductible) is? Any unpaid and/or owed medical bills may be used one time to meet your monthly "share of cost. Once you meet your share of cost you would be Medicaid eligible the balance of the month. It is important to try and schedule any diagnostic imaging other tests, labs, visits, scripts, (any medical expense) etc. as close to the first of the month as possible. Medicaid eligibility for the Medically Needy programs, runs month-to month. I will PM you.

Many states have a rule that if Medicare reimburses more than Medicaid the practice must write off any coinsurance and you can't be balance billed. The catch here is that practices/providers aren't obligated/mandated to accept Medicaid. Contributing to that is the fact that "Medically Needy" Medicaid is determined retroactively and many doctors/practices don't want to deal with this program. Some doctors, diagnostic imaging, etc. will write off coinsurances if you ask them, particularly if they know you are financially strapped. Being able to discuss this in a nice way with the practice manager or billing supervisor can give positive results.

-- Edited by Groupergetter on Friday 24th of October 2014 08:56:53 AM

wmlj1960 · Moderator

Groupergetter wrote:
Currently Healthcare navigation has become a total CROCK with the constant changes, managed care plans, etc etc etc.

Agreed! cry

I did manage to find my 2014 Medicare handbook and I've found out a few things. In Mississippi I qualify as QI1. I haven't heard back from the SHIP service yet but the more I read I'm thinking I may be better off staying with what I have now. The way I understand it, I qualify to receive low income subsidy (LIS). I am enrolled in a Medicare drug plan (EnvisionRxPlus Silver PDP). I also qualify for full Extra Help. Extra Help pays my drug plan premium, yearly deductible, coinsurance and co payments. The coverage gap does not apply to me because I qualify for full Extra Help and the gap ends quickly for my Extra Help coverage because of the high cost of my Rx's for ESLD / HIV. That happens usually by February if I remember right. Once this happens I qualify for catastrophic coverage and I pay $0 for Rx copay etc, but I am responsible for 20% of Medical visits, labs, imaging etc. I pay what I can toward those monthly but with my limited income most of these bills are turned over to collection companies (several thousand dollars so far for this year). But this has been ongoing for almost 3 years (since I started receiving disability income) and no legal attempts to collect have been seen...yet.

You might expect to pay around $300 and $400 a month for a decent supplemental policy. Most plans have staff that can explain the specifics. May be worth a call or two. Remember they are usually trying to sell you something.

I have less than $400 from my disability income to survive on for the month after paying rent, utilities, car, insurance. I spend almost $3-400 in food, gas and household items monthly. I can maybe find a cheaper policy, but that will repeatedly put me in bad financial shape monthly, and leave no room for unexpected issues such as automotive mechanical repairs on my 190K mile mini van.

Back to my original concern about coverage to help pay for re-treatment in case of SVR failure. I hope and pray that does not happen but I can't ignore the possibility. If my current coverage will pay for re-treatment, then I certainly want to keep what I have now and can almost afford. If it won't then I don't have enough information yet to make a decision about what to do. I sure wish the timing could have been so that I know my status on post Tx relapse now, during open enrollment but...

I'm very slow at comprehending what's being said in a fast paced phone conversation or online chat, so I try to do any complicated stuff face to face. I'm also very uninformed about the facts so a discussion with an insurance company representative would not be very beneficial and it's real possible I will get talked into purchasing coverage that will not help my situation. So I'm going to call that SHIP service again tomorrow to see if I can set up an appointment.

Until then I've got to take a break from information overload.... biggrin

Thanks again for your help Groupergetter! smile

Groupergetter · Guru

Mike, I really appreciate the daily funnies. When feeling like crap, a little humor goes a long way. biggrin You and Brownie help keep a smile on folks faces. The QMB stands for qualified Medicare beneficiary. If you scroll down on the Tenn care link in the thread you will see the QMB, SLMB and QI1. If your income is below $971 and you have less than $7160 liquid assets you would be QMB eligible. QMB pays your Medicare part B premium and Medicare coinsurance or deductibles if due. The QI1 and SLMB pays only your part B premium. The thing you might consider the supplemental policy for would be the "donut hole" or portion of Part D pharmacy you would potentially have to pay. This link: http://www.medicare.gov/pubs/pdf/11493.pdf helps explain the Part D pharmacy "donut hole" The supplemental policy might also help to pay an inpatient Medicare deductible see Medicare costs here: http://www.medicare.gov/your-medicare-costs/costs-at-a-glance/costs-at-glance.html You have to weigh the costs of the supplemental policy verses costs of deductibles and coinsurance to determine if it is cost effective for you. Your frequency of physician visits, hospital services, and pharmacy costs all come into play when considering a supplemental policy. You might expect to pay around $300 and $400 a month for a decent supplemental policy. Most plans have staff that can explain the specifics. May be worth a call or two. Remember they are usually trying to sell you something. Also some docs will write off Medicare coinsurance and deductibles. If you are QMB eligible they can't balance bill you for coinsurance or deductibles. Currently Healthcare navigation has become a total CROCK with the constant changes, managed care plans, etc etc etc.

wmlj1960 · Moderator

Groupergetter wrote:
States usually offer some type of cost sharing program sometimes called "Medically Needy" these may kick in when a monthly "deductible" or share of cost is met. States also offer some Medicaid Waiver programs which may have higher income standards and cover items not usually covered under their "traditional" Medicaid programs. QMB,SLMB, QI1 are programs that could potentially pay for Medicare Part B premiums.coinsurance and or deductibles . These are income based programs.
Your need for a Medicare Supplement policy would in part be considered based upon Medicaid and or QMB coverage/eligibility. There are so many factors to consider, that it could take some time to navigate the coordination of benefits. You are currently in an open enrollment period, so now is the time you need to be making considerations. Sorry not more help, but in this world individual specifics, and the state you live in play a large part in your decision making process. As you already know this is a very complex challenge. Good luck with it, take care.

QMB,SLMB, QI1... confuse Yes this is a complex challenge and it looks like it is way over my head. So I need to be finding a service that can sit down with me in person to clear up what I already have vs what do I need? I sought help 2 months ago from a medicare / medicaid advocacy service but I can't afford the fee.

After looking at my Medicare.gov documents today, it looks like I am receiving full Medicare benefits, and full Medicaid benefits based on my SSA disability income, plus I'm receiving full 'extra help' benefits. I believe the extra help is paid for by my state. I was also receiving help to pay for HIV meds via The Ryan White Care Act, but I believe Medicare via 'Envision Rx Plus' took over that also. I still however receive some other services from Ryan White Act. Because of my catastrophic coverage classification, the extra help pays my yearly deductible for Envision Rx and I also never pay a copay for any of my 12 medicines. I did qualify and was accepted for a Medicaid waiver program which I needed at that time for non-emergency medical transportation to-from Dr office and hospital ect. 54 miles from my house. But now I am living within a mile of my hospital, liver transplant center (hepatologist) and infectious disease (HIV/HSV) Dr.'s office so I no longer need the medicaid waiver program (for now anyway). I don't need the other services that they offer (house cleaning, personal care at home, frozen dinners delivered etc.) and according to my case worker, no medicine or financial help for medical bills is available.

I think I am covered pretty well at the present time, and may not benefit from a supplemental plan, but my whole concern is will what I currently have be enough if SVR does not happen and re-treatment is required in the future? And would a supplemental policy make a difference? I guess these are questions for the SHIP service.

I called the SHIP service for my state and I left a message on a machine that said I should receive a return call within 24hrs.

So hopefully that will happen on time and I can get some answers.

Thanks for the help Groupergetter! smile

wmlj1960 · Moderator

I found a lot of information from your first link and logged into my Medicare.gov account and entered the required criteria it asked for and came up with a few options, which I don't quite understand. I'll post more info on that later because I've got to try to get a couple of hours sleep before daytime. I see that the open enrollment last from Oct 16 - Dec 7, so I need to do something quickly. I may need to read the 2nd link better (ran out of time). It may offer some better options still for help on this issue.

I'll post more later tonight. Thanks once again Tig ! smile

Groupergetter · Guru

Mike, as you are already considered disabled by SSA your Medicaid eligibility would be income and asset based. Depending upon your income from the disability you may or may not be Medicaid eligible. States have some leeway in the administration of their Medicaid program. You can go here: http://www.tn.gov/tenncare/mem-categories.shtml for more information related to eligibility. Since your part D Medicare plan is primary for your prescription coverage you could go here: http://www.q1medicare.com/PartD-SearchPDPMedicare-2015PlanFinder.php?state=FL&utm_source=2014_0919_Fdr_NL&utm_medium=email&utm_campaign=newsletter

to find Part D plans in your state. Note the formulary's for plans may not reflect Harvoni coverage as it is so new. Note also that sometime Medicaid may cover items and/or some meds not covered by Medicare.

States usually offer some type of cost sharing program sometimes called "Medically Needy" these may kick in when a monthly "deductible" or share of cost is met. States also offer some Medicaid Waiver programs which may have higher income standards and cover items not usually covered under their "traditional" Medicaid programs. QMB,SLMB, QI1 are programs that could potentially pay for Medicare Part B premiums.coinsurance and or deductibles . These are income based programs.

Your need for a Medicare Supplement policy would in part be considered based upon Medicaid and or QMB coverage/eligibility. There are so many factors to consider, that it could take some time to navigate the coordination of benefits. You are currently in an open enrollment period, so now is the time you need to be making considerations. Sorry not more help, but in this world individual specifics, and the state you live in play a large part in your decision making process. As you already know this is a very complex challenge. Good luck with it, take care.

Tig, you and I must have been typing at the same time.....insomnia yes yawn

-- Edited by Groupergetter on Wednesday 22nd of October 2014 11:20:42 AM

Tig · Admin

Hey Mike,

Cant sleep either? I'm finding insomnia to be more prevalent lately. Sleep seems to come in cycles now. Shorter and shorter!

I'm not sure what to expect with the secondary picture for those of us on SSA disability. I've currently got a Medicare Advantage plan through BCBS, but just learned that the OBAMACARE changes have resulted in the cancellation of my fourth health insurance plan since its inception. The new plan offered throws my prescription coverage into a gap coverage and your out of pocket expenses are decided based on use. Just when I begin to understand everything, it changes. There are so many variables, income, employment, location, marital status, disability, etc., etc. Are you by chance a Veteran? That changes things yet again!

Heres some information on the 2015 Medicare Open Enrollment and prescription drug coverage. It's a start and may answer some questions.

http://www.cms.gov/Center/Special-Topic/Open-Enrollment-Center.html

Medicare Beneficiary Ombudsman

http://www.medicare.gov/Publications/Pubs/pdf/11173.pdf

Tig

wmlj1960 · Moderator

I know nothing about insurance etc and don't know where to find an answer to this question. I've had limited luck finding out anything at the Medicaid office. I have Medicare that pays most (80% I think) of my Dr bills etc. and Envision Rx Plus for medicine, and Medicaid fits into the picture somehow, but I have no Medicare supplemental policy. I am thinking that I read somewhere that fall of the year is the time for open enrollment for some types of insurance. I only pay for part of my Dr bills and I pay $0 for meds, $0 for copay and $0 for deductible. But if I fail to achieve SVR after this current Tx, I may need the additional coverage of a supplemental policy in order to pay for re-treat, if I can even get it then. I'm not freaking out about relapse or anything like that, but I want to prepare for the possibility while open enrollment is open, if that is how it works. I'm not sure if Medicare has a limit on coverage, but I suspect they do, and between my HCV Tx medicine and high cost HIV meds (for lifetime), I suspect I may need to learn something about insurance and claim limits.

Current HCV Tx cost for 24 weeks:

Sovaldi $26,909.41 per month x 6 months = $161,456.46

Ribavirin $822.82 per month x 6 months = $4936.92

Total for 24 weeks Sov / Riba = $166,393.38

HIV meds per month = $4298.02 x 12 months = $51,576.24 per year for lifetime

My HIV meds have been paid for by my work insurance for the last 17 years and now for almost 3 years by Medicare since 1-1-2012 when I started on disability.

Also these figures do not include any of the $ for Dr's, hospital's, labs/imaging etc.

Thanks for any suggestions or guidance on what I can do! smile

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