ACA vs Medicare For Disability Cases

SSA provides for people with disability findings to receive Medicare benefits after 24 months of disability. In some extreme cases, such as patients with ALS or other conditions, they can receive Medicare benefits immediately.

This was often the only choice for disabled individuals who would not be accepted or their conditions covered due to pre-existing condition clauses in most healthcare policies. Our focus at SHINE has been to find such an individual an appropriate special needs plan, SNP, tailored to the client’s condition.

With the ACA, however, the prime motivation for moving to Medicare may have gone away since the patient can now get a “normal” policy without underwriting exclusions. This can dramatically change the landscape.

I have a current 35 year old client who received a disability finding two years ago and is just now eligible for Medicare. He wanted advice on plan selection and was interested in a certain Medicare Advantage plan supplier recommended by his parents.

Of course the Medicare insurance only covers the patient with the disability. His children would get coverage under the Florida CHIP provisions, but his wife, who was his primary caregiver and also needed to care for the pre-school aged children, would have no coverage since their income from SSA was well above Medicaid cut-off levels.

The answer seems to be the ACA which allows them to sign up for a Gold Level plan, which is, more or less, on a par with Medicare Part A and B coverage and has PDP provisions on a par with MA plans, for around the same cost as a single Part B premium.

When a client is in this sort of condition, it may be wise to check to see what alternatives may exist.


Mysteries of Medically Needy Program

Does anyone really know how the Medically Needy Program, also known as Share of Cost works?  Since it is really a Medicaid program, its interaction with Medicare is often rather vague.

For starters, if a client is qualified for QMB status due to income and assets being below the current limits, it is a non-issue.  MNP only applies to those who are more fortunate than QMB recipients, for example SLMB, QI1, or even higher levels of income.  

A couple of valuable benefits accrue to the client who can qualify for MNP at some point during the calendar year.  Any unpaid bills from a Medicaid provider will be paid going back up to 90 days from the date that the client meets share of cost and the client will automatically receive LIS/Extra Help status for the balance of the YEAR.  

This last item can be a real boon to people in very bad circumstances.  For example an MS patient who requires Avonex is faced with a $1000 or higher copay per month on Special Needs Plans for the drug which has a retail price of $250,000!  If LIS is available, the price drops to $6.  

The first step is to qualify the client for share of cost using the same MSP buy-in form used foor QMB, SLMB, and QI1.  When the Notice of Action is received, the client will be assigned an SOC figure in  lieu of a QMB acceptance.  

Once that is acquired, the next step is to find enough qualified bills to meed the SOC in some 90 day or less period and submit them to ACCESS per plan instructions.  The client will get a notice if and when the cost level is met.  The notice will describe what action the DCF will take in paying any unpaid amounts and what other benefits are available and for how long.  

The client will have to apply for an appropriate MAPD or PDP as appropriate to ensure that all necessary drugs are in the plan formulary.  Then the Extra Help price levels will be applied.  Note that going on Extra Help automatically provides a continuous SEP so the the client can do this.  It is even possible to change month of month if that were necessary to choose plans to cover all drugs with separate formularies.

Medicare, Medicaid, and you

Florida SHINE is a (mostly) volunteer organization whose mission is to answer questions that you might have regarding your access to healthcare services within the Medicare system.  This blog is for creating discussions on some of the more obscure issues that face Medicare recipients and how Medicare works with state Medicaid programs.