Had to pay one month out-of-pocket. Spending down to allotted amount for the county ($15,150.00). Not sure the person sending in the Medicaid application & paperwork I gave her (5-year look back, etc.) knows what she is talking about. She sent the info to Medicaid before we could spend down my mom's bank account. I still have one more payroll check to her home health aide and an Amex bill. This person said not to worry about the Amex bill: 'the doctor at the nursing home will send a letter to Amex, stating my mom is Medicaid-pending in a nursing home, and Amex will forgive the payment.' No one I asked ever heard of that before. I know they help with the last 3 months of unreimbursed medical bills, but this is not the case. If my mom has $15k in the bank, why would Amex let her skate on a $1600 balance??
- right now your mom is not yet on Medicaid as she’s “Pending”, so she still needs to have her secondary insurance policy (the gap) in place to be there to cover whatever the gap will pay (more on that below). So it needs to still come out of whatever income source that pays the $ 148.
- when your mom becomes Medicaid eligible, Medicaid should retro coverage to day 1 of her application or the start of that month. Whatever services done during “Pending” & billed to Medicare “should” then have any copay needed billed to Medicaid at Medicaid rates as Medicaid became her secondary insurance as of date application or start of application month.
BUT!!!
- the old secondary insurance could have made payments during the “Pending” period. Secondary insurers will not pay for any services IF another payor (like Medicaid) can be considered to be a payor or new secondary insurance.
- This can pose a problem. What can happen is the old secondary will clawback any payments made & back to the date Medicaid goes in force if the old secondary policy allows for this. If any of the vendors paid during the “Pending” period do not participate in Medicaid, they will not be happy and will bill your mom / you as dpoa for the services when they finally (maybe be months & months later) realize they have gotten a clawback of $ paid.
- A better & well managed NH with Medicaid beds know this happens and has either has all as staff (so billed by NH) or has all outside vendors at the NH participating with both Medicare & Medicaid.
- the $148 should be reimbursed. Insurance could take out a fee but your mom will likely get $ back. Whether it must be a retro SOC (share of cost) to the NH or waived depends on your state. State Medicaid will send a letter advising what the exact copay or SOC needs to be once approved. NH billing could do this wrong. What state says $ is, is what matters. I’d suggest if retro insurance premium $ happens to your mom (months from now), and she has a retro SOC to pay to the NH, that you do each month retro copay as a unique check written to NH.
If your mom’s NH is clueless in “dual” billing management, like they’ve shown to be on admissions, there could be fallout or copay errors when insurers change. Duals = on MediCARE & MedicAID. Good luck!
And I know that pharmacy system. It’s out of network and forget about ever using any of mom’s Expressscripts again. They will tell you that they have a blister pack ordering system and that Express Scripts cannot do what they need. I dealt with this & using Medco (which merged with Express). You might hear that mom’s VA $ ($90) and her needs allowance $ can pay for it. Yes it can but you as dpoa can use that $ to buy her toiletries, clothing replacement instead. To deal with RX or medical stuff, my suggestion is: at mom’s first care plan meeting (should happen within first few weeks) you take Xerox’s of the old/new pharmacy stuff; you ask for the medical director to change her medications to one covered by whatever Medicaid or Medicare covers as there will be no private pay to Pharmscript; and THEN you either write this in above your signature or you have it typed up/printed and you bring your teeny stapler and staple it to the page and denote this above& along with your signature. I did this for my mom’s 1st CPM at her first NH as they screwed the pooch on leaving out mom’s RXs in the admit forms so there was a whole Medically “at need” Medicaid appeal we had to deal with & what my attached letter was about. The charge nurse for the meeting was peeved. The CPM info is Included in their medical chart, so whatever in it is a documented request / question which has to be answered either by the DON (director of nursing) or the MD medical director. The DON did a followup letter to me & things got resolved as DON really is the power center at the NH.
And I too spoke with the initial caseworker directly. Good for you as this will proved to be priceless. Our was a guy and he was great. They want to get them Approved and get that application and novel of paperwork off their desk. But They have tight rules set by the state as to length of time to leave it open and what can qualify as valid paperwork that is kinda out of their hands. I had issues with a car transfer and type of life insurance, and both had to have clarification letters & info over within 72 hrs..... My mom’s documentation stack was about 130 pages & I faxed & USPO certified mail with return registration card duo everything..... with Medicaid it’s good to be OCD.
Just a thought but whats this NH like? Why this NH instead of another? if you have concerns or just a gut feeling it’s not where she needs to be, pleAse, please do NOT let the NH become your mom’s direct or representative payee for her SS or any other income. If that lovely billing Person or anyone else at the NH tells you that it needs to be that way, it’s b.s. Your mom can continue to have her monthly income going into her old bank account and you as a signatory on her account can write a ck to the NH for the exact amount the state tells you is your mom’s copay or SOC (share of cost) by the due date. Any late fees are on you though. Her PNA (personal needs allowance) can stay in her bank account, it does NOT need to reside in a NH trust fund account that she/you can draw from. If she’s getting her hair done at the NH every week, you can put $ for that in the NH PNA account for just that. By keeping mom’s income in her old bank account, IF you need to move her it will eons easier to do. I moved mine within her first year after she cleared Medicaid and got billing straightened out & moved her to an much better NH.
& for long term fun with Medicaid, your state probably has an annual renewal. Our was multi page questionnaire & required some of the initial documentation to be submitted again along with the most recent 4 mos of bank statements, last/current awards letters & real property info. All submitted within 14 days. I didn’t know renewals were done. & didn’t occur to ask either..... I had put all paperwork up storage. By the next years renewal I was totally ready with all.
It it sounds like your states Medicaid program uses the system where the facility is the middleman for the intake aspect of the LTC Medicaid application. This is the format we dealt with for TX but not so much for LA. But whichever way, there’s a Medicaid caseworker assigned to your mom’s case who you can & should speak with regarding any questions or concerns.
You may may find that Medicaid wants all income & assets once a elder is a resident in a facility and in Medicaid “spend down mode” to ONLY use their $ for needs &/or care. Paying the home heath aide should fall into that category (& make sure you have a bill or invoice as to this so not looked upon as “gifting” to a person). The AMeX bill does NOT fall into that category as it’s debt. It’s in my experience, expected that the elders default on any pre-existing debts from their old before-living-in-a-NH life, whether it’s paying credit card debt or property taxes on their old homestead they continue to own ONCE Medicaid spend down is placed. Please try to find out as your gonna be some kinda peeved if there’s a penalty placed on that $1600 and you have to private pay an extra month for her....
I think the system of using the NH as the intake for LTC Medicaid applications are done so that it allows the NH to do a review of the documentation to determine IF they will accept the resident as “Medicaid Pending”. If the NH accept the elder as Pending and it’s goes wrong, they are ineligible for Medicaid, the facility has no beef with the state for payment. It’s just too bad from the states perspective. Facilities don’t necessarily have to do Pending.