Was Medicaid falsely terminated? Should we appeal this decision?
My father was diagnosed with ESRD back in May of this year along with congestive heart failure. He was able to qualify for Medicaid and will start receiving SSI disability in November. His kidney disease automatically qualifies him for Medicare but he was just notified by mail that his full Medicaid coverage will be terminated in November and reduced to “family planning” due to his income, even though he is below poverty line. This does not make any sense to me. He will start receiving ONE check a month which like I said leaves him below poverty line but he doesn’t qualify for Medicaid anymore because of his income? Is this an error? Is there something more to this decision that we were not told? We are very grateful that he has Medicare to help pay for his treatments and such but extremely worried about his Medicaid being terminated because that is what is helping him pay for his in home caregiving, transportation to and from dialysis, covers what Medicare won’t, etc. we have not heard back from his case worker and feel stuck as we don’t know what to do next. Should we appeal this decision? Re apply? Has anybody every been in a situation similar? So many questions that we have, so much stress. I am so terrified that he is going to start receiving medical bills that he cannot afford. Please don’t take me wrong I am very grateful for the benefits he has now but am soooooo confused on why his Medicaid was terminated. We were under the impression that he would qualify for dual eligibility but I guess we were wrong!
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All dialysis centers must have a MSW on staff to assist patients with obtaining/keeping insurance.
His income on SSDI may take him over Medicaid eligibility but speak with the social worker. I have seen many dialysis patients as having both Medicare & Medicaid. He may be eligible for both.
Good luck!
Talking to the social worker at dialysis as Shane suggests is also a wonderful idea. Maybe he or she can help you with the appeal.
Come back and let us know how this works out. We care!
*I’d like to add that I just went back and checked his benifits report and it states that $1220 is before deductions if any apply. Which they don’t because of SLIMB.
Your local council on aging may be able to help you investigate a trust -- in my state, NY, we needed a pro bono lawyer to set it up.
**Supplemental Security Income (SSI)
Categories 001, 003, and 004 – The Social Security Administration determines eligibility for
these categories. SSI provides cash benefits and Medicaid provides health care coverage for
eligible individuals under aged (Category 001), blind (Category 003), or disabled (Category 004).
The maximum monthly income benefits provided under this program are $735 for an individual
and $1,103 for a couple. If the applicant is a minor child, a certain portion of the parents’ income
is considered available to the child. Resource limits are $2,000 for an individual and $3,000 for a
couple. A burial fund of up to $1,500 is excludable.**
www.hsd.state.nm.us
New Mexico DOES HAVE Qualified Income Trusts. Your father may qualify for one of these programs where the money from disability goes into a Trust above the qualifying amount. You may find a low cost or pro bono attorney that does it; it could be well worth more to get state benefits that your father makes too much money to qualify for at $1220.
So, now he will need a secondary policy to pay the 20% Medicare won’t covef for dialysis.
Many states have separate programs for ESRD patients to assist them in getting a secondary. For instance in Maryland we have Maryland Kidney Fund that can assist with paying secondary insurance premiums. Again your dad’s dialysis social worker should be able to help with getting your dad enrolled in a secondary policy & maybe even paying the premiums for him.
Now that you have taken your precious time to get a definitive answer, go back to the MSW @ dialysis & inform her of what you just learned.
She/he should assist in finding him a secondary policy due to his special status as ESRD.
Usually if an ESRD patient has their own insurance through their employer or through ACA, the patient’s insurance continues to be their primary & Medicare their secondary for a period of time, last I knew it was for 36 month “coordination” period as Medicare delays paying the 80% as long as they can and bill the commercial primary.
That’s why I don’t understand why Medicaid was denied at all.
Confusing? Absolutely.
I am sorry the both of you are going through this. Are you certain that your father doesn’t have an old 401k somewhere from a prior job? Something you all don’t know about or maybe dad forgot about it?
I can’t figure this one out either.
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.
Next step is to decide how you want to cover what Medicare doesn't cover. This is where Medicare Supplement or Medicare Advantage plans that you buy in the public market place comes in. Or you may get help from charities that help with costs for people with certain types of illnesses. And here is where additional aid from the state Medicaid program comes in. So whatever the program is called in your state, you have a cost sharing responsibility which might be called cost sharing or spend down or something else. This means that if qualified based on resources you will have a certain amount you have to pay...or at least owe...in a 3 or 6 month period before the state picks up the rest for you. Example: income of 1220 per month, less 20 (it's just the rule) = 1200 -735 (which is the max in 2017 that a person on SSI gets...it's just the rule) = 465 per month available for medical expenses. Muliply 465 x 6 months =2610 which is your share of your mefical costs. Submit the bills to the state within 30 days of the end of the 6 months and the state will pay the amount over your share of 2610. You renew your eligibility for this every 3-6 months. You decide which is better for you, paying for your Advantage or Supplemental plan, spend down or both. Hopes this helps. I work with eligibility for this program on a daily basis. My state has whole units of people whose job it is to look at people's medical bills when they have qualified for spend down and pay those bills. Oh, and other news...you can ask for three months retroactive coverage when you first apply. So say you were hospitalized in last three months and only had Medicare because you hadn't done anything to cover what Medicare doesn't pay. Now you have a huge bill. Apply for state assistance and if you are considered financially needy part of that retro period bill may also be covered. Just don't delay. Hope this helps.
Well I let her checking account go over the minimum $2K by accident and it's been hell every since. I reapplied per Nursing Home Office Mgr.,
then they wanted more into, I sent that. Nursing home office told me to private pay for month of September to show we are doing our part in the meantime, I did.
They denied her application, I was then told I had to submit about 2-3 years of bank statements, which was a royal pain in the behind and to submit receipts for any transactions over $200! OMG!
I submitted all the bank statements, but not the receipts at the time, cause I don't even think I have all the receipts anymore. She was denied AGAIN. She is 90 years old! We cannot afford the nursing home bill nor are we qualified or able to bring her home.
I, like you, am at my witts end. I don't know what to do anymore. If I reapply it will probably be denied again. And it IS very hard to get
definitive answers from those that should be able to help me. I don't understand why they are now looking back at everything when she was originally approved 1 year ago!
I'm just praying she won't be put out on the curb. She is such a sweet and loving lady. Feel free to email me anytime.