Your gonna need to look into MADP & by 2/14/20! Medicare Advantage Disenrollment Period (1/1 - 2/14/2020) Why? well.... Please realize that IF you are on an “advantage plan”, you have basically made the decision to exit original / traditional MediCARE & moved your health insurance coverage to a much more narrow system that is designed to have you use & actually go to providers, facilities etc. that are “in network” for the specific Advantage Plan you signed up for. MC won’t likely be in network, ever.
To get the most out of an Advantage Plan -imo - you have got to use MDs, clinics, labs, hospitals etc. that are “in network”. All have signed off negotiated rates with Plan. That is part of the way that Advantage Plan are able to appear cheaper. Often much much cheaper than a Original Medicare & a “gap / supplemental” would be.
To get low or no-cost, you have to HAVE TO stay “in network” Out of network may cost you anywhere from 20%-80% of whatever rack rate the provider or facility bills you & the out of network terms of the agreement on the Advantage Plan you picked.
And for institutional care - NH or MC - that’s almost always going to be out of network. If your elder is in NH, their not likely to be able to do an appointment with old ophthalmologist and get themselves over to that doctors office at the medical center downtown. Once in MC or NH, they are now under the care of the MD who is medical director of NH and get all their care done at NH (or MC) unless seriously ill and then they get hospitalized. Unless there’s something extraordinary, once in MC or NH, it’s going to be all routine care... like flu shots, taking temps, BP/pulse reading, medication management AND all orders for care and drugs come from the MD / medical director of the MC or NH.
So what to do??..... I’d suggest you ask the MC to have a care plan meeting ASAP. You need to find out what gap insurance the MC and the medical director participate in (if any). Then do the MADP paperwork to get back into original MediCARE then get a gap policy Lr do LTC Medicaid application.
THIS iS IMPORTANT- between 1/1 and 2/14 is MADP, MediCARE Advantage Disenrollment Period. You can get out of that Advantage Plan & back into original MediCARE with no problems. But you gotta do this ASAP. And the MC can tell you at the care plan meeting what gap or supplemental plan works best or if your elder needs to go to a MCO (managed care organization) & which one or perhaps go onto Medicaid.
Advantage plans really tout about being zero or low cost premiums or have some sort of “silver sneakers” gym membership or other “free” stuff. But imho they really only work if you are healthy (so you can actually get to whatever clinic, lab, PT they own), don’t really travel (so always able to go into their hospital) and have 2 -3 big hospital / clinic systems with speciality care units that compete against each other to get Medicare age enrollees and your not needing long term care.
A current trend by states for Medicaid for “duals” (both on Medicare AND Medicaid) is to be in a MCO. Both for individual and facility. Facility gets a set amount of $ per enrollee. As it’s Medicaid, each state is going to do this uniquely (like TX has STAR Plus). 2 big players in this - Molina & HealthSpring. MCO system basically uses the playbook that CHIP (kids Medicaid) has done for decades & with pretty good cost containment & level of care done.
Remember switch out of Advantage must be done ASAP!
If the person can't afford care in an AL or MC then Medicaid can be applied for. Generally, Medicaid only pays for LTC in a nursing home. You will have to check your State to see if they have waivers for ALs or MC.
They will not pay for facilities. Unless it is rehabilitation after a 3 night hospital admission.
It is health insurance not long term care insurance. I know it gets confusing when it is medically necessary for placement, but room and board is never covered by regular insurance. All of the medical treatment required will still be covered.
Medicare Advantage Disenrollment Period (1/1 - 2/14/2020)
Why? well.... Please realize that IF you are on an “advantage plan”, you have basically made the decision to exit original / traditional MediCARE & moved your health insurance coverage to a much more narrow system that is designed to have you use & actually go to providers, facilities etc. that are “in network” for the specific Advantage Plan you signed up for. MC won’t likely be in network, ever.
To get the most out of an Advantage Plan -imo - you have got to use MDs, clinics, labs, hospitals etc. that are “in network”. All have signed off negotiated rates with Plan. That is part of the way that Advantage Plan are able to appear cheaper. Often much much cheaper than a Original Medicare & a “gap / supplemental” would be.
To get low or no-cost, you have to HAVE TO stay “in network”
Out of network may cost you anywhere from 20%-80% of whatever rack rate the provider or facility bills you & the out of network terms of the agreement on the Advantage Plan you picked.
And for institutional care - NH or MC - that’s almost always going to be out of network. If your elder is in NH, their not likely to be able to do an appointment with old ophthalmologist and get themselves over to that doctors office at the medical center downtown. Once in MC or NH, they are now under the care of the MD who is medical director of NH and get all their care done at NH (or MC) unless seriously ill and then they get hospitalized. Unless there’s something extraordinary, once in MC or NH, it’s going to be all routine care... like flu shots, taking temps, BP/pulse reading, medication management AND all orders for care and drugs come from the MD / medical director of the MC or NH.
So what to do??..... I’d suggest you ask the MC to have a care plan meeting ASAP. You need to find out what gap insurance the MC and the medical director participate in (if any). Then do the MADP paperwork to get back into original MediCARE then get a gap policy Lr do LTC Medicaid application.
THIS iS IMPORTANT- between 1/1 and 2/14 is MADP, MediCARE Advantage Disenrollment Period. You can get out of that Advantage Plan & back into original MediCARE with no problems. But you gotta do this ASAP. And the MC can tell you at the care plan meeting what gap or supplemental plan works best or if your elder needs to go to a MCO (managed care organization) & which one or perhaps go onto Medicaid.
Advantage plans really tout about being zero or low cost premiums or have some sort of “silver sneakers” gym membership or other “free” stuff. But imho they really only work if you are healthy (so you can actually get to whatever clinic, lab, PT they own), don’t really travel (so always able to go into their hospital) and have 2 -3 big hospital / clinic systems with speciality care units that compete against each other to get Medicare age enrollees and your not needing long term care.
A current trend by states for Medicaid for “duals” (both on Medicare AND Medicaid) is to be in a MCO. Both for individual and facility. Facility gets a set amount of $ per enrollee. As it’s Medicaid, each state is going to do this uniquely (like TX has STAR Plus). 2 big players in this - Molina & HealthSpring. MCO system basically uses the playbook that CHIP (kids Medicaid) has done for decades & with pretty good cost containment & level of care done.
Remember switch out of Advantage must be done ASAP!
It is health insurance not long term care insurance. I know it gets confusing when it is medically necessary for placement, but room and board is never covered by regular insurance. All of the medical treatment required will still be covered.