Why is it suggested to keep Mom's supplemental insurance after going into skilled nursing facility on Medicaid?

Thought I'd update this thread in case it helps anyone else. My mom is on Medicaid in a SNF. I kept her supplemental insurance for a couple of months to be safe and here is where it came in handy. We live on a state line. A certain pulmonologist she needed to see in our state was two hours away and 6 weeks for an appt. using her supplemental insurance we were able to go across the state line to see a specialist right away. So my question was answered by that appointment. Other than that, now that she is beyond help, keeping supplemental ins is a waste a money. Thanks all!

Lynnslight's answer is correct. I'm a retired long term care administrator from PA. State Medicaid programs routinely will allow the recipient to continue Medigap coverage while also being covered for long term care by Medicaid. This is viewed as insurance for the state's Medicaid funds as whatever the insurance will pay is less that the Medicaid program will need to pay. The cost of the Medigap insurance is actually paid indirectly by the state in that the expense of the insurance is added to the formula used to pay the facility and deducted from the portion paid by the recipient (resident/POA). Either the resident or facility then pays the insurance premium. There is no more money for either the facility or the resident.

Nasmir - meds and PT are both billed to Medicare first. After Medicare pays it's share, it is forwarded (by Medicare) to the secondary. The secondary pays it's share. Both insurances send an Explanation Of Benefits. The EOB details who was paid and how much. It also lists the "Amount You Owe" and this is paid by the patient. In our case, the supplementary picks up approved items like PT and a good portion of the prescription costs.

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How can I pay for nursing home care?

There are many ways you can pay for nursing home care. Most people who enter nursing homes begin by paying for their care out-of-pocket. As you use your resources (like bank accounts and stocks) over a period of time, you may eventually become eligible for Medicaid.

Medicare generally doesn't cover long-term care stays (room and board) in a nursing home. Also, nursing home care isn't covered by many types of health insurance. However, don't drop your health care coverage (including Medicare) if you're in a nursing home. Even if it doesn't cover nursing home care, you'll need health coverage for hospital care, doctor services, and medical supplies while you're in the nursing home.
There are several other ways you can pay for nursing home care:
Personal resources

You can use your personal money and savings to pay for nursing home care. Some insurance companies let you use your life insurance policy to pay for long-term care. Ask your insurance agent how this works.
Help from your state (Medicaid)

If you qualify for Medicaid, you may be able to get help to pay for nursing home care costs. Not all nursing homes accept Medicaid payment.

Check with the nursing home to see if it accepts people with Medicaid, and if it has a Medicaid bed available. You may be eligible for Medicaid coverage in a nursing home even if you haven't qualified for other Medicaid services in the past.

Sometimes you won't be eligible for Medicaid until you've spent some of your personal resources on medical care. You may be moved to another room in the Medicaid-certified section of the nursing home when your care is paid by Medicaid. To get more information on Medicaid eligibility requirements in your state, call your Medicaid office.
Important things to know about Medicaid
Paying for care

You may have to pay out-of-pocket for nursing home care each month. The nursing home will bill Medicaid for the rest of the amount. How much you owe depends on your income and deductions.
Your home

The state can't put a lien on your home if there's a reasonable chance you'll return home after getting nursing home care or if you have a spouse or dependents living there. This means they can't take, sell, or hold your property to recover benefits that are correctly paid for nursing home care while you're living in a nursing home in this circumstance.In most cases, after a person who gets Medicaid nursing home benefits passes away, the state must try to get whatever benefits it paid for that person back from their estate.

However, they can't recover on a lien against the person's home if it's the residence of the person's spouse, brother or sister (who has an equity interest and was residing in the home at least one year prior to the nursing home admission), or a blind or disabled child or a child under the age of 21 in the family.
Your assets

Most people who are eligible for Medicaid have to reduce their assets first. There are rules about what's counted as an asset and what isn't when determining Medicaid eligibility. There are also rules that require states to allow married couples to protect a certain amount of assets and income when one of them is in an institution (like a nursing home) and one isn't.

A spouse who isn’t in an institution may keep half of the couple’s joint assets, up to a maximum of

$119,220 in 2016
, as well as a monthly income allowance. For more information, call your Medicaid office. You can also call your local Area Agency on Aging to find out if your state has any legal services where you could get more information.

Transferring your assets

Transfers for less than fair market value may subject you to a penalty that Medicaid won’t pay for your nursing home care for a period of time. How long the period is depends on the value of the assets you gave away. There are limited exceptions to this, especially if you have a spouse, or a blind or disabled child. Generally, giving away your assets can result in no payment for your nursing home care, sometimes for months or even ye

When in doubt, talk to Medicaid. My Mom is already on a state funded insurance for meds. My fasthers former employer pays her medical supplimental. If ur parent is paying for supplimental look to see if its worth keeping. With deductables and copays my Moms pays very little.

In our case, We were told Medicaid would only cover "Room and Board" for the nursing home. ( "Nursing Home Medicaid" instead of "Full Medicaid"). If a community spouse is insured through BCBS, check with the supplemental plan for it's rules about spousal coverage. This point proved tricky. If my spouse drops his private plan I loose coverage. His retiree benefits offer spousal coverage only if the retiree remains eligible for the company's plan.

All providers like patients to keep private insurance. It pays better than Medicaid. In some cases Medicaid is allowed to bill after the primary and supplementary have paid, but not always.

Medicare pays as primary and the private supplemental as secondary. Supplementary only pays if Medicare first covers a specific charge. Secondary pays a small portion only after Medicare first pays it's share.

I don't know if Medicaid can bill for anything not approved by Medicare first. If no supplemental is in place for your mom, she will likely have more out-of-pockets costs and these add up quickly.

The eligibility officer for Medicaid will advise you. If the gap premium garners more benefits than the premium, it makes sense to keep the gap. Past experience taught me the premium is paid by your mom (the one getting the benefit); and her share of cost is reduced by the premium. It should be a win win.

Stressed - also another ? to ask the about to move into NH/SNF, is how this NH deals with outside providers.

For both my late mom & MIL, once they moved into a NH, all their medical care & medications was now under the orders of the MD who is the medical director of the NH & under the direction of the DON (director of nursing & the true power center for a NH). No more going to see their old docs & getting RXs or care plans or orders for treatments from them. If they needed to see a specialist, the NH provided transport to the hospital /ER that took Medicare & Medicaid & worked with the NH's medical durector OR the specialist came to the NH (podiatrist & cardiologist did & they took Medicare & medicaid).

NH care really becomes a closed 24/7 system for care & kinda needs to be. The NH MD may review your moms old medical chart & medications & will likely jettison some items and change things to those that work better in a NH environment done by staff. For my mom & mil, Everything got billed to either Medicare (original) or medicaid. No need for supplemental & it's costs/copays & determination if the vendor participates with the supplemental insurer.

Now if you are thinking that mom may see her old docs, you may find continuing to take mom out of the NH to see her old docs becomes a contentious situation and brought up at the care plan meetings as a concern by the NH. CPM are required under Medicare, first done in about the first mo and then every 90/120 days thereafter. You want to get any concerns out & into writing at the CPMs as it's an opportunity to get stuff into moms chart as a permanent record. Comprende?

The government keeps cutting what is covered by medicaid and medicare, plus they have started finding ways to penalize doctors that make claims. This is to assume that doctors who make frequent claims are abusing the system, in return the doctors are put in a position to think twice about treatments. This also is why some doctors just dont want to accept medicare or medicaid, they want to treat people for their needs and not be scrutinized for the health care they provide. They are also trying to slowly force people to just be dependent insurance companies so they can continue to offer less and less and phase the programs out completely. Obama care was a 1st big step in that direction. Some of this is what is behind the pressure and sales to get people to take out supplemental plans, as time passes each yr they have planned cuts to go into effect where less and less is covered . They do not necessarily phase out the treatment but the approved amount they will pay for the individual treatment so the doctor get paid less, and if they are a violator or considered excessive claims they are penalized. A doctor who participates is put under pressure to offer less care . If the doctor has large numbers of patients on medicare and or medicaid , the more likely they will be scrutinized because of the number of claims they submit. The real abuse is coming from the insurance and drug companies who just have to keep raising premiums to make profit so they can pay out dividends to their stock holders and at the same time attract new investors. Even if everyone could take 100% generic drugs and or have excellent health they would have to find a way to still raise premiums to generate profits. U are looking at the slow eradication of it.

The government keeps cutting what is covered by medicaid and medicare, plus they have started finding ways to penalize doctors that make claims. This is to assume that doctors who make frequent claims are abusing the system, in return the doctors are put in a position to think twice about treatments. This also is why some doctors just dont want to accept medicare or medicaid, they want to treat people for their needs and not be scrutinized for the health care they provide. They are also trying to slowly force people to just be dependent insurance companies so they can continue to offer less and less and phase the programs out completely. Obama care was a 1st big step in that direction. Some of this is what is behind the pressure and sales to get people to take out supplemental plans, as time passes each yr they have planned cuts to go into effect where less and less is covered . They do not necessarily phase out the treatment but the approved amount they will pay for the individual treatment so the doctor get paid less, and if they are a violator or considered excessive claims they are penalized. A doctor who participates is put under pressure to offer less care . If the doctor has large numbers of patients on medicare and or medicaid , the more likely they will be scrutinized because of the number of claims they submit. The real abuse is coming from the insurance and drug companies who just have to keep raising premiums to make profit so they can pay out dividends to their stock holders and at the same time attract new investors. Even if everyone could take 100% generic drugs and or have excellent health they would have to find a way to still raise premiums to generate profits. U are looking at the slow eradication of it.

If her money isn't being paid for insurance , it will go to the NH, because on Medicaid a person is only allowed a certain amount each month for personal expenses. Dropping the insurance will not put any more money in her pocket.

In my Dad's case, we kept his private insurance because there are some doctors and hospitals that he likes that are not covered by the general plans. I would think there may be no need if you never anticipate going outside the facility she is in. Check that things like eyeglasses and hearing aids will be covered before you drop the private pay.

So very complicated. I would suggest you discuss with the NH again why to keep the additional coverage. Ask for specific examples. Stress that you thought Medicaid was to pay, so that's primary, what would Medicare supplement provide? It may be hospital care, renal failure care, but ask for specifics. Providers that don't participate in Medicaid are common, but it sounds like a buzzsaw to be in between.

So the person encouraging this is staff @ the NH? If so, it's likely they want mom to have an insurer to bill that pays a higher rate than what Medicaid pays.

You kinda need to clearly find out IF once mom goes onto Medicaid (mediCal) WILL moms old insurance stay in force or instead decline to pay as between Medicaid & Medicare they become her primary / secondary insurer AND will the old insurer do a clawback of payments? If so, this can become a real headache.

For my mom, she moved from IL (totally private pay & she saw the MDs of her choice of which most did not participate in Medicaid) to a NH (medicaid pending for almost 6 mos with all care funneling from orders given by the MD / medical director of the NH). Mom had a BCBS with extremely good coverage - like virtually no copay on anything even RXs. So the NH & their vendors started billing Blues for anything they could - drugs, PT & OT (lots of gait training), podiatry, ancillary services, ambulance, etc. Mom was "medicaid pending" so Blues paid as technically she was not on medicaid. But once Medicaid eligible, medicaid retro'd paynent back to day 1 of the application. If there is another insurer who could pay, other insurers often will suspended (or cancell) coverage and will do a clawback of all payments. The vendors needed to rebill to Medicaid. NH was notified of the suspension too. BUT since clawback doesn't happen immediately, could take several months to be done; plus payment adjustments are constant so a vendor may not really notice. What's bad is if some of the vendors don't participate in Medicaid so they will private pay rate bill mom & could be months / years later. My mom had a couple of bills from those who did not participate in Medicaid, & billed way over a year later which by that time mom had moved to a different (& better NH). Insurers will do whatever to lessen costs.

Medicaid pays about 1/2 to 2/3 less with stricter terms so vendors will not be as happy.....Try to find out clearly if the supplemental is guaranteed to pay & if till forever.