Need Free Help Fast?
For no fee (0$)) you can contact the Patient Advocate Foundation (PAF) to help you solve your insurance issues. The PAF employs case managers to help people with financial, insurance, and employment related issues relating to chronic, debilitating, and life-threatening illnesses. You can contact the Patient Advocate Foundation by calling 1-800-532-5274, by email at help@patientadvocate.org, and from their website at www.patientadvocate.org.
For issues related to Medicare or Medicaid, you can call the Medicare Rights Center phone hotline from 9:00am to 5:00pm Eastern time at 1-800-333-4114, or the official Medicare information line 24 hour a day, 7 days a week at 1-800-633-4227.
Health Insurance Basics
Today, health insurance helps pay for some of the medical costs associated with prevention, certain screenings, basic illnesses, and many major conditions. However, it is highly likely that you will still have out-of-pocket costs. When you add your out-of-pocket expenses to your monthly premium, which is the amount you pay every month for your policy, you can figure out about how much you will have to spend on your health care.
Before you start comparing policies it helps to know a few key terms:
Premium: The monthly amount you pay for your policy.
Deductible: How much money you have to pay each year before the policy coverage starts.
Co-pay: The amount you have to pay for services.
Co-insurance: The percentage of the total charges that you have to pay in addition to your co-pay.
Out-of-Pocket Maximum: The top amount a member will spend in cash outside the premium during the benefit year.
Since consumers are paying more of their medical expenses through higher premiums, higher deductibles, and co-insurance it is important to know exactly what your health insurance plan covers and what it does not cover. For most insurance plans the important rules fall into the following groups:
Doctors and Hospitals
Insurance providers sign contracts with certain doctors, hospitals, and providers to care for their plan members. Your plan will likely refer to these groups as providers. In return the doctors, hospitals, and providers agree to certain reimbursement rates for the services they provide, and to follow the plan’s rules. This group of providers is often called the plan’s network.
Tip: Your insurance company might not pay for you to go to a provider who is not in its network, or it may pay much less. You are responsible for the part of the bill that the plan doesn’t pay.
Even if your doctor is part of the plan’s network, he or she may prefer to send patients to a hospital that is not in the network. If that happens, ask if your doctor can send you to a hospital in the network. If that is not possible, you can ask the insurance company if it will approve the use of the out-of-network hospital. If no other arrangements can be made you might have to choose a different doctor who has privileges at a hospital that is in your network. Your insurance company customer service can help you find qualified doctors who practice at in-network hospitals and treatment facilities.
Rules for Seeing Specialists
Many managed care plans, especially health maintenance organizations (HMOs) will not pay for you to see a specialist unless your primary care physician thinks it is necessary. If you see a specialist without a referral you might have to pay more for the care you receive.
Rules for Getting Expensive Services
If your doctor decides that you need to go to the hospital, have surgery, or have certain tests, your insurance company may refuse to pay for it unless it can pre-authorize the treatment; (approve it beforehand).
Medicines
Almost every managed care plan has a drug formulary. A formulary is a list of prescription medicines that your health plan has approved. If a drug isn’t on the formulary you will probably have to pay more for it. Your insurance company can give you a list of drugs that are on the formulary. If necessary, show the list to your doctor when the doctor writes you a prescription.
Choosing a Health Insurance Plan
Here’s how to choose the health insurance that works best for you.
Step 1. Understand the details of each policy.
If you don’t understand the details call the insurance provider and ask them to explain how much money you will be responsible for paying on each plan you are considering. Make sure to ask about your monthly payment, your deductible, your coinsurance, and to get a list of benefits; (what is covered, and what is not).
Step 2. Calculate your expected annual cost for each policy.
Calculate your health costs for the coming year to see if you are better off with a high deductible and lower monthly bill, or a lower deductible but higher monthly premium. The way to do this is to add the amount of money you spent out of pocket on prescriptions, doctors’ appointments, and medical devices and equipment in the past year and compare that with the co-payments and/or co-insurance offered by the plan you are considering.
If you choose a high-deductible option, consider using a Health Savings Account (HAS) to set aside pretax dollars to pay for medical expenses. HSAs are explained later in this section. You must record your use of this account and keep detailed records. Don’t forget to add the expenses for all of the people who will be covered by the policy. As best you can, consider any additional or likely expenses for the upcoming year.
Step 3. Based on the type of services you expect to need, compare the costs of using doctors who are in the network vs. doctors and hospitals that are not in the network. Check the maximum out-of-pocket amount to see whether the deductible, co-payments and pharmacy expenses can be applied toward it.
Step 4. Before you decide what policy is best for you, take the time to contact the insurance company and get answers to all of your questions.
Step 5. Compare the performance of the plans you are considering.
Many health care organizations, such as the nonprofit National Committee for Quality Assurance (NCQA), gather data on how well doctors and facilities in managed-health-care plans follow practice guidelines. Then they use the results to grade those practices and facilities. To see how your health plan and others in your area fare, go to www.healthchoices.org. Experts hope that eventually the grades will extend all the way down to practice groups and even individual physicians.
Working with Your Insurance Company
Health insurance plans can be confusing. However, you are responsible for knowing what benefits you are entitled to under your policy. If you do not fully understand something, ask your insurance representative or your employer’s benefits administrator to explain it.
Following the steps below can help you work with your insurance company to make sure you receive all the benefits to which you’re entitled.
Step 1. Make sure you have accurate contact information for your insurance company.
Step 2. Contact your insurance provider and request an up-to-date copy of your plan, and its summary.
This will tell you how your plan works, its benefits, and how to file a claim. Be confident when calling your insurance company. You are their customer. You have the right to receive complete information regarding your health benefits. Your insurance company’s customer service representatives are there to assist you. Part of their job includes answering questions to your satisfaction. Communicate as clearly and calmly as possible. Be courteous and polite, even if you are not happy with your insurance provider. The person on the other end of the phone probably wasn’t responsible for what ever has disappointed you. Remember that your goal is to get coverage for what you need.
If you are met with resistance, simply restate your request. Carefully follow the steps outlined by your health plan for requesting prior authorization, submitting claims or filing appeals. Not following these steps may result in a delay in processing or a denial of your request for coverage.
Tip: Don’t give up. Don’t take “No” for an answer.
If you have tried discussing your request with your health plan’s customer service representative, but are not satisfied with how your insurance matter was handled, ask to speak to a Supervisor in the Customer Service Department, or the Manager or Director of Customer Service, or Member Services.
Follow up in writing or email after speaking with a health plan representative on the phone. Keep your correspondence simple and to the point. Include relevant dates, names of representatives with whom you spoke to, and what they told you. Also be sure to include your name, policy number and any other identifying information. Do not hesitate to ask for help from your employer’s human resources department and your healthcare provider.
In many cases, your employer makes decisions about what will and will not be covered under your health plan. Your employer’s support may result in the approval of your request for coverage. Having your healthcare provider (doctor) contact your insurance representative can also be helpful since he/she can support the communication that you have had with your insurance company as to why the requested medical products or services are needed.
Advocate for yourself at all times. If needed, write to your state health insurance commissioner and/or your state and federally-elected representatives to enlist their help. Informing them of your health needs and what has occurred with your health plan insurance claims. Notify your insurance company that you have requested help from the State Health Insurance Commission and other agency representatives in resolving difficulties in meeting your healthcare needs.
You can make a difference! Remember the expression, “the squeaky wheel gets the grease.” The more you make your needs known, the more likely you will get those needs met!
Working with Insurance Providers after a Diagnosis
Once you have determined your preferred treatment with your doctor(s) find out which procedures require you to pay a co-payment and co-insurance, and how much they will be. If you buy your own insurance rather than receiving it as a benefit of your or your spouse’s employment, make sure you pay your premiums on time.
Tip: Request a Case Manager to speak with each time you call your insurance company.
Tip: Make notes about each call. Record of the date, the name of anyone you spoke with, and any instructions you were given. You can save and organize your records with a few file folders, a more elaborate system, or by scanning and saving them on your computer.
If your doctor wants to refer you to one or more specialists make sure they are covered in your plan. If they are not in your network and you still feel you want to see them, consider that you will likely be responsible for that doctor’s entire fee.
Organize your records and paperwork, including bills, claims, payments, a record of phone calls to and from doctors and your insurance company, and letters to and from your employers, doctors, and insurance company. Include dates, who you spoke to, and a brief note for each occurrence.
If you’re required to submit bills to your insurance company, try to send them in as soon as you get them. If you’re recovering from treatment, ask a loved one or friend to help you.
Handling Claims
Keep detailed records of all the claims you submit and note when they were submitted, whether they’re still pending, and when they were paid. Also keep copies of any and all paperwork related to your treatment, diagnosis, and insurance claims, including:
- Requests for sick leave
- Receipts
- Letters from your doctor, employer, and insurance company
- Letters you write to your doctor, employer, and insurance company
- Bills
- Summaries of phone calls to your insurance company, including the date, time, and the person’s name to whom you spoke
Managing Costs
Know if the procedure you want requires you to pay a co-payment and co-insurance and how much they will be. Ask how you are required to pay for treatment. Does your insurance company make the first payment? Or do you pay the bill and then get reimbursed? If you’re required to submit bills to your insurance company, try to send them in as soon as you get them. If you’re recovering from treatment, ask a loved one or friend to help you. Section 13 of this book is devoted to helping you reduce and manage your healthcare costs.
Fighting Insurance Denials
Many insurance companies deny claims just because they know there is a good chance the consumer will not appeal. Just by taking control and advocating for yourself you let the insurance company know that you are not going to go away without a fight for the coverage you expected and are paying for. Sometimes just being the persistent and polite pest is enough to get your denial reversed.
So, how do you know if your claim is denied? An Explanation of Benefits (EOB) which is sent by your insurance company to you is one of the only ways to determine what the insurance paid to the provider and how much you may still owe. The EOB should also disclose if your claim has been denied. If the insurance company portion of the payment shows $0, this can indicate a denial. The payment amount should be followed by a “Reason Code(s).” This code provides an explanation for the lack of payment. The insurance company may also send you a letter confirming the denied medical claim and detailing their reason(s) for denial.
Make sure to keep copies of all correspondence you receive from the insurance company, including denial letters and approval letters.
Make copies of all correspondence you send to the insurance company, including letters, your health history, medical files, doctor’s letters, etc. As mentioned earlier in this section, keep a written record of all contact and phone calls with the insurance company
If your insurance company denies a claim, follow the steps below:
Step 1. Check your plan to make sure the benefit you want is included. Make a note of the part of the policy that leads you to believe your claim should not have been denied.
Step 2. Collect and organize all information pertaining to the denied claim. Make sure you have the original bill (containing the date(s) of service and the provider’s name), your EOB, and your insurance card before placing a call. If the insurance company sent you a letter have that available as well.
Step 3. Call the number provided on the letter from your insurance company, or if you did not receive a letter call the customer service number. There is a possibility the claim was denied because of missing information. Once the missing information is provided the claim will be re-processed and you’re done.
Step 4. Sometimes claims are denied because of miscoding. If that is the case, ask your doctor to review the coding and re-submit a request with more specific medical justification for the procedure or medication, and you should be done.
Step 5. If your claim was not denied for missing information or miscoding, find out why it was denied and how you can file an appeal.
Step 6. Ask the insurance provider’s representative for suggestions or guidelines for appealing a denial.
Step 7. If you would like an appeal form, ask them to send one via the mail or email.
Step 8. Make sure you have the address for the appropriate department to return the completed appeal documents.
Step 9. Always keep a record of the date, time and the name of the insurance provider representative you talked with, along with a brief summary of the discussion. Keep this with copies of any documents you send to the insurance company.
Tip: For no charge, the Patient Advocate Foundation (PAF) will help you solve your insurance issues. Contact the Patient Advocate Foundation by calling 1-800-532-5274, by email at help@patientadvocate.org, and from their website at www.patientadvocate.org.
Step 10. In appealing the denied claim, you should have the opportunity to review the information the insurance company used to make their decision.
Step 11. If necessary, get your doctor involved. Their office should have staff that can help explain why the procedure or care is needed, or medically necessary.
Step 12. Get help wording your appeals so that it mentions medical problems and does not include words that automatically trigger denials. Talk to the person who handles insurance claims at your doctor’s office. This person may be able to help you with the appeal process and provide any documentation your insurance company requires.
Step 13. Remember each insurance company has its own appeal process. Before submitting your information, make sure you have completed and include all the required paperwork. Once all your documents are complete make a copy of everything for your reference.
Step 14. Continue to go through all levels of appeal.
Step 15. If your insurance company denies the claim again, in most cases, you can contact them to request an external appeal. Usually this appeal will be conducted by a medical professional or group of medical professionals not associated with the insurance company.
Step 16. Sometimes it takes the threat of a lawsuit to get your insurance company to move.
Send all your correspondence to the insurance company via certified mail with return receipt. Be persistent. Remember that a denial is not necessarily the final word. Ask your insurance company to reconsider their decision and follow-up to make sure they take action.
Medicare
Medicare is health insurance offered by the federal government to people who are 65 or older and meet specific eligibility requirements. The specific requirements can be found on the Medicare website at http://www.medicare.gov. Some people qualify for both Medicare and Medicaid. This is called “dual eligibility.”
The Original Medicare Plan is a fee-for-service plan that covers many healthcare services and certain drugs. Usually, you can go to any doctor or hospital that accepts Medicare. With all the recent and expected changes to Medicare, it is important for you to contact your local Medicare office to discuss your situation every time you expect to need services. At the end of your conversation you want to know as best you can what expenses Medicare will cover, and what your financial obligations will be.
Medicare has four parts:
Part A helps pay for hospital bills. Part B is a supplemental insurance option that pays for physician services and supplies outside of the hospital. Part C includes private health plans that are Medicare approved. Part D is prescription drug coverage.
Part A: Hospital Coverage – The Basics
When you sign up for Medicare, you automatically get Part A. If you or your spouse paid Medicare taxes while you worked, you will not have to pay a monthly premium for Part A coverage. If you paid Medicare taxes for less than 7.5 years your premium was about $460 per month at the time of researching this book. If you paid Medicare taxes for more than 7.5 years but less than 10 years, your premium was about $255 per month.
Part A covers much of the cost of inpatient hospital stays including semi-private room, food, tests, and doctor’s fees. However, Medicare beneficiaries still pay a portion of their costs. Part A also covers brief stays in a skilled nursing facility if certain criteria are met. In general, the criteria are:
- A preceding hospital stay must be at least three days, three midnights, not counting the discharge date.
- A nursing home stay must be for something diagnosed during the hospital stay, or for the main cause of hospital stay.
- If the patient is not receiving rehabilitation but has some other ailment that requires skilled nursing supervision, then the nursing home stay would be covered.
- The care being rendered by the nursing home must be skilled.
The maximum length of stay that Medicare Part A covers in a skilled nursing facility per ailment is 100 days as of the writing of this Guide. The first 20 days are paid for in full by Medicare, with the remaining 80 days requiring a co-payment. If a beneficiary uses some portion of their Part A benefit and then goes at least 60 days without receiving facility-based skilled services, the 100-day clock is reset, and the person qualifies for a new 100-day benefit period.
Medicare part A does not pay for custodial, non-skilled, or long-term care. It does not pay for help with activities of daily living (ADLs). Examples of ADLs are personal hygiene, cooking, cleaning, bathing, etc.
Part B: Medical Coverage – The Basics
The purpose of Part B is to cover physician and medical services not covered under Part A. The additional services covered typically include:
- Doctor visits as an inpatient or outpatient, at a hospital, doctor’s office, or health care facility.
- Laboratory tests and X-rays.
- Physical therapy or rehabilitation services.
- Ambulance service.
- Some home health care.
- Some medically necessary medical equipment.
Medicare Part B is optional. It can be deferred if the beneficiary or their spouse is still actively working. However, you must sign up for Medicare Part B if you want it.
If you sign up you will pay a monthly premium and yearly deductible. The premium cost may increase each January, and it is deducted from your Social Security check. You are also responsible for a twenty percent co-payment for the services and supplies you are approved for. If you do not sign up for Medicare Part B when you are first eligible, you may have to permanently pay a higher monthly premium.
Part B coverage includes physician and nursing services, x-rays, laboratory and diagnostic tests, influenza and pneumonia vaccinations, blood transfusions, renal dialysis, outpatient hospital procedures, limited ambulance transportation, immunosuppressive drugs for organ transplant recipients, chemotherapy, hormonal treatments, and other outpatient medical treatments administered in a doctor’s office.
Tip: The actual administration of medication is covered under Part B only if it is administered by the physician during an office visit.
Part B also helps with durable medical equipment (DME), including canes, walkers, wheelchairs, and mobility scooters for those with mobility impairments. Prosthetic devices such as artificial limbs and breast prosthesis following a mastectomy, as well as one pair of eyeglasses following cataract surgery, and oxygen for home use are also most often covered.
Deductible and Coinsurance
After a beneficiary meets the yearly deductible, they are required to pay a co-insurance of 20% of the Medicare-approved amount for all services covered by Part B. Lab services are an exception, and they are often covered at 100%. You may also be required to pay an excess charge of 15% for services rendered by non-participating Medicare providers.
Part C – Private Health Plans (Medicare Advantage)
Medicare part C gives consumers the option to receive their Medicare (Parts A and B) benefits through private Medicare approved health plans. When you join this type of plan you are still in Medicare. Often called Medicare Advantage Plans, private plans often cover more services and have lower out-of-pocket costs than the original Medicare plan.
These plans are not available in all areas. They usually include: Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), Private Fee-for-Service Plans, Medicare Special Needs Plans, and Medical Savings Account plans (MSA)
Medicare Advantage plans provide hospital and medical coverage and medically necessary services. They generally offer extra benefits, including drug coverage. For people who choose to enroll in a Medicare Advantage health plan, Medicare pays the private health plan a set amount every month for each member.
Members of these plans pay a monthly premium to cover items not covered by traditional Medicare; (Parts A & B). These items may include prescription drugs, dental care, vision care, and gym or health club membership. These plans often restrict members to a network of providers they can use without having to get special permission and/or paying extra themselves. That means you may have to see the plan’s doctors, and go to certain hospitals to get care if you want the plan to pay their part of the expense
If you have a Medicare Advantage plan, you don’t need supplemental insurance, or a Medigap policy.
Medigap Plans – The Basics
Medigap policies are standardized by the Centers for Medicare & Medicaid Services. They are sold and administered by private insurance companies. They cover some of the out-of-pocket costs from Medicare part A & B. Medicare beneficiaries can not have both a Medicare Advantage Plan and a Medigap Policy. Medigap policies may only be purchased by beneficiaries that are receiving benefits from Original Medicare; (Parts A & B).
Medigap plans are not like Medicare Advantage plans that run HMOs and PPOs. Examples of expenses that are usually covered by Medigap plans include co-payments, coinsurance, and the yearly Medicare deductible.
Tip: A Medigap policy can only cover one person. If you are married both you and your spouse must buy separate policies.
There can be big differences in the costs and benefits of various plans. Therefore, the government requires that the companies providing these plans must clearly identify that the policy is a “Medicare Supplement Insurance” on the front of each policy.
Remember, that Medicare pays for many healthcare services and supplies, but it doesn’t pay all your health care costs. There are costs that you must pay, like coinsurance, co-payments, and deductibles.
You might want to consider buying a Medigap policy to cover these gaps in Medicare coverage, or a Medicare Advantage policy to replace your original Medicare Plan. Some Medicare Advantage Plans include prescription drug coverage. You can also add prescription drug coverage by joining a Medicare Prescription Drug Plan.
Comparing Plans and Plan Ratings
To compare health plans and Medigap policies go to the Medicare website at www.medicare.gov. From the home page, click on “Compare Health Plans.” You can also compare prescription drug plans, nursing homes, hospitals, home health agencies, and dialysis facilities from the www.medicare.gov website.
In December 2009 the Kaiser Family Foundation published a report that rated Medicare Advantage organizations on a five star scale. The ratings were based on data from CMS, the Consumer Assessment of Healthcare Providers and Systems (CAHPS), the Healthcare Effectiveness Data and Information Set (HEDIS) data, and the Health Outcomes Survey (HOS). New plans did not receive ratings, because data was not available. Almost sixty percent of the Medicare Advantage programs were rated. The rated plans represented 85% of the enrollment for 2009. The report found the following:
- Private fee-for-service plans and regional Preferred Provider 0rganizations (PPOs) had below average ratings that were significantly lower than traditional HMOs and local PPOs.
- Non-profit plans had higher ratings than for-profit plans.
- Plans with contracts that began before 2004 had higher ratings than newer plans.
Part D: Prescription Drugs – The Basics
Some Medigap policies sold before 2006 may include coverage for prescription drugs. Medigap policies sold after the introduction of Medicare Part D on January 1, 2006 are prohibited from covering drugs.
Medicare Prescription Drug Plans are stand-alone plans that add prescription drug coverage to the original Medicare plan, some Medicare Cost plans, some Medicare Private Fee-for-Service plans and Medicare Medical Savings Account plans. To compare health plans and Medigap policies go to the Medicare website at http://www.medicare.gov. From the home page, click on “Compare Drug Plans.”
Part D is prescription drug coverage provided by private companies. Everyone with Medicare can get this coverage. There is usually a monthly premium for this coverage. If you decide not to enroll in a drug plan when first eligible you may have to pay a penalty if you join later. Part D coverage is not standardized by Medicare. Each plan is free to choose which drugs they cover, what their coverage levels are, and which drugs they don’t cover. If plans cover drugs excluded from coverage by Medicare, they are not allowed to pass these costs along to Medicare.
If you are dual eligible for Medicare and Medicaid, consider that Medicaid may pay for drugs not covered in a Medicaid part D plan.
Medicare Prescription Drug Choices
The decision to get Medicare prescription drug coverage depends on how you intend to pay for your drugs now and how you get your Medicare coverage. Most people with Medicare pay for drugs and get their Medicare in one of five ways:
- Original Medicare only.
- Original Medicare and a Medigap policy without drug coverage.
- Original Medicare and a Medigap with drug coverage.
- A Medicare Advantage Plan (like an HMO or PPO) or other Medicare Health Plan, which already include drug coverage and other extra benefits.
- Dual coverage from Medicare with Medicaid drug coverage. These people currently receive comprehensive prescription drug coverage from Medicare.
If you have specific drug needs due to a medical condition, Medicare’s Formulary Finder lets you enter a typical combination of drugs used by people with a certain condition to find out which plans in an area have formularies that cover these drugs.
Joining Medicare
Individuals receiving Medicare benefits have a lot of information to go through. If you have never enrolled in Medicare and are about to do so for the first time, you too will need a lot of questions answered to make the best decisions. One of the most important tools available is a handbook put out through the federal government called “Medicare and You.” The most recent government handbook can be found at the www.medicare.gov/publications/website. Consumers can also get a free and secure assessment of their personal Medicare benefits and services at http://www.mymedicare.gov/.
You can join Medicare every year between November 15th and December 31st. At that time, you can make any changes to your existing coverage. On January 1st each year your new coverage becomes effective. There are other sources of information in most areas of the country. Wherever you live, you can get information through your doctor, State Health Department, the Department on Aging, senior centers, or other healthcare or senior organizations.
Medicaid
Medicaid pays for your health care if you are qualified. It is a state and federal partnership that provides health coverage for selected categories of people with low incomes. Its purpose is to improve the health of people who might otherwise go without medical care for themselves and their children.
Medicaid is a state administered program and each state sets its own guidelines regarding eligibility and services. Each state has rules. These rules may be for those in nursing homes. They may be for a child with a disability who lives at home. Usually, a state caseworker will work with you. Most states have programs to help certain people who do not get Medicaid.
Depending on your state, you may also have to pay a small part of the cost. This is called your co-pay. Many groups get Medicaid. You may get Medicaid based on your age, if you are pregnant, if you have a disability, and by your income and resources.
As a general rule, if your income is low and you meet one of the following criteria, your odds of qualifying for Medicaid are good. Criteria include if you are pregnant, or the parent or guardian of minor children, or aged, or blind, or disabled. Many groups of people are covered by Medicaid. Low income is only one test for Medicaid eligibility; assets and resources are also tested against established thresholds.
Medically needy persons who would be eligible except for income or assets may become eligible for Medicaid solely because of excessive medical expenses. As noted earlier, the rules for counting your income and resources vary from state to state and from group to group. There may also be special rules for those who live in nursing homes and for disabled children living at home.
Your child may also be eligible for Medicaid coverage if he or she is a U.S. citizen or a lawfully admitted immigrant, even if you are not. However, there is a 5-year limit that applies to lawful permanent residents. Eligibility for children is based on the child’s status, not the parents. Your income does not apply to this child. If a person’s child lives with you, he or she may get Medicaid. Apply for Medicaid to find out if you can get it.
People who are eligible for Medicaid may or may not also receive cash assistance from federal programs like the Temporary Assistance for Needy Families (TANF) and/or Supplemental Security Income (SSI) programs. You should contact your state Medicaid office to find out if you are eligible for benefits. For the most part, you should apply for Medicaid if your income is low and you match one of the descriptions of the eligibility groups in your state, and you or your family needs health care. This will allow a qualified caseworker in your state evaluate your situation.
Remember, Medicaid does not pay money to you; instead, it sends payments directly to your health care providers. Depending on your state’s rules, you may also be asked to pay a small part of the cost (co-payment) for some medical services.
Screening Tools – Know Your Benefits
To help you see if you may be eligible for a variety of federal, state, and local programs, you can use the www.govbenefits.gov and www.benefitscheckup.org.
When Medicaid Eligibility Starts
Coverage may start retroactive to any or all three months prior to application, if the individual would have been eligible during the retroactive period. Coverage generally stops at the end of the month in which a person’s circumstances change. Most States have additional “State-only” programs to provide medical assistance for specified poor persons who do not qualify for the traditional Medicaid program. No Federal funds are provided for state-only programs.
Low-income Medicaid beneficiaries who would otherwise become ineligible for Medicaid due to an increase in wages or hours at a job are entitled to up to 12 months of Medicaid benefits under the Transitional Medical Assistance (TMA) program. This temporary coverage increases the likelihood that low-income people who start a job or find higher-paying work will not lose the security of health coverage because they found a job or will earn higher pay.
Working with a Medicaid Case Manager
Family Tips Checklist
If you are getting ready to interview or hire a professional case manager for yourself, a family member, or a loved one, here are some questions you may want to ask during the interview process:
- How long have you been a Case Manager?
- How many people are on your case load?
- Where do you live?
- How often do you contact each client and their families?
- How do you communicate with service providers?
- Do you develop a care plan for your clients?
- How often do you review and update your clients care plan?
- What is the best way to contact you?
- What if is an emergency and we can’t reach you?
Medicaid Planning
There are a few things you can do using Medicaid planning to rearrange finances and legally shelter your assets from the state. The strategies can be very complicated so you may want to consult an elder law attorney to help you with the specifics. You can find qualified Elder Law Attorneys in your area at the National Association of Elder Law Attorneys (NAELA) website which is found at http://www.NAELA.org.
Medicaid planning helps shelter assets, preserve assets for heirs, and provide resources for a healthy spouse. The total value of your countable assets including your income determines whether you are eligible for Medicaid. Under federal guidelines, each state has a list of exempt assets. This list usually includes items like your home, prepaid burials and contracts, term life insurance, and one automobile.
You can rearrange your finances so that countable assets are exchanged for exempt assets and thus made inaccessible by the state. For example, you can exchange spending your savings on nursing home bills for:
- Paying off the mortgage on you family’s home.
- Prepay for burial arrangements.
- Make home improvements.
- Purchase one car for your healthy spouse.
Preserving assets for your children and heirs allows you to provide financial help for your loved ones. An irrevocable trust can help you accomplish this. Consult an experienced attorney about how to set this up for your circumstances because “irrevocable” means that you can not come back and change it later or decide to end it. Not to mention, that laws vary from state to state and from year to year.
Property placed in an irrevocable trust will be excluded from your financial picture for Medicaid purposes. Anything that you place into the trust can be sheltered from the state and preserved for your loved ones. More often than not the trust must be in place and funded over a specific period of time for it to be an effective Medicaid planning tool. You might be able to use an annuity to guarantee that your spouse has enough money to live on if you have to go to a nursing home?
When the state is considering eligibility for Medicaid a couple’s assets are pooled together. Your healthy spouse is generally given a resources allowance amount to one-half of the assets. As you can imagine this may not be much money over the long term especially if your spouse needs to take time off of work.
If you’re married an annuity can help protect your healthy spouse. An important loophole in the current law is that your healthy spouse can use jointly owned countable assets to buy a single premium immediate annuity for their benefit. By doing so, you effectively convert countable assets into an income stream. Each spouse is then entitled to keep all of their own income instead of pooling assets. The end result is that the institutionalized spouse can more easily qualify for Medicaid.
Medicaid Planning Risks
Since laws vary from state to state and from year to year, Medicaid planning is more effective in some states and at certain times than others. For example, when you are applying for Medicaid the state has the right to look back at your finances for a period of months before the application date. Generally, there is a 36-month look-back period for transfers of countable assets, along with a 60-month look-back period for similar transfers into irrevocable trusts.
Countable asset transfers for less than fair market value made during the look-back period will commonly result in a waiting period before you can start to collect Medicaid. For example, transferring your house to your children a year before entering a nursing home may make you ineligible for Medicaid for quite some time.
Without question, you should consult with an experienced Elder Law attorney who is experienced at Medicaid planning in your state. They will be aware of the look-back periods, estate recoveries, possible disqualifications for Medicaid in your state, and all the details you need to be aware of.