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My 92-year old mother who has dementia has been approved for Medicaid Star-Plus Waiver to receive in-home care beginning Jan 1, 2019. However, her Medicare will also change to Medicare Advantage, which is an HMO, so she will lose her doctor. Is there a way to keep her regular Medicare and still receive in-home care paid by Medicare or Medicaid? I am at my wits end trying to get answers from Medicare and Medicaid, to no avail.

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Countymouse - yeah US health system beyond complicated.
and it’s going to only get much worse when the tsunami of boomers start hitting needing care AND LTC facilities in big #s in about 5 years. It’s going to be beyond awful for Aging in America unless your really wealthy. Like top 25% on a NY, MA level. As a health planner last millennium I flat cannot believe we are abt to hit 2019 and folks in the US cannot understand what single payor is much less why it needs to be done. It’s not ideal but at least it’s a standard framework.

If I recollect correctly the maximum that SS will pay for ‘19 for folks who do FRA is $2,861 and about half new retirees will get paid the max as they worked during the boom years so have big SS entitlement due. So none of these will ever, ever, ever be able to be eligible for LTC NH Medicaid like our parents have been as our folks get $800-$1500 SS so under the Medicaid eligibility max of abt $2100 mo income.

Just where are the boomers supposed to go to live and get care?? Their not ever to be eligible for Medicaid. Care in their kids homes, yeah sure and I’m getting into my size 6 slacks again.

If you have a good employer sponsored plan in the US, it’s actually pretty straightforward if your in a big city to get care with somewhat manageable copay. Like for us in New Orleans, we have 3 competing health systems. But if you live out in the country, there’s no real options. When hubs had day surgery, waiting room filled with folks who had to drive in 2+ hours as no surgery center for what they needed that was covered by their plan. and those with experience knew to bring phone chargers, pillow, blanket and snacks. It was like a bad airport terminal situation.

We’ve been thinking Uruguay (you guys have a British hospital there with a expat plan that’s pretty great & comprehensive) ...... plus its young demographic country so probably won’t be quite so peeved with old foreign retirees as neighbors.
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Lots and lots of info from people here who are trying to be helpful, but might not understand how Medicare and Medicaid work together in Texas. Medicare plans can vary from state to state, and Medicare Advantage Plans even vary from county to county. Medicaid rules vary even MORE between states, so it's important to talk to *local* people who are in the know when it comes to something as important as health insurance coverage.

My suggestion:

As you live in Dallas, you can call the North Central Texas Area Agency on Aging and speak to someone in Information & Assistance or ask for a Benefits Counselor. They probably have a deeper understanding of how Medicare works with the Medicaid programs available in Texas.
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I know how you feel. I recently applied for a Medicaid Waiver and got so confused I finally gave up. The problems I’ve heard with MA plans is mostly that most doctors don’t accept Advantage. I’m afraid if she wants to keep her doctor, she will have to self-pay.
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Medicare Advantage plan is NOT Medicare. They turn everything over to your new insurance company. Ask them, they will tell you, you are no longer on Medicare when you get an Advantage plan.

The name is deceptive and it causes lots of confusion.
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mmcmahon12000 Nov 2018
That's not true! You have to have Original Medicare parts A & B to qualify for a Medicare Advantage Plan in the first place. If you don't have either, you don't get access to an MAPD. The Advantage plan covers the 20% left by Medicare when you see a dr. That means you still have to maintain parts A & B of Medicare bc of what it's designed to do. An MAPD plan covers parts C & D outside of Original Medicare.
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No, she would have to decline waiver OR old MD would have signed a contractor agreement with waiver group earlier this year & MD would have sent out letters to their patients informing first of 2019 change.
Why? ..... this is gonna be long, get a cup of coffee.....

To me, the “wits end” issue is your not speaking with the service provider for her new star plus waiver. It’s not MediCARE (CMS) or state of TX Medicaid per se but insurance contractor who is managing waiver she signed up to be on starting 1/1/19. Look to see if her new plan is with “Superior Health” (if not Superior it’s another group like them).

They are the big BIG player for Medicaid waivers in TX. Their HQ is in Austin. & they do all types of Medicaid waivers, like they have health providers and programs from kids on CHIP (medicaid for kids from low income families) to at home health services for elderly.

It runs on an “Advantage“ program model for Medicare in that in order for your mom to have coverage with no or low copay she MUST ONLY see the providers & facilities in the Superior network as they are under contract with Superior at predetermined rates of reimbursement. Advantage model is similar to an HMO but true HMOs (like Kaiser Permanente) requires you to be part of a group / employer in order to belong to the HMO; for Advantage anyone eligible for Medicare can enroll in the Advantage plan if available in your area. The vibe I’m getting for a Superior is they are using the Medicare hospice system for elder care in that there is an overall MD group that that evaluates and determines care needed or uses the state’s needs assessment on her to determine what level of in home services she’s requiring (like say she’s assessed at 23 hrs a week of caregiver). But the actual boots on ground (in your mom’s case boots in the house as it sounds like in home care) will be done by NP, or maybe PA, on the once or twice a week in home visit and all other care done by CNAs. Whatever service needed has to be done by the best way to contain costs within the existing network which means services only with providers under contract and an NP or PA is lots less $$ than an MD. If your mom is the type thats used (& likes) to going every mo or 8 weeks to her old MD office, those days are over. She only gets to get an MD appointment if the weekly NP/PA assessment shows need; and the MD will be at the clinic or health care system contracted with Superior.

Your mom seeing her old MD, if he’s not with the Advantage plan will be totally out of network AND cannot be at all billed to either MediCARE or Medicaid; it will be truly private pay. Unless her doc has moved to “concierge” model to bill, his office will be befuddled to even figure out how to bill to your mom. Plus this downstreams to payment on lab work done, therapist seen, RXs filled.....

Google Superior Health Plan, HQ on Ben White in Austin, they have a good website that gives an overview of how it runs. It’s pretty tight. Their all over TX. If she’s not with Superior again it’s going to be another Advantage plan like Superior. As an aside, I wouldn’t be surprised that they have a model to take over services at SNF & that will be the final nail for smaller NHs already struggling to stay open in TX.

My mom (dead a couple of years now), got a raft of letters from a bunch of her old old MDs at beginning of 2018, notifying her of new alignment with various MediCARE Advantage plans OR that they were leaving their old medical group effective 1/1/19. Letters literally sent to patients going back a decade.

Did you ask what her old MD participates in?
Your moms old MD might be affiliated with another Advantage plan, but not with Star Waiver. Or old MD might not do any advantage plan but only take original MediCARE & gap supplemental.

Out of curiosity, why go the in home waiver system?
Why not go for SNF / NH onto Medicaid placement for your mom?
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anonymous594015 Nov 2018
It's an excellent suggestion to ask the business manager at her current doctor's office to advise you. The doctors don't usually know which insurances they accept. Their business office does.
We also had an Aging Life Specialist help our elderly parents go through their options for insurance. She was a big help because she was aware of all the ifs, buts and ands associated with the policies. She did not tell them which one to pick but she made sure they were aware of the benefits/deficiencies of each.
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According to this article about 20% of people can be on Medicare and Medicaid at the same time.
https://www.medicareresources.org/faqs/can-i-be-enrolled-in-medicare-and-medicaid-at-the-same-time/
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Rock and hard place here. Medicare does not pay for in home care. Yes, once on Medicaid, you use their doctors. She cannot selfpay for her doctor. Reason being if she has the money to pay her doctor, then she doesn't need Medicaid. The doctor knowing she is on Medicaid should not except payment.
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anonymous594015 Nov 2018
It might be dependent on the state. Our family member is eligible for Medicaid services in the home and is still able to see her own doctors.

It sounds like Chynabelle's problem is her mother changed her Medicare plan and the current doctor won't take the new Medicare plan. Medicaid services in the home has nothing to do with it.
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😖

How are you not all fit to be tied?

How the heck does anyone in America ever know what doctor they're supposed to register with and to whom they're supposed to hand their wallets?

I suppose it's out of the question for Chynabelle's mother to retain this doctor privately, for old times' sake? - if the family were able to afford his fees, perhaps.
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worriedinCali Nov 2018
Self pay is not really an option because if you can afford to self pay, you don’t need Medicaid. We don’t have to register with a specific doctor. We have to use one “in-network” or who takes our insurance and it’s very easy to find out who does. You can call a specific medical practice and ask, you can call your insurance and ask-many will even give a list of providers :)
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She may not be able to keep her current doctor. Give the new one a chance.

I have seen so many instances of older people being forced to switch doctors (either for convenience sake or because of insurance) and EVERY time they wind up being healthier and (therefore happier). Often, no matter how well-intentioned and beloved a person's current doctor is, a fresh look from a new doctor can result in adjusting meds and re-evaluating diagnoses. American seniors are often over-treated and that means lower quality of life.
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If she’s in Dallas, for Star + Plus waiver 2 choices - either Superior or Molina. They both use a Managed Care Option type of program. It looks like MCO allows only in network MD but you can pick the MD and can change doctors and see another but have to wait to get change allowed letter before you see a new MD.

Star + Plus will pay for family caregivers but not for spouse caregiver. There is a waiting list & current in a NH residents given priority to get the waiver.
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rovana Nov 2018
Igloo, could you comment on the issue of dual eligibility? Thanks.
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