Medicare Advantage Plans and Medicaid


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I wanted to post this so it might help other agents. Today I received a call from a 55 year old woman that had some issues - she was a referral from a local pharmacy who needed some help.

She told me that her part d was cancelled because she was not able to pay. She has no Part D coverage and she just got a bill from the hospital for $1200 dollars. This peaked my interest.

She said before she signed up for part d everything was paid for by medicare and title 19 (medicaid). She was told by a sales person at Walmart that she was being signed up for medicare part d and everything would stay the same except for the way she got her medication.
BUT -- what he didnt tell her was she was signed up for a pay fee for service plan with her prescription drug plan -- Humana Gold

I took down some info from her and immediately called medicaid -- luckily she is still eligible for medicaid and none of that was screwed up -- because she is on medicaid she can switch part d plans every month till she finds the right one to fit her needs. And because Humana has already cancelled her because of non-payment this reverts her back to medicare.

I know the person who signed her up for this plan -- in fact I know alot of seniors that I have changed because of this agent ( wanting to make 275 commission instead of 60 bucks )

I am going with her to the states insurance department to file a complaint against this agent on Monday afternoon after we get her Medicare benefits back into order.

Word of advice -- before selling a pay fee for service plan -- check with your local medicaid office and find out if this will screw the senior by signing them up --

now to figure out who is going to pay the hospital bill of 1200 bucks -- since it should of been paid by medicaid????
would that be the agent?
what do you think?

The same thing happened to one of my clients who also happens to be in Wyoming. Actually, he wasn't my client when it happened but I "fixed" it.

The man (and wife) are Medi-Medi. Some dishonest agent moved them into Humana Gold, taking him out of a "free" benefit and into copays.

While it took a few months, I re-wrote him into the Humana Part D only and corrected the situation.

Not to pick on other states (but I will), I had a similar issue in North Carolina. Dual Eligibles were put into programs with copays apparently because the agent wanted to make his $250.

This kind of crap gives those of us with ethics, intelligence, and professionalism a bad name. And it makes it harder for us to help a prospect because they (rightly) don't trust insurance agents.

I've run into the same thing. Seems like ther no shortage of cowboys out there that will do or say anything to make a sales
Here is what you need to find out from your carrier and /or state Medicaid program:

Will they co-ordinate benefits with a Medicare Advantage plan?

Each state is different on this.

Example: In Kansas, they will work with MAPD plans. You might have some premium depending on your level of Mediaid and spend down, but it can work in Kansas.

In Missouri, Medicaid will not pay co-pays, only dedcutibles and co-insurance. So, a MAPD plan will not work unless you have a high spend down.

Medicaid beneficiaries can change plans monthly, either MAPD or Part D.

If you find seniors who live in a senior community, talk to the management. I have done that and gotten agents band from communities.
thanks for the tips. I haven't pursued the medi-medi mkt because I perceived it as being tricky. Too many different levels of medicaid and I guess their eligibility changes by the month.

However, after listening to an recommendation by a trusted agent, I will pursue this niche and see how it works out for me.

I understand that Secure Horizons probably has the best product out there with their Evercare. Do you folks agree with this, or do you prefer another company. I realize not all co's are doing business we're not familiar with all of them, but 2 imp factors for me: client gets service and I GET PAID.
If you find seniors who live in a senior community, talk to the management. I have done that and gotten agents band from communities.

What do you mean "band"? banned? And if banned, do you mean that your talk to management keeps (bans) agents from the senior community?
Oops. Banned. No more seminars. When it comes to personal appointments that is harder to regulate, and I am not sure how they do that. But they have told me that they have called agents and told them not to return there for anything.
Great article on coordination


Center for Medicare Advocacy May 31, 2007

More than one million Medicare beneficiaries who also have Medicaid benefits (dual eligibles) are enrolled in Medicare Advantage plans. This number represents 15% of dual eligibles, up from 3% in the late 1990s. A little more than half of the one million are enrolled in Medicare Advantage Special Needs Plans, specifically targeted for dually eligible people.

Because most of these individuals are eligible for the full array of services offered under their state Medicaid plans, including services not covered by Medicare, they may not be receiving much value by being in Medicare Advantage plans, whose selling points are often the provision of benefits not available in original Medicare. Advocates will want to examine the offerings of a Medicare Advantage plan, even a Special Needs Plan, extremely carefully to determine if the plan does, indeed, offer anything the client is not already entitled to under Medicaid.[1]

Regardless of the value of extra benefits, these individuals should at least be getting the benefits that are available to them under Medicare Parts A and B. And, to the extent that they are Qualified Medicare Beneficiaries (QMBs), they should not have to pay any cost-sharing including premiums, deductibles or coinsurance, for Medicare-covered services provided by their Medicare Advantage plan.

In recent weeks, the Center for Medicare Advocacy has fielded many inquiries about states' obligations to pay cost-sharing for their dual eligibles in Medicare Advantage plans. This Weekly Alert addresses that issue.

What Are States Required to Pay?

Medicaid law is silent on states' obligations to pay Medicare cost-sharing for duals who are not QMB participants. On the other hand, guidance from the Centers for Medicare & Medicaid Services (CMS) is clear about states' obligations to pay such cost-sharing for duals who are QMB participants. The CMS guidance reflects the statutory grant of permission to states (but not mandate) at 42 U.S.C. §1396d(p)(3), to pay Medicare Advantage premiums for QMB participants.[2]

The significant question, therefore, becomes who are Qualified Medicare Beneficiaries? The law says they are people with Medicare Part A and with incomes up to 100% of the federal poverty level (FPL) and countable assets of not more than $4,000 for an individual or $6,000 for a couple. They can be, but do not have to be, eligible for full Medicaid services. The QMB program pays the individual's Medicare premiums and cost-sharing.

Because most categories of Medicaid for older people and people with disabilities require that the individual's income be not more than 100% of the federal poverty level, most elderly Medicaid recipients and nearly all of those with disabilities who have Medicare Part A should also qualify for the QMB program. The exception to this would be people who qualify for Medicaid as medically needy because, while their income is above the normal level for qualifying, they have very high medical bills. These individuals would generally not qualify as QMBs. However, even many Medicaid recipients who should qualify for QMB may not. Although a CMS guidance for the QMB program directs states to screen all of their dually eligible beneficiaries for QMB eligibility,[3] it is not clear that states have actually done so. In 1991, the Health Care Financing Administration (HCFA) [the previous name of CMS] identified over 2.3 million dually eligible beneficiaries who were eligible for, but not enrolled in, the QMB program.[4] More recent figures are not available to the Center.

Thus, your state might have many dually eligible individuals whose incomes are less than the QMB income standard, who are, nevertheless, not enrolled as QMBs and thus are not, technically speaking, entitled to have the state pay their cost-sharing (in original Medicare or in a Medicare Advantage plan). Advocates might inquire of their states whether they have, in fact, enrolled all those eligible into the QMB program.

Medicaid Recipients Not Automatically Eligible for Medicare Part A

An additional wrinkle pertains to certain very low-income elderly SSI-only Medicaid recipients. Because they do not have enough work quarters (credits attributed toward eligibility for future Social Security benefits), they do not receive Social Security retirement checks and they do not qualify for premium-free Part A. Because Part A is a prerequisite for QMB, they cannot be found eligible for QMB without first enrolling in Part A, which they cannot afford. The Part A premium for 2007 is $410 per month; the monthly income of a person at 100% FPL is $851.

Thirty-five states and the District of Columbia have agreements with CMS regarding Part A enrollments. These agreements allow them to enroll Medicare beneficiaries eligible for QMB benefits into Part A at any time of the year and without having to pay any late enrollment penalty. In 1991, despite the existence of the agreements, HCFA found that 145,000 dually eligible individuals in states with Part A buy-in agreements had not been enrolled by their state into Part A and thus had not been enrolled in the QMB program.[5] More recent information is not available.

In the remaining fifteen states without Part A buy-in agreements,[6] individuals can only enroll in Part A during the first three months of each year, after their initial enrollment period. Moreover, the state paying for the QMB's Part A premium will have to pay any late enrollment penalty that applies. Under a process created in the early 1990s by HCFA, a low-income Medicare beneficiary wishing to qualify as a QMB would go to her Social Security office between January and March and ask to enroll in Part A on the condition that her state would pay the premium (which is part of QMB cost-sharing). She then would go to her state Medicaid program and show them her "conditional" enrollment in Medicare Part A and ask to enroll in the QMB program. When the Part A became effective, her QMB benefit could become effective.[7] In 1991, HCFA identified about 215,000 QMB-eligible-but-not-enrolled individuals in the states without Part A buy-in agreements.[8]


The answer, then, to the question of whether states are obligated to pay cost-sharing for dual eligibles in Medicare Advantage plans is a complicated one, but for most dual eligibles, the answer would be yes, if they are QMBs. Advocates are advised to determine whether their states screen all current elderly and disabled Medicare beneficiaries on the Medicaid roles for QMB eligibility, as they are required to do, and to help those Medicaid beneficiaries without premium-free Part A to become enrolled in Part A so they can qualify as QMBs.

The documents linked to this Alert will allow advocates to approach their states to assure that the states are 1) Paying co-pays for their QMBs in Medicare Advantage plans, 2) Screening all dually eligible beneficiaries and enrolling them in QMB if they are eligible and 3) Assisting those dual eligibles with incomes under 100% FPL who are lacking Part A to enroll in Part A so they may also get QMB benefits. If your state is not doing these things and is not willing to undertake them, advocates are advised to contact their CMS Regional Office. On the issue of co-pays to Medicare Advantage plans, advocates can contact Christine Gerhardt (
[email protected]
), at (410) 786-0693.

For more information, contact attorney Patricia Nemore (
[email protected]) in the Center for Medicare Advocacy's Washington, DC office at (202) 216-0028.