Mid 30's, SSDI, Medicare--pregnant

[yorkriver1]

This woman seems to fall into a nether region. Can't afford the spouse coverage at work, Medicare supplements not available in our state for under 65, out of AEP for Medicare Advantage.

Medicare told her they only cover services if the woman's health is in danger. If she's disabled, it would seem that may be true.

Anyone run into one of these situations?

 

[TN_agent]

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c01.pdf

Chapter 1, section 80. Pregnancy should be covered, as it is recognized as a medical condition that should be monitored.

Any woman's health is technically in danger being pregnant, not just disabled ones. Pre-eclampsia, etc.

The child's care, however, is not covered, but the spouse should get a special election to enroll child in group care beginning day of birth (or medicaid depending on state and income).

 

[insuranceconceptscindy]

This woman seems to fall into a nether region. Can't afford the spouse coverage at work, Medicare supplements not available in our state for under 65, out of AEP for Medicare Advantage.

Medicare told her they only cover services if the woman's health is in danger. If she's disabled, it would seem that may be true.

Anyone run into one of these situations?

And I thought I was the only one that ran into really crazy Medicare cases! Haven't had a pregnant one yet. . .

I agree with York- any pregnancy has the potential of complications. Since she is already deemed disabled by SSA, it should be covered. There will be claims issues. I have a feeling that many OB/GYN's don't have a lot of experience billing Medicare.

 

[plannerman]

I had a client In her 40's have a baby while on a Humana MAPD. Turns out that they were not the Devil this time, cost her around $500, well after we showed them that they had to cover due to Medicare's guidelines

 

[Ronnie Carter]

This woman seems to fall into a nether region. Can't afford the spouse coverage at work, Medicare supplements not available in our state for under 65, out of AEP for Medicare Advantage.

Medicare told her they only cover services if the woman's health is in danger. If she's disabled, it would seem that may be true.

Anyone run into one of these situations?

I may be missing something here, but she should be able to enroll in any MA plan available, unless I'm badly mistaken.

Anyone whose income and resources are low enough to qualify for SSDI that I've run into also qualified for LIS (Extra Help) from SS for Part D drugs. That immediately gives the beneficiary an ongoing SEP.

I was assuming from your post that she's already on Medicare due to having disability for at least two years. And don't feel too badly about not having Med supps available for <65's -- not too many people on SSDI can afford them, and lots of carriers discourage you from enrolling people by paying zero commission.

 

[yogooglethis]

I may be missing something here, but she should be able to enroll in any MA plan available, unless I'm badly mistaken.

Anyone whose income and resources are low enough to qualify for SSDI that I've run into also qualified for LIS (Extra Help) from SS for Part D drugs. That immediately gives the beneficiary an ongoing SEP.

I was assuming from your post that she's already on Medicare due to having disability for at least two years. And don't feel too badly about not having Med supps available for <65's -- not too many people on SSDI can afford them, and lots of carriers discourage you from enrolling people by paying zero commission.

Income has no bearing on whether one qualifies for SSDI .Maybe you are thinking of SSI which is available for all ages of SS beneficiaries whose SS income is below 750.00 monthly. SSI beneficiaries automatically get Medicaid for Medicare deductibles and co insurance but they still have to qualify for a Medicare Savings Program to get their part B premium paid for by the state.

I have run in to cases where a person had full Medicaid through SSI but because of having over the state asset limit ( about 7500.00 for single in Fl ) they didn't qualify for a MSP and still had to pay their part B premium.

https://www.medicare.gov/Pubs/pdf/11445.pdf

 

[TN_agent]

Her household income is likely too high for help since she has a spouse that works, so no SEP probably.

 

[yorkriver1]

Wow, what great experiences/info/support, thanks! Yes, Cindy, for a minute when 1st in the call I was thinking, hooboy, here's a new one!! I contacted a health/community advocate I know in client's local area. She referred us to a hospital chain with a compassionate care program. Client was able to get an appointment, finally, with an ob/gyn in their group. I didn't mention that several ob/gyn's had turned her down, don't take Medicare patients. The ob/gyn office isn't sure what Medicare will pay, but will work things out either way. I wonder if they might need help with billing, considering high risk coding accounting for the mother's health conditions. As Cindy mentioned, she is likely pretty much by definition a high risk pregnancy as a disabled person.
I had found Medicare chapter 1, section 80, in an article online; Medicare coverage info., good long term resource.
With her SSDI and spouse's income they are above LIS, but mentioning it is good and the experience with Humana paying on the pregnancy, big help. We'll see about her and MAPD for AEP and will be doing individual coverage for the baby when born, depending on whether group EE+child is better than IFP--say if there are big NICU bills, etc. The group dependent coverage is pretty pricey, that's why I am getting referrals from group admin. Client said we'll cover baby when/"if" born...she's concerned, as I guess all new mothers are, but has evidence for worry. Ob/gyn should help with plan to manage risk.

 

[Ronnie Carter]

Income has no bearing on whether one qualifies for SSDI .Maybe you are thinking of SSI which is available for all ages of SS beneficiaries whose SS income is below 750.00 monthly. SSI beneficiaries automatically get Medicaid for Medicare deductibles and co insurance but they still have to qualify for a Medicare Savings Program to get their part B premium paid for by the state.

I have run in to cases where a person had full Medicaid through SSI but because of having over the state asset limit ( about 7500.00 for single in Fl ) they didn't qualify for a MSP and still had to pay their part B premium.

https://www.medicare.gov/Pubs/pdf/11445.pdf

You guys are quite right. Most SSDI's I've ever worked did qualify for LIS, but some don't. I know the difference but was thinking of SSI.

Shouldn't post that late -- not thinking straight!