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Information about all aspects of finances affected by a serious health condition. Includes income sources such as work, investments, and private and government disability programs, and expenses such as medical bills, and how to deal with financial problems.
Information about all aspects of health care from choosing a doctor and treatment, staying safe in a hospital, to end of life care. Includes how to obtain, choose and maximize health insurance policies.
Answers to your practical questions such as how to travel safely despite your health condition, how to avoid getting infected by a pet, and what to say or not say to an insurance company.

Summary

Getting Medicaid is one thing. Keeping it, and maximizing use of it, is another. 

To maximize chances of keeping Medicaid, it is advisable to:

  • Know your worker, or case manager, or representative, or whatever the person's title is in your state.
    • You should have received, through the application process, the name and phone number of a contact at Medicaid to call with questions and changes. It is important that you know who this is. It doesn't hurt to periodically stay in touch with the person as well. See Make a Friend At The Insurance Company. The same advise applies to Medicaid.
  • Read your mail.
    • It is important to open and read all of the correspondence that Medicaid sends. The primary reason people lose their Medicaid coverage is that they ignore requests for information or fail to respond to correspondence sent to them.
    • Medicaid sends a lot of correspondence, including:
      • Questionnaires to be completed.
      • Advice about changes.
      • Once a year, Medicaid re-screens people for financial eligibility.
    • If you don't understand a particular letter or document, ask someone who does. Call your Medicaid Worker, or ask someone knowledgeable at your local disease specific nonprofit organization.
  • If you think Medicaid has stopped covering you, call immediately to find out why.  For some reason, in many states Medicaid has an ugly habit of just stopping. While it may seem like it stops for no reason, there usually is something that triggered your loss of eligibility. Whatever the reason, odds are that if this happens, Medicaid will notify you in a letter.
  • If you receive Medicaid because you qualify for Supplemental Security Income (SSI), even if you lose SSI you don't necessarily have to lose Medicaid particularly if the loss would be because of an increase in income from Social Security Disability Insurance (SSDI) due to inflation.

To maximize use of Medicaid:

To avoid penalties for fraud:

NOTE: It is worth checking to see if Medicaid in your state covers the cost of transportation to and from treatment.

To Learn More

Do What You Need To Do To Keep Medicaid

Know your worker, or case manager, or representative, or whatever the person's title is in your state.

You should have received, through the application process, the name and phone number of a contact at Medicaid to call with questions and changes. It is important that you know who this is. It doesn't hurt to periodically stay in touch with the person as well. See Make a Friend.

Read your mail

It's important to open and read all of the correspondence that Medicaid sends. The primary reason people lose their Medicaid coverage is that they ignore requests for information or fail to respond to correspondence sent to them.

Medicaid sends a lot of correspondence, including:

  • Questionnaires to be completed.
  • Advice about changes.
  • <>Once a year, Medicaid re-screens people for financial eligibility.

If you don't understand a particular letter or document, ask someone who does. Call your Medicaid Worker, or ask someone knowledgeable at your local disease specific nonprofit organization.

If you think Medicaid has stopped covering you, call immediately to find out why.

For some reason, in many states Medicaid has an ugly habit of just stopping. While it may seem like it stops for no reason, there usually is something that triggered your loss of eligibility. Whatever the reason, odds are that if this happens, Medicaid will notify you in a letter.

When You Apply For Medicaid, Submit Prior Unpaid Medical Bills

Medicaid is generally effective on the first of the month in which you apply for it. However, if there are prior unpaid medical billsand you request it at the time of application, Medicaid is permitted to provide up to three months retrospective coverage.

Notify Medicaid of Changes

It is important to keep Medicaid informed of any changes that might affect your benefits. Even if you got your Medicaid through Supplemental Security Income (SSI), it doesn't necessarily mean that any information you provide to Social Security after initial approval will be passed on to Medicaid. Notify both agencies of changes.

Always notify your worker at Medicaid when<:

  • Your address changes.
    • Remember most people lose coverage because they didn't reply to an inquiry Medicaid sent out. If they don't have your current address, well…….
  • Your income or your assets change.
    • You may think that not telling Medicaid about winning the lottery is good since you won't lose your Medicaid. However, it will hurt more when Medicaid finds out that you were paid a bunch of money when you weren't eligible for it. The odds are that Medicaid will find out.
  • Your marital status or living situation changes.
    • If you add or lose dependents, let Medicaid know.
  • There are other changes in your life that could have a bearing on your Medicaid eligibility.

While it's okay to call your worker with update information, you need some kind of proof that you informed Medicaid, especially if it would affect your coverage.

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  • Most offices will send you confirmation of such phone calls.
  • If you don't receive a confirmation letter within a week after your call, follow-up with a letter sent by overnight service or by registered mail, return receipt requested. In the letter, repeat the information and confirm it was given by phone on a certain date.
  • Be sure to keep a copy of the letter. Attach to it the receipt proving delivery.

If You Receive Medicaid Because You Qualify For Supplemental Security Income (SSI), You Don't Have To Lose Medicaid Even If You Lose SSI Because Of An Increase in SSDI Due To Inflation

"Pickle Eligibility" is an unusual name for another common reason people lose eligibility. This occurs when people get their Medicaid through Supplemental Security Income ("SSI") and SSI supplements Social Security Disability Insurance ("SSDI") benefits.. Each January, Social Security increases the SSDI benefit by the Cost of Living Increase. The increase can reach the point where the recipient loses eligibility for SSI.

For example, Tom B. receives $482 per month from SSDI. Because that is below the SSI benefit of $500 in the state in which he resides, SSI will pay Tom $18 plus grant him Medicaid. If the annual Cost of Living increase pushes the SSDI benefit to $508 per month, Tom doesn't lose any money, but because his SSDI is now above the SSI limit.

Tom could lose his right to SSI and Medicaid, but doesn't because of the so-called "Pickle Amendment" (named after Representative Pickle). The law provides that someone who stands to lose Medicaid solely because income from SSDI is increased to keep pace with inflation, is permitted to keep Medicaid coverage even though SSI eligibility will be lost.

Pickle Eligibility doesn't always happen automatically. If the increase for inflation that takes effect each January 1 pushes you out of SSI, watch your mail in case you fell through the cracks. If you receive a notice that Medicaid is being terminated due to loss of SSI eligibility, your state Medicaid office is supposed to provide you with an application to move your Medicaid under the Pickle eligibility so you can continue to receive Medicaid .

If you receive an application with notice that you lost your SSI because of the Cost of Living Increase of your SSD contact your Medicaid office immediately and tell them that under the "Pickle Amendment" you should be allowed to continue your Medicaid under "1619B." The Medicaid worker will provide you with the paperwork, if any, which is necessary to continue your Medicaid coverage.

If you want to try to calculate whether the Pickle Amendment applies to you on your own, see:

http://www.healthlaw.org/search.cfm?fa=detail&id=70854&areaid=77&q=pickle%20amendment&expand=0&oq=&dr=0&ts=&ia=0&ct=4&po=0&r=expand~~0,searchrows~~3,fa~~search,x~~38,searchkeys~~,ia~~0,fromfa~~,searchstart~~1,oq~~,po~~0,ts~~,q~~pickle%2520amendment,y~~4,ct~~0,maxrows~~5,dr~~0&fromFa=search

Find A Medicaid Provider Who Meets Your Criteria And Who Knows The Medicaid System

Not every doctor or other medical provider accepts Medicaid patients. 

Every doctor, hospital, pharmacy, and other provider that does take Medicaid patients must have a prior agreement with Medicaid to do so. Part of the deal is the provider must  agree to accept a Medicaid payment as payment in full. The provider must also agree not to seek any further payment from the patient unless the Medicaid plan itself provides for co-pays. 

There was a time when it was difficult to find top quality providers who were willing to accept Medicaid because of the low fees that Medicaid pays. However, with the limitations imposed by managed care, Medicaid dollars are more competitive as is the quality of care.

 

Public and non-profit medical facilities are the ones most likely to work with Medicaid and accept Medicaid patients. Based on the area of the country you live in and the reimbursement rate paid by your state's Medicaid plan, there may be a lot of private doctors who accept Medicaid or there may be very few.

 

To locate providers who accept Medicaid:

  • Check with your worker at the Medicaid office. Some offices maintain lists of participating providers that you may access.
  • Ask your local disease specific nonprofit organization, members of your support group, and other people you know with your health condition.
  • Ask your current providers and other medical providers to whom you may have access.
  • Ask your pharmacist if they accept Medicaid. If they do, ask who the doctors are that are submitting Medicaid prescriptions to them, especially those who are familiar with your medical condition. 

When you choose a doctor:

  • First look at the suggestions in Choosing A Primary Care Doctor, Choosing A Specialist, Choosing A Doctor For A Second Opinion.
  • Determine that the doctor is a Medicaid participating provider.
  • Find out how much experience the doctor has with the Medicaid system. Just as you want a doctor who is very familiar with your particular medical condition, you also want to find a doctor who knows the Medicaid system. Medicaid can be a formidable bureaucracy. Your doctor needs to be able to work within the system to get you all the appropriate treatment.

Get Your Prescriptions Through A Medicaid Participating Pharmacy

Prescriptions are one of Medicaid's most important benefits. While prescription coverage is considered an optional benefit, all states provide a prescription program of one form or another.

 

The two important tasks for you are to:

o       Find a pharmacy that participates in Medicaid. Finding a participating pharmacist is discussed above. o       Learn about your own state's prescription program. While it is not always easy to get details of the coverage under Medicaid, there are several avenues through which you might gain information:

        Ask your eligibility worker. While he or she may not know the details of the drug plan, there is often literature available that will provide some information.

        Ask the pharmacist about the plan.

        Check your state's Medicaid web site. While this is something of a long shot, your state may have added this description by the time you need the information.

 


Take Advantage Of Dental Coverage


As a general matter, Medicaid covers dental services.  This is particularly likely to be the case if dental services are needed because of the effects of a treatment or your disease.

 

If You Can, Get Medicaid To Pay Health Insurance Premiums.


As a general rule, private plans pay health care providers more money than Medicaid does, opening doors to more health care providers.

 

It may sound odd but you can get Medicaid even if you have health insurance.

 

Whether you apply for SSI and incidentally get Medicaid, or are after Medicaid because you are having trouble paying the health insurance premiums, Medicaid will look at allowing you to keep your private health coverage while Medicaid takes over paying the premiums for you. While the criteria differ from state to state, the basic idea is that Medicaid will look to see whether it is cost effective to pay for your health insurance.

 

For instance, if your premium is $350 a month, and your medical bills run over $1,000 a month, it is clearly in Medicaid's interest to pay your $350 premium instead of the $1,000 medical bills.

 

In some situations in some states, Medicaid will assume it is cost effective to pay your health insurance premium rather than make a calculation. For instance, if you have HIV and live in California, Medicaid will automatically approve payment of your health insurance premiums without doing a cost calculation.

 

Keep your plan's Explanation of Benefits (EOB) that show how much the plan is paying on your behalf. Many premium payment plans will require three to six months of EOBs to show that it is cost effective for Medicaid to pay your premiums.

 

Ideally, if you have Medicaid you won't have to pay any co-pays or deductibles under your health insurance. However, this isn't the case unless the health care provider has an agreement with Medicaid.

 

It is worth noting that in some states, rather than provide Medicaid, the state will automatically enroll you in the state high risk pool. See High Risk Pools (

 

NOTE: In some states, you will be penalized if you have health insurance and let it lapse without applying for the premium payment program. Penalties vary, but states want to you to keep and use private health insurance whenever possible.

If Necessary, Learn How To Survive In A Medicaid HMO

You will, however, have to function under two sets of rules: the rules of Medicaid and those that govern an HMO

The rules of Medicaid. You will have to follow all the normal rules of Medicaid, including maintaining your eligibility.

The rules that generally govern an HMO. A managed care plan under Medicaid is no different that other managed care plans such as HMOs. To learn more about life under managed care plans, see: HMO.

Also, look in the explanatory literature at:

  • The rules requiring a referral to a specialist.
  • Which providers you can see.
  • The requirements for covering emergency care out of the network. You will want to know this information in advance so you'll know what needs to be done to assure coverage.
  • Out-of-Service Area Care. Medicaid does not cover treatment in other states except for emergency situations of a life-threatening nature. This can be an even larger issue with HMOs since many only cover a limited service area instead of an entire state. Find out what happens if you live at one end of the state and you need important (though not emergency) treatment when you are visiting at the other end of the state where your HMO does not have facilities.

If you have a fee-for-service (indemnity) type of Medicaid policy and are told you must switch to a Medicaid HMO: In those districts where there is a gradual conversion of recipients from fee-for-service to HMO, most make concessions for people already under treatment for a serious illness. The most common concession is to permit people to remain in the fee-for-service plan or, if the fee-for-service plan is being terminated completely, to arrange for continuing treatment by your current doctor and other medical providers, at least temporarily.

Notify Medicaid If You Obtain Or Become Eligible For Health Insurance While Receiving Medicaid

During the application process, the eligibility worker is supposed to tell you that if you become eligible for health insurance later, either through coverage as a spouse or domestic partner or through work, you are required to report it. You are generally also prohibited from refusing the coverage.

In most states, if Medicaid finds you declined other health insurance while on Medicaid, you can be suspended from receiving Medicaid. This conforms to Medicaid's goal of being the insurer of last resort.

If You Receive Home Care, Work With The Agency In Charge Of Your Care To Maximize The Services You Receive.

After you are qualified to receive Medicaid you then must qualify for actual services.

If you receive home care, the visiting home nurse will act as liaison between you and your doctor and the system. The nurse will also take care of any supplies you need, such as wheel chairs as well as any services, such as a physical therapist. If you need some type of ambulette or ambulance service to and from a medical appointment or to and from a hospital, you call the company in charge of your home care.

The company likely also has a consulting doctor. If you can't leave your home and you need a doctor, there is generally a doctor who is under contract and who will make a house call for you.

If you don't get what you want from a home health attendant or a health aide, ask for it. Start with a pleasant but firm way. If you make several attempts to get what you want and you still don't get it, or if you're not comfortable with the person, then you have to have a person replaced. Call and tell the agency. They will replace the person with somebody else.

Don't expect a home care worker to take the initiative to take care of your house on their own. If you're not feeling up to it, ask a friend stop in and make sure that the right thing is being done.