Traditional Medicare/Supplement Not Accepted Locally?

[RetMD21]

The list of accepted providers is much shorter for 2025:

https://www.tvc.org/patients/medicare-advantage/

What a mess. Will she need a dual eligible special needs plan? It looks like there were only 3 for Adams Co in 2024. https://www.hca.wa.gov/assets/free-or-low-cost/d-snp-service-area-guide.pdf

 

[mountainsoft]

What a mess. Will she need a dual eligible special needs plan? It looks like there were only 3 for Adams Co in 2024. https://www.hca.wa.gov/assets/free-or-low-cost/d-snp-service-area-guide.pdf

I honestly don't know. In hopes of getting everything setup before she runs out of money, I applied for her Medicaid last month (with the estimated date she would need it), but was told it would be rejected until she gets below $2000. So I had to withdraw the application and wait to reapply in another month or two. It's kind of stressful because it took them 20 days to process the first application, and if it takes that long this time she'll end up overdrawing her account and bills will not be paid. There's apparently no such thing as planning ahead with Medicaid.

I was already stressing about switching over to Medicaid, then received the notice about her advantage plan not being accepted. The social worker said not to change anything until she starts Medicaid. So I'm kind of in limbo knowing things need to be done, but having to wait until the last minute.

 

[pacergal]

I am so sorry you and your Mom are going through this.
There is a difference between Medicare and Medicaid, who accepts what and where.
It was something I had to discuss many times to new clients.

 

[mountainsoft]

I am so sorry you and your Mom are going through this.
There is a difference between Medicare and Medicaid, who accepts what and where.
It was something I had to discuss many times to new clients.

Yep, mom is already on MediCARE (an advantage plan). Unfortunately, she's running out of money and will need to start on MediCAID to cover her expenses. She made it about 7 years off the funds she got from selling her house, but that's running out in the next month or two.

I won't start MediCARE myself for another 5 years.

 

[RetMD21]

I am so sorry you and your Mom are going through this.
There is a difference between Medicare and Medicaid, who accepts what and where.
It was something I had to discuss many times to new clients.

And then there is Medicare + Medicaid which seems to be where OP's mother is heading. I'm glad she has a social worker for advice

 

[Brat]

The Kaiser Medicare Advantage Plan also offers a dental plan with hearing aid allowance of $500 each ear every 36 months. The hospital you would use is in Clackamas and is highly rated. That may be your mother's best option.

I recomend you and your mother visit an attorney who specializes in the elderly. That person would be knowledgable about Medicaid in your state. It is time to research facilities that acept Medicaid.

 

[RetiredHappy]

From my understanding, if one is already on a Kaiser plan and then go on to Medicaid, Kaiser will keep you or take you back. At least, that is how it works in California.

 

[mountainsoft]

The Kaiser Medicare Advantage Plan also offers a dental plan with hearing aid allowance of $500 each ear every 36 months. The hospital you would use is in Clackamas and is highly rated. That may be your mother's best option.

I recomend you and your mother visit an attorney who specializes in the elderly. That person would be knowledgable about Medicaid in your state. It is time to research facilities that acept Medicaid.

Mom lives up in Battle Ground, a long way from Clackamas. I live in Camas, which makes it even more of a drive. Legacy Salmon Creek is the closest hospital for her.

She is already in an assisted living facility that takes Medicaid. That was one of the main criteria we watched for when we were touring the various places in our area. There aren't that many that do take Medicaid. In fact, her facility was just bought out by another company and they aren't taking new Medicaid residents either. Mom is just grandfathered in because she is a current resident.

I didn't think she would be able to private pay very long after her stroke, but she has made it over seven years. So not bad in the grand scheme I guess.

 

[mountainsoft]

From my understanding, if one is already on a Kaiser plan and then go on to Medicaid, Kaiser will keep you or take you back. At least, that is how it works in California.

Yep, we were able to stay with Kaiser for the several months we were on Medicaid after we retired. Until my wife's pension started, we were just under the bottom limit to qualify for an ACA plan. We're on an ACA plan now, but Kaiser was too expensive to keep so we went with a Regence plan instead.

 

[RetMD21]

Let us know how this turns out. Washington isn't California and Kaiser isn't on the list from Apple Health Medicare Connect.

 

[a60dan]

I couldn’t help verifying this with the clinic.

The person in billing that I spoke with said that no NEW patients with traditional Medicare would be accepted. She has worked there 2 years and it has been that way since she started. They do bill Medicare for existing patients.

Unfortunately she does not know the rationale for not accepting new patients with traditional Medicare.

This is intriguing as I’m planning to go with traditional Medicare and have been wondering to myself if my pharmacy might be unwilling to bill Medicare Part B for my insulin pump insulin, instead of the part D.

This case is the first I’ve encountered where traditional Medicare isn’t accepted.

 

[gauss]

MA plans are also notorious for having narrow 'in-network' providers as well as high rates of denial for expense ancillary tests or procedures coupled with a high rate of prior authorizations being denied. Numerous articles on this from independent sources (google search traditional Medicare vs. Medicare advantage).

I agree. My understanding is that Medicare Advantage is actually "managed care" and can deny or delay treatment. Medicare Supplement plans, on the other hand, do not have the authority to do this.

I believe there is more of a difference between MA and Supplemental than merely the ability to limit networks of providers.

-gauss

 

[mountainsoft]

I couldn’t help verifying this with the clinic.

The person in billing that I spoke with said that no NEW patients with traditional Medicare would be accepted. She has worked there 2 years and it has been that way since she started. They do bill Medicare for existing patients.

Unfortunately she does not know the rationale for not accepting new patients with traditional Medicare.

This is intriguing as I’m planning to go with traditional Medicare and have been wondering to myself if my pharmacy might be unwilling to bill Medicare Part B for my insulin pump insulin, instead of the part D.

This case is the first I’ve encountered where traditional Medicare isn’t accepted.

Was this Vancouver Clinic? I sent them a message through MyChart about this, but they never responded.

I have a few years before I start Medicare, so I'll have to research other medical facilities in our area to see who takes traditional Medicare. It would be kind of useless if no one accepts it.

 

[Mark1]

Mom lives up in Battle Ground, a long way from Clackamas. I live in Camas, which makes it even more of a drive. Legacy Salmon Creek is the closest hospital for her.

She is already in an assisted living facility that takes Medicaid. That was one of the main criteria we watched for when we were touring the various places in our area. There aren't that many that do take Medicaid. In fact, her facility was just bought out by another company and they aren't taking new Medicaid residents either. Mom is just grandfathered in because she is a current resident.

I didn't think she would be able to private pay very long after her stroke, but she has made it over seven years. So not bad in the grand scheme I guess.

I don't know much about supplementals for medicare or medicaid, but I will share some information for what it's worth.

DMIL was on a medicare supplemental plan in 2020 with no real savings (her SS check was large enough to keep her off medicaid and pay the bills), but then she got hurt and needed to go to a nursing home. She almost immediately went off medicare and onto medicaid with no change to her supplemental (at least that DW and I noticed). At some point after that, her state Department of Human Service case worker told DW that DMIL could keep her supplemental or ditch it going forward as the state didn't care either way. The case worker did comment that if DMIL might even be well enough to leave NH, she might want to maintain the supplemental going forward. Fast forward 4 years, DMIL is still in NH with a supplemental paid by her money (> $500/month) with the balance of her SS check going to the NH (minus $50/month she gets to keeps). In esssence, the state is paying the $500 as their monthly payment to the NH is $500 higher then it would be if she dropped the supplemental. Of course, this is somewhat offset, becaue the supplmental is paying some of the medical bills.

I doubt the state missed this issue, as DMIL has been reviewed yearly now by multiple DHS case workers. In fact, every year when her supplmental premuim goes up we have to notify the state such that they can tell the NH to adjust down the withdraw they take from DMIL chcecking account.

 

[mountainsoft]

I couldn’t help verifying this with the clinic.
The person in billing that I spoke with said that no NEW patients with traditional Medicare would be accepted. She has worked there 2 years and it has been that way since she started. They do bill Medicare for existing patients.

It took two months to get a reply, but I finally heard back from The Vancouver Clinic.

"Vancouver Clinic does accept Medicare part B for established patients and Medicare supplements are always billed secondary to Medicare Part B."

The subtle wording "established" would seem to confirm the information you got. Existing patients could use traditional Medicare/supplements, but new patients coming to Vancouver Clinic would only be able to use an advantage plan.

While we are currently patients at Vancouver Clinic, I don't know that I would want to rely on that loophole in the future. Other than the two main hospitals (Legacy and Peace health), they're the biggest health care group in our area. Not surprisingly, they're number 4 on the list of largest employers in our county.

Top Employers | Columbia River Economic Development Council

A list of local businesses and partners with CREDC. join the growing list of business partners that make CREDC what it is today!

credc.org

Kaiser is way down at number 14.

 

[statsman]

It appears that UHC is being dropped by many medical services in our local area of Central Texas (not related to the recent shooting). Our chiropractic office has had a sign up for several months at their reception desk to mention if they have UHC. Our chiropractor accepts UHC, but when he needs to make a referral to someone else, like an X-Ray specialist, many of those providers do not accept UHC.

So, the patient with UHC Medicare would have the choice of not having the X-Ray (probably a bad idea), driving quite a distance away to a medical provider that will accept UHC, or paying for the X-Ray out of pocket.

 

[Pluperfect]

So, the patient with UHC Medicare would have the choice of not having the X-Ray (probably a bad idea), driving quite a distance away to a medical provider that will accept UHC, or paying for the X-Ray out of pocket.

You mean a patient with UHC Medicare Advantage. Whole different ball of wax from the original post, which is about a provider not accepting traditional Medicare (and it turns out that applies only to new Medicare patients--they'll still see existing patients who have traditional Medicare).

 

[sengsational]

Unfortunately she does not know the rationale for not accepting new patients with traditional Medicare.

I can speculate. You're running a business and and operator of a Medicare Advantage plan comes to you and says, "I see you have X hundred doctors. How would you like to keep them all 100% utilized? Sign right here, you agree to take ALL of our Medicare Advantage patients and NO NEW Traditional Medicare patients. You won't have time to see new Traditional Medicare patients anyway...your doctors will be booked 6 months out."

 

[RetMD21]

I was interested in the issue about it getting "messy" to find a Medicare Advantage plan accepted by the clinic and with pending Medicaid. Maybe it isn't so complicated. Although there are MA plans specifically for dual eligible individuals not need to select one of those plans. KFF has article about what people actually choose, How Do Dual-Eligible Individuals Get Their Medicare Coverage? | KFF

 

[mountainsoft]

I was interested in the issue about it getting "messy" to find a Medicare Advantage plan accepted by the clinic and with pending Medicaid.

I only found one Medicare Advantage plan (Regence MedAdvantage +Rx Primary) for my mom that is accepted by the Vancouver Clinic and is in-network for the pharmacy her assisted living uses (Omnicare). I'm still digging through the weeds to understand all the moving parts, but it looks like Medicare's "extra help" will pay her portion of the pharmacy expenses not covered by the advantage plan. Medicaid will cover her plan premiums (technically they allow her to keep the amount the plan will charge).

Mom has to pay a portion of her assisted living expense, and Medicaid will cover the rest. With things still in transition a bit, the final amount isn't completely set yet. Eventually I will set this up on autopay, but for now I'll have to write a check each month. This is kind of a pain because she doesn't get her railroad income until the 1st, rent is also due on the 1st, and she's about a half hour drive from me to run the check up there. Unfortunately, mom has less than $500 to her name now and medicaid doesn't allow a buffer in checking to cover a month's payment. As someone who is used to keeping a fairly good buffer for unknown expenses, this makes me a bit nervous.

She only gets to keep about $105 for personal needs. That won't go far with haircuts, nail trimming, streaming TV, and a few groceries.

 

[RetMD21]

I don't know about her AL facility but if you can find another pharmacy that delivers you might not have to use theirs. The timing of the income and the payments sounds very challenging.

 

[youbet]

. Employer sponsored MA often offers way more coverage than those sold by celebrities to the general public.

Actually, employer sponsored MA plans often offer more coverage than traditional Medicare.

 

[RetMD21]

Actually, employer sponsored MA plans often offer more coverage than traditional Medicare.

If they approve your request for services

 

[youbet]

If they approve your request for services

Hmmmm, don't know what you're referring to RetMD21. DW's employer sponsored MA plan automatically approves everything that Medicare approves without requiring pre-approvals or "requests". It also includes some additional benefits. And her network is the same as Medicare: any provider that accepts Medicare.

Again, as I stated in my post, I'm talking about employer sponsored MA plans.

 

[RetMD21]

Hmmmm, don't know what you're referring to RetMD21. DW's employer sponsored MA plan automatically approves everything that Medicare approves without requiring pre-approvals or "requests". It also includes some additional benefits. And her network is the same as Medicare: any provider that accepts Medicare.

Again, as I stated in my post, I'm talking about employer sponsored MA pla MA plans have

i'm glad they haven't required pre-approval or denied claims in her case. Are you saying that they have promised not to do so in any case? Are you sure that providers aren't doing prior authorization without your knowledge?