My sister was recently approved for Texas Medicaid as she is in a nursing home since January this year with late stage dementia. She also has Medicare which she is covered for hospice that we recently decided on due to her quick decline. I am very confused on how medicaid works, not sure I understand why she needs to choose a plan Star Plus when she already has Medicare that covers doctors, emergencies, hospice. What does Star Plus offer and why or is it not needed. Any help on this, we do have an elder care attorney but thought maybe I could get a quicker answer here.
https://www.hhs.texas.gov/services/health/medicaid-chip/medicaid-chip-members/starplus
Like Sissy is low income and so has no $ to pay for her NH stay so has filed for LTC Medicaid for that and as a part of that it also removes whatever old secondary / supplemental health insurance she was on (Humana, Blue Cross, etc) because as part of that process she has also filed for Medicaid for health insurance as well. The Star + is the health insurance part and it is a MCO /managed care organization as how TX runs their program. She is a l dual” on Medicare and Medicaid for health insurance and her NH custodial care costs for Sissy is done via TX LTC Medicaid program. It pays her room & board costs & other incidentals related to her being a resident. She will have a copay of her income to the Nh for being on LTC Medicaid less $ 60 every month. That $60 is her PNA, aka personal needs allowance for TX. It will essentially be the only $ she has for her own spending. If the NH has been made her representative payee, (that is what JoAnn posts refers to, she did that for her mom, but for my mom I didn’t but paid the NH a ck each month the exact amount of the copay) then her SSA income is paid to the NH as her required by LTC Medicaid copay/share of cost and then the $60 is placed in a PNA Trust account at the NH for her use (or your as her POA use). PNA $ used to pay for things like onsite twice a month beauty shoppe visits, snacks, magazines, clothing, etc.
HOWEVER….
LTC Medicaid does NOT pay billable to health insurance type of costs. Those are billed to Medicare & Medicaid via the Star+ waiver (MCO / managed care organization). Her providers will & have changed once she becomes fully ensconced at the NH as her health care will be determined by the MD who is the medical director of the NH and the DON the Director of Nursing of the NH and within the MCO network. Should she actually need to go to the ER, they determined which ER it will be. They determined if she should need to see a specialist, who’s the specialist will be. Providers need to be within the MCO.
NH likely suggested the possible hospice companies for her or you from the ones already with a relationship with this NH, even tho Hospice is self-directed and 100% a MediCARE benefit.
It can take several months for all the paperwork to settle once they become fully LTC Medicaid eligible. Sometimes the Medicaid Pending can be 5-6 months, so until Pending ends and their eligibility retroactively goes to date of application filing, their old secondary health insurance stays in force then cancels retroactively as well.
Medicare only pays 80% of what they consider reasonable. So, lets say a doctor charges $200 for a visit. Medicare thinks $160 is reasonable and then pays 80% of that=$128, a balance of $32 is left. The supplemental pays that $32.
Medicare pays for Hospice Services.
You will drop your sisters now supplemental when the Star one becomes effective. I would assume she pays for her supplemental? Once on Medicaid, she will not be able to afford the cost of a supplemental and you are not responsible for that.
But...as mentioned, some states require she continues to carry her previous supplemental. When this happens the cost is deducted from ur sisters SS payment. Medicaid payment is adjusted accordingly.
You really need to talk to your sisters caseworker to see how your sisters Medicaid will work.
I also suggest that you allow the NH to be payee for her SS and any pension she may receive. For me it meant I was out of the picture financial wise. No worries about writing that check monthly and needing to keep records. The NH will set up a Personal Needs Acct (PNB) in my State thats $50 a month, some higher or lower. If there is a supplemental to be paid for non Medicaid provided, the NH would be responsible for that, I would think. My thought by doing this was, if after Mom passed her last SS payment she was entitled to did not get paid to the NH, they could fight with SS not me. Since I have never received anything from the NH, I guess they received everything they were entitled to.
Sissy has a husband, who I’m guessing is still totally competent living at the family home, and that is a very very different path for how the LTC Medicaid program works entirely. He is a Community Spouse and the point person - financial and medical - for her. He as her husband and his own finances are paramount in how LTC Medicaid determines her copay and you as the SIL who lives in another State are not a part of this equation. It is their financials as they are married and the segregation of those that will be dealt with for determining the “at need” for LTC Medicaid. He as her husband is in charge of her medical care plan as well.
TX LTC Medicaid is very narrow on how “at need” runs. A good CELA attorney knows how this rolls for a CS / NH situation to maximize the best for each. Hubs has gotten her eligible and I imagine has gotten an appropriate for his situation CSRA/MMNA and set up a PNA at the NH. Really please pls try to stand back for this, he is her husband…. He determines her care plan, he oversees the finances. That you did not even mention there was a husband till way into this convo, is beyond disconcerting imho. There is no “us”, there is “them” as they are married.
Again her husband is the point person for her both medically and financially; and for LTC Medicaid when there is a CS aka a community spouse, he and his financials really drive what happens for her financial “at need” for copay / mandatory share of cost. They are about month 6/7 for her LTC Medicaid filing so it’s at the retroactive & merger point for old health insurance drop/merger into MCO system.