I finally got her into a nursing home. Rhonda has MS and dementia, I am her legal guardian. Her Insurance is Blue/advantage. Blue Cross has been difficult to deal with, not only for me, but for hospitals and her nursing home. The biggest issue has been rehab therapy. It has been difficult to get it approved and is very limited, when it is approved. I was advised to change her plan back to regular medicare ( A and B ) then add on medicare D to cover her meds. I have also submitted all the paperwork to get Medicaid, for which she does qualify. I am just nervous about the decision. I would appreciate input from anyone on this forum. It was due to advice on this forum, that I was able to get her Into a nursing home, in the first place. So, thanks to you all, for sharing your knowledge.
For what it's worth this is some of the issues I had in dealing with BCBS with my mom & Medicaid. This is going to be long as its convoluted. Mom went into NH from living in IL had Medicare & a high option BCBS for federal employees ( dad was a fed). Now her blues pay extremely well to docs, PT, etc & would pay for PT,OT beyond the # of days that Medicare ever would (mom had rotor cuff surgery years before so went thorough that). Mom applied for Medicaid & took about 6 mo to process & be accepted. Her part D was covered by BC. BC had no copay for anything ever & her premium taken out of fed retirement.
Now about month 8 got a letter from BC that due to Medicaid now being available to mom, that her BC needed to be either cancelled OR suspended. BC would not pay if medicaid was available to pay. Being suspended is what to do as you never know what can happen. There was specific paperwork on this. Once processed, moms retirement income changed due to no $ being taken out for BC premium as moms federal BC is now "suspended". Her income increased so medicaid had to reopen file and recalc acceptance & her copay. But Now nobody never ever gets stuff done immediate, so there was a 3 month lag for Medicaid to know that the income deducted for moms BC taken out of her federal retirement was not being done anymore and change moms copay to the higher amount mom needed to pay NH.
The higher copay did not have to be paid till, the state issued the letter. This was at month 9. NH did not have to be paid the higher amount for mo 1-8 either. they only got paid the increase effective the month the letter stating that went out.
Now here is where it all got sticky......since Medicaid retro'd acceptance back to month 1, so in theory Medicaid should be paying for everything that Medicare doesn't. So BC does a full clawback of all payments to vendors who got paid anytime between month 1-month 9 as Medicaid should be billed and pay. The NH should clearly change all billing info within their system and with their outside vendors that BC is no longer valid, everything is now only Medicare or Medicaid.
My moms NH #1billing dept could flat not get their sh** together on this. I sent NH registered letters on the change once I got the cancellation / suspension letter from the Feds. but they kept on billing BC and kept the BC info in moms "face sheet" so the vendors kept submitting bills to BC. This NH had other billing & staffing & care plan issues too & I moved mom to another NH at month 11.
Now all the vendors paid by BC got a clawback of 100% of what they were paid. And this happened over a period of months. They needed bill for everything to Medicaid back to month 1. The nh should have the change in the file for this to happen. Nh notified by BC and I sent registered letters to NH too. I did my fiduciary duty as DPOA. Nh totally dropped the ball on this. Mom started getting bills for full private pay amount for services as BC did not pay. Vendors did not want to rebill Medicaid as the reinbursement is so much lower than BC. For ambulance BC paid about $400 but medicaid $75 & if they take Medicaid they have to accept the assignment. If they take federal BC they have to allow the clawback too or BC will suspend payments to the vendor. BC is super efficient in billing too as is statements from CMS for medicare. So I had statements with vendor details to send the change of insurance billing letter to. The problem is that the vendors all have different billing systems & there is a time lag in all this of months & months. Vendors will press family to pay the difference between the assignment paid by Medicaid and the much much higher BC rate. I am still dealing with the fallout on this and it's 3 years now all due to mom's first NH not changing billing details in their system & that some of moms old docs automatically submitted bills to BC and did not update moms insurance profile even though given her Medicaid info. Sometimes I think part of this is deliberate to get the much higher payout from BC.
None of these issues at all with moms new NH #2 which she has been at now for 2 years.
So please please make sure to do with BC once she goes onto Medicaid to ensure billing done right.
I have talked with NH, Medicaid, and Medicare. It is like none of the agencies and NH want to have to pay more than they have to, so I have been told I need the supplemental. I need a straight answer.
btw, I paid the premiums because of the process delay, and trying to be consciensious (sp?), didn't want to owe bills. Silly me!