Insurance question

H1235 · November 12

Mom has had Medicare and through dads retirement benefits blue cross and blue shield. Her coverage has always been very good and she has seldom had out of pocket costs. She has recently moved to a nursing home. She has been approved for Medicaid. The nursing home is suggesting she sign up for a Medicare part b (I think that’s what it is) through Aline. They tell me that the nursing home doctor only visits two days a week and if she were to develop for example pneumonia symptoms on a day the doctor is not there, they would need to send her to the hospital. They tell me she would need to stay for a mandatory 3 days. With the Aline they can apparently consult an Aline doctor and have medication prescribed vs the trip to the hospital. They tell me this would also cover foot care, dental, optical and a few other things. The cost of the Aline program is offset by the amount she would be expected to pay each month (with her social security and dad’s pension), so there would be no cost. I am so confused! Does anyone have any suggestions or experience with this. I obviously need to make more phone calls to both Aline and the nursing home, but I I thought maybe someone here could give me some advice with real experience.

harshedbuzz · November 12

This sounds kinda fishy to me. Especially the bit about a mandatory 3-day hospital stay. Who is mandating that rule?

When Dad developed symptoms of pneumonia in the MCF, the DON contacted the facility's geriatric doctor who ordered blood work and a mobile X-ray. With a plan to treat once results came back.

I'd get a second opinion from a Medicare information service/broker or CELA.

HB

Quilting brings calm · November 12

Please call a Medicare insurance agent in your area. It sounds to me like your dad was a government worker of some sort where the retirement insurance was able to take the place of part B plus a supplement( to cover copays and deductibles). If you replace it with a Part B you’d have to have a supplement too. In addition, she would be underwritten and might not even be accepted into Aline’s part B coverage.

The 3 day point has to do with the fact that Medicare won’t cover rehab unless the patient has been ADMITTED to the hospital for 3 days first. And it’s admitted rather than in-patient for observation. You don’t have a good enough understanding yet to remove your mom from your dad’s retirement benefits.

There are some combination Medicare-Medicaid Insurance policies. That may be what they are trying to persuade you to switch too - but it may not be in her best interests

In terms of the doctor issue, the nursing home doctor is not in good standing for your mom’s existing insurance. If he was, he could order her medication on his days elsewhere just like he does for patients covered by Aline. Many pharmacies deliver to nursing homes.

JulietteBee · November 13

For the fact you said it covers dental, vision, etc, it sounds like Aline is a Medicare Advantage plan aka Medicare Part C.

H1235 · November 13

Thanks for helping me sort this out. Moms blue cross and blue shield is just typical insurance, nothing special. I have received no additional bills not covered by bcbs, Medicare or Medicaid. They have expressed no problems with medication not being covered. Yes I believe the Align is a Medicare advantage plan. It says it is designed for senior living and offers on site care. I believe this on site care is what is supposed to be so appealing to this plan. I guess I going to spend my day on the phone making calls and trying to figure it out.

SDianeL · November 14

https://alzconnected.org/discussion/comment/258420#Comment_258420

"Align medical medicaid" can refer to Align Health Plan, a private company offering Medicare Advantage plans, or government initiatives like the Medicare-Medicaid Alignment Initiative which aims to integrate Medicare and Medicaid services. It can also relate to aligned enrollment, where a person is enrolled in both a Medicare and Medicaid plan from the same company in the same area to simplify benefits. Alignment Health Plan

What it is: A private company that offers Medicare Advantage plans.
How it relates to Medicaid: Some of its Medicare Advantage plans are designed to work alongside Medicaid benefits to provide a more integrated experience for people who are eligible for both programs.

harshedbuzz · November 14

@H1235 said:

I believe this on-site care is what is supposed to be so appealing to this plan.

But would it be? YMMV, but if mom gets pneumonia and we see the PCP or pulmonologist she is immediately turfed to the ER and likely admitted or kept for observation/treatment depending on severity. It's so predictable, I've cut out the middleman. If your mom is at a stage in her disease that you would still treat aggressively, she might not be treated in the facility anyway.

HB

H1235 · November 14

So here is what I have found out, since it may help others in a similar situation. Moms blues cross and blue shied while very good, is geared towards doctors visits to an actual office. The align ( Medicare advantage) offers in nursing home visits that are not possible with bcbs. It still seems to me that the nursing home should have this covered with their doctors, but apparently not. The director at the nursing home said this is the coverage most of their residents have and it is much better than bcbs. I will apparently have to cancel her bcbs, which is kind of scary, but I think/hope this is the best coverage and care for her. To complicate things mom has already signed up for a different Medicare advantage plan that I will now need to cancel. I believe Align has more to offer. I am absolutely furious they let anyone even talk with mom about this let alone sign any papers. She does present as competent, but she is in a nursing home. I let the nursing home know how I feel. To make matter worse when I tried to cancel the program mom signed up for they refused to talk with me without me sending them a copy of the DPOA. I will do that, it’s not a big deal, but they just let someone with dementia sign up for their program with out questions. So unethical! In addition this company has already sent everything to Medicaid. I will somehow need to switch it over to align. I can’t talk any of this over with my brother, since he still can’t figure out the difference between Medicare and Medicaid. It’s so stressful. Thanks for advice and letting me vent.

JJ401 · November 14

If Mom has recently been approved for Medicaid, I’d talk to them about what the nursing home recommended.

H1235 · November 15

So the the nursing home gave me a bill (sent to mom at the nursing home from another company) that I thought was another Medicare advantage plan that mom signed up for. They gave me a really rough time about canceling it, but I finally managed to get it done. Turns out I should have never been given the bill, because it was an outside company (hired by the nursing home that helps them manage care and not something mom was even involved in. The bill should never have been given to me and the service should not have been canceled. I have found out that no one at the nursing home is able to give me any straight answers about Align, because they have just started working with them. I am in tears. What a mess! At this point I could care less about Align. I just want this nightmare over. I will go in to the nursing home on Monday to see if I need to call the company to get services back for mom or if they need to. Then I am done with this mess. Things should not have to be this complicated.

Insurance question

Comments

Commonly Used Abbreviations

Community Guidelines

Categories