Golden Opportunity

I am the step-mother of an adult mentally challenged daughter.  Developmentally, she is between the ages of 3-5 and is non-verbal.  She cannot read, cannot write and will NEVER be employable.  As such, she is covered by Medicaid.  She has been since she reached the age of 18 – an adult considered responsible for her own earnings or lack thereof.  She received an SSI (Supplemental Security Income) payment from the age of 18 and after my husband (her natural father) deceased, a payment from his Social Security Disability account.  As she will always be a dependent, she will always be entitled to that payment.

Medicaid was assigned regardless of whether or not the family had (which we do) insurance that could cover her.  We can either keep her insured under our plan in addition, or just use Medicaid/Medicare. 

As many of you will not have to deal with these circumstances, I thought I would share some of what I find to be areas of concern.

First, let me say, I am very grateful that she is eligible for Social Security disability.  While it is not sufficient to live on by itself, it helps tremendously!  Medicaid, while there for her medical needs before she turned age 26, is now used to compensate day programs and after care directly related to her condition.  The program she attends bill Medicaid for those services and that is where they receive the funding from to continue the program – my daughter being just one of many clients they serve.

Now, because she is older than 26, she has been assigned Medicare.  That is her insurance for health issues.  We are quite fortunate in that she has little need for medical attention barring the yearly physical required by the state as she is in an institutional setting (TB testing 1 x per year) flu shots, etc.  Because she is Medicare/Medicaid, we receive absolutely no bill what-so-ever for these services. 

But there is more to this story:  Years ago, while she was under our health insurance AND Medicaid (which was necessary for the day placement payment portion) she had a problem with her knee.  She had fallen a few times and injured her knee to the point where she required medical attention.  I made an appointment with a local Orthopedic office for her to be seen.  After waiting over one week and arriving at the office, I was informed that we would have to go to a doctor in the next town to be seen (that was the assigned physician for Medicaid) and subsequently be referred back to where I was in order to comply with the rules of Medicaid (an insurance plan we were not planning to bill or use in any way for this event).  In short – she was REFUSED to be seen and sent packing.  We then had to make an appointment with this doctor that we did not know in any way.  He saw her for all of 90 seconds and wrote out the referral.  Then, we had to wait AGAIN to come back to the doctor we had the original appointment with to be seen.  This was going to take WEEKS!  She was injured and in pain and told to wait.  And, two doctors were billing and paying Medicaid for something when one would have easily sufficed….not because we were using Medicaid but because she fell under the Medicaid umbrella and they could not bypass their regulations or they would no longer be able to be Medicaid providers!

Skip ahead.  When she became eligible for Medicare instead of Medicaid for her health insurance (not because of her age but because of her condition), I notified my insurance provider as instructed.  If anyone on the plan is Medicare eligible, they must be notified.  I am not now nor was I then eligible for Medicare.  But – once she was eligible for Medicare that instantly shifted her coverage thru our plan as a supplemental plan.  What I didn’t know at the time was that the moment she became “supplemental” so did everyone else in our family.  Boom – all three of us!  So, she had Medicare primary and our insurance secondary and we had NOTHING but secondary.  Needless to say, I had to drop her from the plan to ensure that hubby and I had primary sufficient coverage.

It is no secret that Medicaid and Medicare are shelling out a ton of money taking care of all who need it.  But with just the little experience I have with them – I am beginning to understand why.

On top of this – we have the billing done by our day placement programs.  The services (and they are wonderful) that she is given during the day are paid for by Medicaid.  The centers bill for those services (I believe) monthly.  It is (or at least should be) based upon her attendance.  Many years ago, I would be sent a statement requesting my signature verifying that she had indeed attended the program and received the services on those dates – but no more.  I have not seen any evidence in over 5 years!  Am I suggesting that they are committing fraud – No.  But I am suggesting that there are no checks and balances where they are needed and too many where they could be done without. 

Further to this problem, many Medicaid recipients chose to avail themselves of medical treatment thru emergency rooms when a trip to a local family doctor would suffice.  ER is for emergencies.  You may feel bad – but a cold, sinus, bronchitis, etc, is NOT reason to go to the emergency room.  That is a prime example of when a patient should require a referral. 

For any/all candidates that want to improve our budget; start here!  Doctors should be the ones establishing these systems – not bureaucrats.  That’s the reason there are so few Medicaid eligible doctors – the amount of nonsense paperwork involved in participating.  This system is necessary.  This system is valuable beyond measure.  But it is in need of streamlining by those who know best how to work it. 

Ben Carson would be ideal at this – by the way.  Let him head a task force to revamp the Medicaid/Medicare system and get this working like a well-oiled machine.  Just think of the money you will save!

R-O-A-R!!!!!! $$$$$$$