Medicaid ..spend down questions???

Discussion in 'General Parenting' started by TexasTornado, Feb 15, 2007.

  1. TexasTornado

    TexasTornado New Member

    Well we finally got "the letter" in the mail yesterday. Our case worker had warned us before hand, abt our income and abt spend down-which I wasnt going to worry abt-just wanted to make sure we got approved first.
    Well we are approved and now I have no clue-LOLOLOL
    We have a spend down limit of $89 per month. husband doesnt think its worth it. I WANT it!
    The school isnt helping with anything Autism Spectrum Disorders (ASD) related for our difficult child-so its up to us to supply everything we think he needs-social classes etc and counseling, problem Occupational Therapist (OT) for Sensory Integration Disorder (SID) issues etc, medications.
    We just were not doing any of teh services recommended before -as the co-pays were too expensive as we would have to pay them 2 times every week or more.
    So if we were to get the services that have been recommended-its abt 300 dollars a month-just with social classes each week its $60=so I think it would be worth it.....if anythng he NEEDS the social skills classes.
    What do you all think? Also it said we could pay the spend down with medical bills-does this mean past bills since submission date that we have already paid in?
    Just wondering if anyone knew anything about spenddown, if you would think its worth it at 89$ a month, and ANY other info you could give me would be very appreciated :smile:
    Luvz,
    Kathy
     
  2. tiredmommy

    tiredmommy Site Moderator

    If I remember correctly from my Dad, you can apply medical supplies, medications and/or co-pays and primary insurance premiums. Our office reviewed yearly and would adjust the spend down to reflect any over or underpayment for that next year. It was well worthwhile in his case. Is just for your difficult child or the whole family?
     
  3. Kit_Kat_MI

    Kit_Kat_MI New Member

    When i was on it, they basically wouldn't cover the first $150 per month of any medical bills - which meant I had to spend that much out of pocket befoer they would pay. and i was a single mom making $8/hr, so i never used it. I say call up your social worker and ask how the system in your stay works - just ask do you send me a bill for my spend down or do i have to sendyou the paid bill(s) for that much money first?
     
  4. OTE

    OTE Active Member

    I'm not clear as to which kind of spend down you're referring to. There are several different kinds. Could you please be more specific?

    Are you sure they cover the kind of service that you want?
     
  5. tiredmommy

    tiredmommy Site Moderator

    OTE-
    This is where the family earns too much after expenses to qualify for medicaid. In this case, they make $89 too much a month. That must be either paid out to the applicable agency (as in my Dad's situation in NY) or made up out of pocket as in Kazinmich's case.
     
  6. TexasTornado

    TexasTornado New Member

    I called the case worker and she explained a little more to me-Im still sooo confused though abt all the plans and their names, what they mean etc-Ive tried looking up info and I just get more confused.
    I have private insurance, but the co-pays make it impossible to recieve the services-the amt needed with the treatment plan with mental health-this is all I care abt-is if I can get the copays paid for etc, and any other co-pays that come up etc-with psychiatric doctor and things, medications, etc. and if I could then get the services-that are in the treatment plan-then it would be a good deal.
    Im already finding out though that many docs dont take Medicaid-like the psychiatrist I was wanting to transfer difficult child to :frown: I thought every doctor-at least in hospitals and things did???So this might be a problem-as Id have to go through the doctor for medications etc. So Medicaide would be no help there.....but I need a reputable doctor as the school is always questioning the Autism Spectrum Disorders (ASD) with their own specialist credentials-mine have always trumped theirs-so there has never been a problem. Do they have to come up with the doctor, or can I pick?
    Ugh...why is everything so complicated.
    The Medicaid is just for difficult child-I asked abt husband and they said he didnt qualify as he works???
    She also gave me the impression that you could do either or-paid in or made out-as long as the $89 was given somehow??
    Thanks for all the info :smile:
    Luvz,
    Kathy
     
  7. OTE

    OTE Active Member

    TM: That is not the case in all states and there are other instances in which the term spend down is applied eg asset limitations. But not all states allow you to "spend down" because your income is too high. Wish mine did.

    Kathy: I can't comment on the rules in Texas or the other plans available. There are very extensive differences from state to state. While Medicaid may be Federally funded, in part anyway, each state has different plans. They allow and don't allow different things, include and don't include different people.

    It is generally true that any hospital that takes any kind of state funding, including Medicaid that also has an ER, has to have some kind of "indigent" or low income/ uninsured patient plan. That is, the hospital cannot turn anyone away for insurance reasons. They are required to provide treatment and work out payment arrangements later. The terms (income limits, co-pays, etc) are typically determined by the state and often follow Medicaid numbers. FYI they also typically get money from the state to subsidize their "shortfalls" for treating such patients. So if you are receiving services in a hospital under this umbrella then they have to take Medicaid. I will qualify for those who have other situations, that it is possible in some states that if the doctor is not an employee of the hospital or affiliated with the hospital the rules might be different. But I'm not personally aware of any such state. Note that with regard to life threatening services, eg ER services, no such hospital or doctor can refuse any patient period.

    The other rule, and again I'm not sure but I believe this is Federal for Medicaid... if you are on Medicaid no doctor can take you as a private paying patient. You need to check this before you start looking at docs. It's also true that there are few private providers in the psychiatry and psychology fields who take Medicaid. They just don't pay enough. Most of us end up at those hospital clinics which will take Medicaid....same hospitals as above.

    Since your state has one of the highest numbers of illegal aliens/ indigent and uninsured populations I'm sure your state has tight reins on Medicaid spending and indigent treatment co-pays. Also, since the kind of services I think you're looking for such as social skills classes is considered elective or not medically necessary there are probably even tighter restraints. Again, you need to ask Medicaid if they even cover the kind of services you want.

    Suggestions:
    1. I keep my income under their limits so I don't have to deal with all this hassle. Also,check into how they look at your income. eg if it's the W-2 and you have a 401(k) or medical cost plan that is pre-tax, increase your contribution to that plan by the $89.
    2. Talk to the providers of services like social skills classes and ask if they can change the treatment numbers on the insurance forms to something that will be covered. In particular, Pervasive Developmental Disorder (PDD) is a developmental disability, not a psychiatric disease. Can they find a way to ethically use a code under daughter rather than psychiatry to get more of this covered? So when my Pervasive Developmental Disorder (PDD) kid gets speech therapy or Occupational Therapist (OT) it's got a daughter code, not a psychology code. This involves some creativity and you may need to offer some suggestions to get them thinking creatively. eg if once a week psychology is allowed and once a week social skills is allowed and they call their twice a week class social skills can they call one session social skills and one session psychology?
    3. Again, talk to the hospital providing services and ask if you can work out a payment plan for the deductibles.
    4. Many charities will help with deductibles. Many clinics have grants to serve people who can't afford treatment. If you are near a teaching or research place, see if there are any research programs you can get into that will provide services.
    5. Have you applied to the State for daughter services? While there's a waiting list in every state, if you put him on it when he was younger and his name has come up.... you might get them to pay for this sort of thing.
    6. Many programs have scholarships. You only need a partial one. Try to find a program that will give you a partial scholarship.
    7. Apply for grants for daughter kids yourself. Eg some time ago I posted that CAN was offering $500 grants to parents. Check your local and state charities focused on kid's medical expenses or on daughter kids to see if you can find one you can apply to. eg local Lions group, catholic charities, etc. They may want to pay the provider directly, but that's OK.
    8. I'd worry less about the school district. Remember that if you don't agree with their person's diagnosis you have the right to make them pay for a second opinion.

    Yes, all of this is very complex and time consuming. Ask for something on paper explaining the program in detail.

    This is totally off topic, but you mention your younger son is a climber. You are aware that climbing is not uncommon to Pervasive Developmental Disorder (PDD) kids, right? It's proprioperceptive stimulation that many of them crave. While that it a sort of Sensory Integration Disorder (SID) kind of symptom, with another Pervasive Developmental Disorder (PDD) son, given that Pervasive Developmental Disorder (PDD) runs in families... you have had him tested, right?
    http://www.sensory-processing-disorder.com/sensory-processing-disorder-checklist.html
     
  8. TexasTornado

    TexasTornado New Member

    Thanks OTE-WOW! You have a wealth of information :smile:
    Right now everything is covered through my private insurance. but the co-pays-which HAVE to be paid and are a set rate, everytime difficult child is seen is what is keeping us from these services.
    I thought I could use my third party insurance and have Medicaid just cover the co-pays that I cant afford, deductables etc.
    My husband doesnt thinkit is worth it as we already pay so much fro private insurance(which comes out of the paycheck)-so I need to convince him if we are to do this....
    Basicaly all the services-well the social skills classes and counseling would be at the Mental health clinic-and would be covered-they will even supply transportation from the school :smile:
    Im going tomorrow to speak with them abt all of this and see actually if their treatment plan would be worth paying the 89 dollars-basically for husband's convincing;)
    These hospitals that you are talking about, or clinics-where do I find one that has a compitant psychiatric doctor?
    I also find it VERY interesting that the "compitant" docs I have talked with dont offer or give me any info abt where I can find other support, example-social skills classes, respite, in home behavior help, The only ones who have are the staff at Mental health......why is that? I find that odd?I have found them to be most humanly helpful. Wanting to know how I was doing, actually putting forth the effort to get to know us more as people, not just some disability or label....how does taht make any sense?
    Thanks for all your help in this OTE
    Luvz,
    Kathy
     
  9. OTE

    OTE Active Member

    Found some things that may help from Tx website. First one if from the state website medicaid section under FAQ.

    "I was told I make too much money for regular coverage, but that my child might qualify for spend down. What does that mean?

    Spend down is another name for the Medically Needy Program. You can be reimbursed for unpaid medical bills if, by paying them, your income would be low enough to qualify you for Medicaid coverage. For example, a family of four with an income of $1,000 a month would be covered if their medical expenses were at least $692 a month. Doctor visits, prescriptions, past medical bills, and medical insurance charges are covered. If you have other insurance it must pay first. Only the amount that it doesn't pay may be counted. This program is for children and pregnant women only."

    Here's the list of people who qualify for Medicaid in Tx. So each line represents a different category of people who qualify. You don't fall into the regular Medicaid (line 1)presumably because your income is over those limits. Your son doesn't qualify for line 2 because he's not on SSI (again presumably because your income is too high). But if you look down the list you'll see a lot of other categories and one is called Medically Needy. Your son is falling under that category. And under that category, which is for children only, your son can have other medical insurance. This is similar to my situation in which my middle son and I qualify in category 1 and my youngest and oldest are in category 2. In my state that means that we have different kinds of Medicaid with different rules. eg my middle and I are on a managed care plan, an HMO. My SSI kids are not. So if you, your husband or another child want to qualify you would have to look at the rules of each line to figure out which line you might fall under. Also note that the title of this is Medicaid waivers. So that only the first couple of lines are regular medicaid and every other line is a separate Medicaid waiver plan.

    So what they were trying to say is that it IS medicaid, but it's a different kind of medicaid, a different category or whatever word they want to use.
     
  10. TexasTornado

    TexasTornado New Member

    Hey OTE-I just saw what you wrote abt my other son-the climber. Sorry I totally missed it when I was reading before....
    MANY things resemble the two boys together-the squelling, the taking every wheel off of every car deal, movies he can watch agn and agn, trains, he is changing so much now its hard to know what behaviors will stick ard. He can be so happy, and then has a fit.
    But yes the thoughts come into my mind all the time even with my easy child daughter as she is a twirler. Every time she is twirling ard I try and think about something else. But She is very social-has many friends, is doing well in school, and is a constant gabber and listener. Maybee im doing the same for my younger easy child son. But Ive never had the same feelings of uneasiness or that something was off -like I had when difficult child was younger. I havent had him tested. But we are holding him back starting K next year-we will be enrolling him in a pre-school instead I just dont think he has the maturity yet that he needs to have -hes an early b-day. But I will be watching to see how he does.....I used to worry abt it all the time-husband woudl flip-hes just barely come to the acceptance of difficult child(hence teh fighting ove rmoney fro services is still an issue)-so Ive just been observing easy child son to myself...I dont see any red flags-like difficult child had...but I keep watching and looking anyway.
    Luvz,
    Kathy
     
  11. OTE

    OTE Active Member

    I'm trying to attach my jaw to my mouth now that I have picked myself up off the floor. It looks to me like if you get this...well the rest of us will die of jealousy. The medically needy you are talking about is a sub-category of what we call, on this website, a Katie Beckett waiver. That is, that it gives you services designed to keep your child "in the community" aka at home, rather than in a residential placement. But when you look at the list of services here that you could get....well I'm jealous!

    You can get any of these services if you can get the case mgr to put it in the plan. That includes medications, transportation for all medication appts, respite care (that parent's night out), in home help in managing life skills aka taking care of himself, Residential Treatment Center (RTC) should you need it some day, YIKES, the list goes on and on.
     
  12. TexasTornado

    TexasTornado New Member

    ThanKs OTE-
    I understand it much better now. I had no idea there where certian catagories and different rules for each catagory-no wonder I was getting all confused when I looked things up :wink:
    Okay-this is how I understand it-please tell me if Im lost still.....
    -I could pay the 89 every month
    -recieve the services
    (they would bill my private first then submit unpaid portion to Medicaid who inturn woudl pay the co-pays that I was before required to pay)-right?
    like for say-the Mental Health Clinic services-right?
    Would this still qualify difficult child for a Medical Care Plan-from what I was reading online-its is best to have one of these-right? but Im not sure as to why? LOLOLOL If I dont-coudl I get stuck paying co-pays anyway????
    Luvz,
    Kathy
     
  13. OTE

    OTE Active Member

    I think this will tell you everything you need to know. The income limit information here is the usual HUH? info they provide. Chances are the person you are talking to now and the ultimate case mgr assigned will not be able to explain it to you. So I'd just ask for a number like you have, the $89, and work with that. Should you really need more help with that I have been successful in the past finding the info but it's tough to find. Look at the section that talks about the illness and be sure that you can meet all of the qualifications. This is a lot of money at stake.

    You do realize that this is not going to pay just deductibles... this will pay flat out for anything your insurance doesn't cover and you can get included in the treatment plan. So if your insur boots the bill for social skills this will pay 100% of it! Yes, you'll have to use their providers but WOW.
     
  14. TexasTornado

    TexasTornado New Member

    LOLOL-Thanks OTE-
    Well when I talked with the Mental Health case manager-he told me Medicaid was the way to go-he said without it-well it wasnt so good....
    What you wrote abt was what he had put into difficult children treatment plan.....I was so excited at first, until I found out abt teh co-pays and deductables, and taht they wouldnt cover teh inhome ehlp etc. The Case manager submitted it to my private insuranse-who said no way to the inhome help.....which I figured they would:(
    As far as case manangers-who are we talking about here-the case manager who wrote up difficult children treatment plan at the Mental Health Center, or the Medicaid case manager? Who sets up the plan for Medicaid to pay for services here like you were talking about?
    Luvz,
    Kathy
     
  15. OTE

    OTE Active Member

    I'm still not sure what that pay down terminology means. Have you found anything with that wording in it? I'm also not sure what you mean by a medical care plan. Could you show me where you found that wording? If it means the case mgmt plan then you have no choice, it's necessary to get services from Medicaid under the Katie Beckett waiver category.

    If you can get this I definitely would not pay money for any other medication insur at all that would include difficult child.

    In terms of paperwork. Typically the provider does the service and bills your primary insur. You should then get a paper from the primary insur carrier, whatever yours calls it, a Statement of Benefits? That would tell you your co-pay. You would then submit that to Medicaid for payment. But again, going to vary by state. Unlikely that the provider will be able to directly bill because the state is worried the provider will end up collecting twice. Typically people will collect a couple of months of insur stmts and submit a pile to medicaid at a time. Easier to keep track of that way.
     
  16. OTE

    OTE Active Member

    I was talking about the Medicaid case mgr. Medicaid is only going to pay what they deem necessary. So if they decide the in home isn't necessary you have to go back to the clinic and ask them to argue with Medicaid for you. First step would be to simply submit the plan from the clinic that you are happy with. If the clinic is a big, public one chances are you won't have any fights because they work with medicaid already and know what medicaid will pay. They've done the same kind of plan at the clinic 100 times and know medicaid will approve it. If your clinic doesn't know medicaid rules it could be more difficult. But right now I'd work on getting the $89 thing fixed so medicaid will approve you. Forget what I said about charities and so forth, this is a full ride on medicaid, go for it! Call the worker again and ask how you pay the $89. Ask if you send her a check every month, if you pay $89 to a provider yourself and send her the receipt. If it gets complex ask her if there's a way to make it simpler. Go back to the stuff I said about reducing your income by $89/mo. Earning that $89 per month is sure a lot less than the deductibles and co-pays you pay now that medicaid will start picking up plus all the additional services. Also, that $89 is going to change every month if your paycheck fluctuates eg overtime, every yr when inflation changes, etc. That's why I find it easier to just earn under the limit and save myself the hassle.
     
  17. TexasTornado

    TexasTornado New Member

    Thank you Soooo much OTE-youve been a life saver in all of this :)Youve been so helpful in finding info and telling me what the best action on my part would be-Id still be running ard if it hadnt been for your help in all of this.
    Luvz,
    Kathy
     
  18. OTE

    OTE Active Member

    I've spent years running around to figure out this stuff for my 3 kids, I sure know what you mean. And since you're working I can't imagine where you find the time, everything you want to look up and understand takes hours and hours.
     
  19. TexasTornado

    TexasTornado New Member

    Oh-OTE-Im a stay at home mom :smile:
    And yes, it seams EVERY part of this whole entire process from diagnosis, school, behaviors at home, insurance, the whole lot-its VERY time consuming. And to think Ive only reached the tip of teh iceburk Im afraid. Its so nice to coem her and hear"yeah Ive been here, and this is what you need to do." Hearing that in a world so uncertain is like music to me ears-LOLOLOL I think Ive learned more in this past year than all my years in schooling;)
    I seriously dont know how working Moms do it either-I just couldnt-period......
    My meeting with mental health was canceleled today :frown: OH I was torked and then they wanted to reschedule-not becuse I cancelled but that HE was sick and wanted it rescheduled for March 2nd-I was like heck no! So Im going in on Wed-thank the Lord-I just want to get this STARTED.
    I think for the first time in all of this I think Im heading in the right direction, with the resources we need, the guidance and supports can finally be here to help us! YEAH!!!!
    Its funny-but I feel soooooooooooooo excited-is that weird to feel like this? I just always thought this was something that was always slipping through our fingers, always setting us back, something that was THERE-but not for us.
    I know I sound off my rocker-but its like Im in a dream and Im scared to blink-LOLOLOLOL, Silly-right?
    And I am so full of gratitude its not even funny......makes my eyes water Im so happy:)
    okay-ill stop now before I get really loopy....LOLOLOLOL
    But thanks for everything!
     
  20. OTE

    OTE Active Member

    Oh I do so know what you mean. My kid was out of control for years and no professional I consulted helped. I knew he was heading for something horrible (he's an addict, criminal, etc). But there was nothing I could do. Then I found this site middle of the night one night when my 12 yr old was out getting high or drunk. I honestly felt at the time like I was "on the edge" of sanity. But with the help of this site and a lot of hours on my part I began to understand that there were options. Some months later I finally got docs to treat him... he needed Residential Treatment Center (RTC) and I couldn't get it.

    Now it's almost 5 yrs I've been here and I'm still struggling with mine. But I'm only 10.5 months from his 18th BD and then he's out. I'll still worry but I've been able to detach over the years.

    Now I have validation that I'm not making up stories about his behavior, it is real. Now I know that he has a serious mental illness though no psychiatrist has yet been able to put a label on it. I know where to get help for him but he still refuses it. I know that I did everything I could for him and then some. It has been a long road and it's not over, but yes, I understand the relief, and the gratitude for this board.
     
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