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Hi everyone. I'm new here. I'm having a tough week. My husband lives in a nursing home with Huntington's disease. He's only in his early fifties. I just found out today that his Medicare medigap plan was terminated because the nursing home didn't pay the premium. He depends on that plan to pay the 20% gap and coverage for his diabetic supplies. He's a type 1 diabetic that uses a continuous glucose monitor (CGM). Because he's under 65 and it's been over 60 days since the insurance was terminated, he can't get reinstated or re-enroll. He has Medicaid, but I'm not sure if they will pay the gap in coverage. Not sure what to do. Has anyone gone through this, or could offer any advice?

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There is not any prior authorization that I know of. I was told this is how it works, Medicare pays for what they pay for and Medicaid pays the rest. This works for my Nephew who is on Social Security Disability and Medicaid. He pays nothing out of pocket. His providers bill Medicare and Medicare sends what they covered and Medicaid pays the balance. There are no summary statements sent from Medicaid.

If Medicaid is paying for Husbands care, you are not responsible for any bills. Call the office person who bills Medicare and Medicaid at the NH. I am pretty sure you do not need to pay for a supplimental insurance. Please come back and tell me what u find out.
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I am from NJ and I dropped Moms supplimental when Medicaid health kicked in which was the same time she received Medicaid for her care. Some States require that you keep your supplimental and the cost of it can be taken out of their SS. I did not realize that NJ did this too. Medicaid, IMO, should be paying for whatever Medicare does not cover. That goes for all husbands supplies.
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Whyme123 Apr 13, 2025
Thank you! I agree. I'm going to inquire about getting a prior authorization for Medicaid to cover the rest.
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Thanks everyone for your replies. When I get answers from the facility I'd be happy to share them with you.
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I agree that the spouse should not assumed that the NH should/would have paid the Medicare and Supplemental Plan premiums. The premiums are usually craved-out from the patient’s monthly social security payment to the NH. Because the patient is under age 65 he was eligible for Medicare coverage because he is on SSDI (Disability.). The problem now is how to rectify this situation. I recommend that the spouse should see an Elder Care Attorney (Lawyer) to determine legal options in this regard.
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swmckeown76 Apr 12, 2025
Not necessarily. I didn't start Social Security until age 70. Medicare Part B premium and Medicare supplement premium from my checking account came from my checking account until then. When I began receiving Social Security at 70, Medicare Part B premium switched to being deducted from my checking account to my Social Security payment, but I still pay for my Medicare supplement payments from my checking account. When my late husband was a private-pay long-term care resident due to frontotemporal degeneration and receiving SSDI, he was on early Medicare, but we paid the 20% that Medicare didn't pay. When he was eligible for a Medicare supplement at age 65, I bought him one, it also came out of our checking account because he died four months before he reached full Social Security retirement age.
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Welcome, Whyme,
I have read your responses and they are good ones.
I think only your facility has the answers for you. You say "meanwhile here I am" as regards the facility, who gets his SS, being responsible to now for paying his Medigap. What do you mean by "here I am". Are you being billed for care, supplies, medications?

I sure do hope you will update when the financial folks get back and give you answers as to what's happening now.

I, like others here, don't understand who now is in charge of paying his bills. I imagine the only one he has is medigap insurance and that comes from his SS as he no longer has assets at all. It is almost sounding like the nursing home itself is in charge as his financial POA? Or are you? This is all so confusing. He is not left with funds enough to pay any Medigap insurance, and I am wondering if now, all his things are not paid for by medicaid.
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Whyme123, when I did a browser search for "Does Medicaid pay for diabetic supplies" here is the result: "Yes, Medicaid generally covers diabetic supplies, but coverage and specific items covered can vary by state. Most states offer coverage for essential supplies like insulin, syringes, blood glucose strips, and sometimes more advanced equipment like continuous glucose monitors (CGMs). " Also, if his gap policy was unpaid then he would have been receiving either snail mail letters or emails to warn about lack of payment. Are you not the manager of his affairs? Even if the business office was managing it, they would have been getting these warnings. Someone would have been getting these warnings. Who gets and opens his mail?
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Whyme123, Medicaid can have different rules by state so maybe this is why this seems unusual (to me). Where I live there is no option for someone on Medicaid to also have gap insurance paid for by this aid (my MIL was in LTC on Medicaid for 7 years and I would have certainly had gap coverage for her if it were an option). It would only be privately paid for and if the recipient has enough funds to pay for a gap plan, then it must be allowed by your state's Medicaid. And also for the facility to manage paying for it... does this mean they have access to his banking? If not, then I don't know how it's possible they are paying for it... the facility certainly isn't paying for it on his behalf. "They get his social security money. They've handled paying his insurance premium from his social security money for the past several years." Usually with Medicaid, one's SS income pays for the custodial care portion only (room and board) and all things medical are covered by the Medicaid financial aid. If it's accurate that the facility has been responsible for paying for his gap insurance then you need to go to the business office and complain loud and long to them for letting it lapse and blindsiding you and your husband.
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Whyme123 Apr 12, 2025
Thank you. We live in NJ. I don't know all of the rules, but when my husband entered the nursing home, he had Medicare plus the Medicare Medigap plan. Several months after his admission the facility enrolled him in a Medicaid healthcare plan.
My husband no longer has any bank accounts. When we had to spend down for Medicaid to cover his long-term care, his bank accounts were closed. The facility receives his social security payments and has an account for him there. He gets so much money each month for personal needs. They had been paying the premium for his Medigap plan up until recently, so I never questioned whether or not it was allowed by the state if he's also on Medicaid.
I contacted the administrator, who referred me to finance, but she is on leave for another week. I'll address it with her then.
I know the rules for Medicaid vary for each state, but I was wondering if anyone else had this experience. Hopefully, I will get answers from the facility soon, but in the meantime here I am.
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Why would the nursing home be in charge of managing his bill payments? Has it been doing this all along? If you are his spouse, what is the reason you aren't managing this? How long has he been in the NH? More information would be helpful.
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olddude Apr 12, 2025
Totally agree. AL facilities do not pay the resident's bills.
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