deductible

Actualizado ** Entendiendo el Deducible de Medicaid, o "Spenddown"

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In English - Updated** Understanding A Medicaid Deductible, or "Spenddown"

La mayoría de los programas de Medicaid cubren todos los beneficios esenciales de salud, como visitas al médico y al hospital, servicios de atención dental y de visión. Sin embargo, algunos programas sólo cubren beneficios limitados. Por ejemplo, el Medicaid de Servicios de Emergencia y el programa MOMS (información aqui) proporcionan servicios parciales a los inmigrantes. Otro programa "parcial" se llama el programa Deducible de Medicaid (anteriormente llamado Medicaid Spenddown).


El programa de Deducible de Medicaid está disponible para personas con discapacidades, ancianos, niños y padres de niños que están sobre el límite de ingresos para el Medicaid completo. A fin de calificar para un deducible, también tendría que cumplir con una prueba de activos (que tiene en cuenta sus activos, excluyendo una casa y un coche). Un individuo que está sobre el límite de ingresos para Medicaid y tiene muy pocos activos puede ser aprobado para el programa de deducible. El Departamento de Salud y Servicios Humanos (DHHS) especificará la cantidad del deducible, un número que oscila entre menos de cien dólares y varios miles de dólares. Este número se basa en los ingresos de su hogar.

LA IDEA ES SIMPLE, PERO LA ACCIÓN ES COMPLICADA

Con un deducible mensual de Medicaid, para que Medicaid llegue a ser completamente activo, las facturas que ascienden al deducible deben ser alcanzadas en un mes determinado. El individuo es entonces responsable del deducible y DHHS paga el resto. Por ejemplo, digamos que el deducible de Martha fue fijado en $ 800, y Martha tiene una factura del hospital en Mayo por $ 5,000.

Martha es responsable de pagar los $ 800 al hospital y DHHS paga $ 4,200. Para que DHHS pague, se debe presentar un informe de deducible.

Si la factura fue incurrida el 1 de Mayo y se presentó un reporte de deducible, durante el resto del mes Martha tiene Medicaid completo y Medicaid pagaría por cualquier servicio médico necesario, como gafas, limpieza dental o medicamentos. A partir del 1 de Junio, Martha no tiene Medicaid, pero de nuevo tendría que cumplir con un deducible.

Si Martha ingresó al hospital el 31 de Mayo y no tenía gastos médicos antes de esa fecha, no alcanzaría el deducible hasta el 31 de Mayo. A partir del 1 de Junio, el deducible / spenddown se restablecería, por lo que probablemente no sería posible de que le limpien los dientes en Mayo! Algunas personas, particularmente las personas que viven en hogares de ancianos, cumplen con su deducible cada mes, pero la mayoría de la gente no.

Recuerde: Para que Medicaid se active, las facturas y un Reporte de Deducible deben ser enviados al trabajador social del DHHS. El deducible debe ser alcanzado de nuevo cada mes para que Medicaid se active.

 

LOS DEDUCIBLES DE MEDICAID PUEDEN AYUDAR, PERO NO SE CUENTAN COMO COBERTURA DE SALUD COMPLETA

Importante: El programa de Deducible de Medicaid no cumple con los mandatos de la Ley de Cuidado de Salud a Bajo Precio. Esto significa que si esta es la única cobertura que tiene, se le puede aplicar una multa al presentar los impuestos al final del año.
La buena noticia es que usted puede tener un plan del mercado de seguromedicos o una cobertura de seguro de su empleador junto con un deducible de Medicaid. (Recuerde, Medicaid puede ser un seguro secundario.)


¿CONSEGUÍO LA COBERTURA CORRECTA?

A veces un individuo es aprobado para el programa de deducible pero realmente debe tener Medicaid completo. Si usted piensa que debe tener cobertura completa, la oficina del Washtenaw Health Plan ofrece una evaluación gratuita. Para obtener ayuda para presentar las facturas de su deducible de Medicaid o si cree que debe recibir Medicaid completo, vaya a la oficina del Washtenaw Health Plan. El horario de atención es de lunes a viernes de 9:00am a 4:00pm. Estamos ubicados en 555 Towner, Ypsilanti, MI.


¿Preguntas? Llame (734) 544-3030.

-Haley Haddad, Ingrid Fonseca, Ruth Kraut and Meredith Buhalis

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Insurance Gaps & Failures--Bills, Bills, Bills: Can Charity Care Be The Answer?

SCENARIOS

#1     You had health insurance coverage at your old job, which ended September 20th. The coverage at your new job starts October 1, but on September 25th you got appendicitis, and now you have a big bill.

 

#2     You should have signed up on the Marketplace, or taken your employer insurance, but health coverage seemed expensive so you took a chance. When your daughter broke her leg at school, they called an ambulance. Now you've got an ambulance bill, an ER bill, orthopedist bills...the bills are more than three months of your rent!

 

#3     You have employer insurance, but it is a high-deductible plan. After your spouse got pneumonia and was in the hospital, your family ended up with a $5,000 bill.

 

IF ANY OF THAT SOUNDS FAMILIAR, THERE MAY BE SOME SOLUTIONS!

 

DON'T DELAY- ACT NOW

First, don't delay. Don't wait until your bills are nine months old and in collections to get help. If you think that the billers made a mistake (for instance, if they have not billed your insurance), call and make sure they have your correct insurance on the record. If you think the bill is correct, start researching your options immediately.

ARE YOU MEDICAID ELIGIBLE?

Explore whether you and your family might be eligible for Medicaid. In some cases, people are eligible but don't know that they are. Remember that income cutoffs arehigher for children and pregnant women, and that Medicaid can be applied retroactively for the three months prior to the application date, if you were eligible at that time. (So, if you apply in September, you may be eligible for coverage in June, July, and August.) Medicaid can also be used as secondary insurance, which works well with high-deductible employer plans. You can get help in evaluating eligibility for and applying for Medicaid in many locations.  Apply for Medicaid.

ARE YOU MARKETPLACE ELIGIBLE?

Explore whether you are Marketplace or employer coverage eligible for the future. If you commit to getting health care in the future, you are more likely to be eligible for Charity Care for your current needs.  Apply on the Marketplace (Healthcare.gov).

 

CHARITY CARE

ARE YOU CHARITY CARE ELIGIBLE?

Explore Charity Care. Charity Care programs are run by many hospitals and medical organizations (including emergency transport organizations and primary/specialty care organizations). Typically the organizations will want to know why you incurred the bills (e.g., why didn't you have health insurance), and what kind of help you need. They will want information about your income, expenses, and insurance (including gaps)--but short-term gaps and high-deductible programs are typical reasons that charity care will be provided.

WHO DO YOU CALL ABOUT CHARITY CARE?

Many organizations have Charity Care programs, but they are often hidden. If you call the billing number on the bill, you can ask for information about the "charity care" program or see if there is a patient financial counselor with whom you can speak. Sometimes a bit of research on the organization web site will allow you to find the charity care application. 

FILLING OUT THE CHARITY CARE APPLICATION

Expect to provide information about your income and assets (typically: taxes, pay stubs, recent bank statements) along with the bills. It also helps to include a letter explaining the circumstances. Generally your application will not be considered until you turn in all of the requested documents and information. 

IF YOU ARE DENIED CHARITY CARE

In some cases, you can appeal your charity care denial. As a last resort, you can ask for a "self-pay discount for the uninsured" to be applied to your bill--this often reduces your bill substantially. You can also negotiate a payment plan--for example, paying $100/month to pay off the bill so it does not go to collections.

If you need additional assistance, contact the Washtenaw Health Plan.  Call (734)544-3030 or walk-in hours are Monday through Friday 9 a.m. to 4 p.m. at 555 Towner, Ypsilanti, MI, 48197.

 

LOCAL CONTACTS FOR FINANCIAL ASSISTANCE

McAuley Support - Charity Care program at St. Joseph Mercy Health System

M-Support Application - University of Michigan Health System Financial Support

Huron Valley Ambulance - Financial Assistance Application

IHA Primary and Specialty Care - IHA Financial Support

 

YOU CAN ALSO:

Apply for Medicaid at MiBridges.gov 

Apply for Marketplace insurance at Healthcare.gov

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Updated** Understanding A Medicaid Deductible, or "Spenddown"

En Espanol - Actualizado ** Entendiendo el Deducible de Medicaid, o "Spenddown"

Most Medicaid programs cover all essential health benefits, like doctor and hospital visits, dental care and vision services. However, some programs only cover limited benefits. For example, Emergency Services Medicaid and the MOMS program (information here) provide partial services to immigrants. Another "partial" program is called the Medicaid Deductible program (previously called Medicaid Spenddown).

The Medicaid Deductible program is available to people with disabilities, the elderly, children and parents of children who are over the income limit for full Medicaid. In order to qualify for a deductible, you also would have to meet an asset test (which takes into account your assets, excluding a house and car). An individual who is over the income limit for full Medicaid and has very few assets may be approved for the Deductible program. Department of Health and Human Services (DHHS) will specify the amount of the deductible, a number ranging from less than one hundred dollars to several thousands of dollars. This number is based on your household income.

The Idea Is Simple, But The Action Is Complicated

With a monthly Medicaid deductible, for Medicaid to become fully active, bills amounting to the deductible must be reached in a given month. The individual is then responsible for the deductible and DHHS pays the remainder. For example, let's say Martha's deductible was set at $800, and Martha has a hospital bill in May for $5,000. Martha is responsible for paying the $800 to the hospital and DHHS pays $4,200. In order to get DHHS to pay, a deductible report has to be submitted.

If the bill was incurred on May 1, and a deductible report was submitted, then for the rest of the month Martha has full Medicaid, and Medicaid would pay for any necessary medical service, such as  glasses, a dental cleaning, or prescriptions. Starting on June 1, Martha does not have Medicaid, but again would have to meet a deductible.

If Martha went into the hospital on May 31, and didn't have medical expenses before then, she wouldn't meet the deductible until May 31. Starting on June 1, the deductible/spenddown resets, so she probably wouldn't be able to get her teeth cleaned in May! Some people, particularly people living in nursing homes, do meet their deductible each month, but most people do not.

Remember: In order for Medicaid to become active, the bills and a Deductible Report must be sent to the DHHS caseworker. The deductible must be reached again each month for Medicaid to become active.

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Medicaid Deductibles can help, but they don't count as FULL health coverage

Important: The Medicaid Deductible program does not meet the mandates of the Affordable Care Act. That means that if this is the only coverage you have, you may be assessed a tax penalty when filing taxes at the end of the year.

The good news is that you can have a Marketplace plan or employer insurance coverage along with a Medicaid deductible. (Remember, Medicaid can be a secondary insurance!) 

Did you get the right coverage?

Sometimes an individual is approved for the Deductible program but really should have full Medicaid. If you think you should have full coverage, the Washtenaw Health Plan offers a free assessment. For help submitting bills for your Medicaid deductible or if you think you should have full Medicaid, stop into the Washtenaw Health Plan. Walk-in hours are Monday through Friday from 9am to 4pm. We are located at 555 Towner, Ypsilanti, MI. 

Questions? Call (734) 544-3030.

--Haley Haddad and Ruth Kraut

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