Question on Medicaid?

[leftyladyfrommo]

A friend of mine is on total disability. Her back has kind of disintegrated and she needs some really strong pain pills. She uses some kind of pain patch and it really helps.

But her prescription was denied by Medicaid. They said she is in the donut hole. The patches she needs are $181 a month and no way can she afford that. She is applying directly to Johnson and Johnson and if she is approved they will provide her pain patches at no cost.
She said this is the first time she has ever had this happen - the donut hole.

I knew there was a donut hole in Medicare but not in Medicaid. And she blames Obama.

Does anyone know about this?

[DemocratSinceBirth]

1. There is no donut hole in Medicaid

Some states have limits on the number of prescriptions you can get on Medicaid. I presume they can veto a prescription if they feel it is unwarranted; i.e. too expensive and there is a less expensive alternative.

Your friend still can appeal.

Also, keep in mind Medicaid is administered by the states, Medicare is administered by the government.

[leftyladyfrommo]

2. Could she be on Medicare? She is only in her 50's.

Wouldn't it be Medicaid for someone like her?

I know nothing about all of this. But she is in a real bind. She hasn't been able to work for a long time so she never has any money to spare.

[DemocratSinceBirth]

3. If she is disabled and is getting SSDI she is probably on Medicare/Medicaid

Her primary insurance is Medicare and her secondary insurance is Medicaid. Medicaid would pay for her prescriptions.

She should set up an appointment with her caseworker.

[jwirr]

4. IF she is eligible for disability under Social Security (and it sounds like she could be) then she

would get Medicare after a short period. If even then she is poor she may qualify for both Medicare and Medicaid. If she is already on Medicare and poor she should apply for Medicaid at her local Social Services Department.

Also ACA supposedly got rid of the gap in Medicare. Is she enrolled in ACA?

[daredtowork]

5. When funding gets tight Medicaid starts denying

Medi-Cal denied me for a referral to a pain management clinic. Ironically I was referred to that clinic because my underlying genetic condition precludes me taking most pain medication meds, so this move would have actually saved them money. They claimed the services were already available "in my network", but there was no "pain management clinic" in my network.

Having been in State systems in California a long time now, I've spotted a practice: when they are short on money, they deny first and put the onus on you - the poor, disabled, possibly mental ill person - to appeal. They see wearing you down as a valid form of weeding you out for the purpose of saving the State money. But the people who get weeded out first are the ones who need it the most.

Also, a lot of misinformation seems to be supposedly coming "from" the enrollment process. For instance I was just told a person near me was angry about being shifted to Medi-Cal because she "couldn't choose her own doctor", when Medi-Cal is managed by HMOs in California. You have to choose an HMO. If anything, there is too much choice, because as an uneducated consumer you can easily choose wrong. Right after I chose (based on the network my current medical clinic was in), I had trouble getting an ophthalmologist because I "should have chosen the other one".

Perhaps this misinformation is something along the lines of DISinformation: people receiving "enrollment" packets in the mail which actually go to competing insurance companies. Perhaps one of these gave this woman the "information" about the "donut hole".

I bet she just got the standard denial. Medicaid is making her work for her pain patch because the State makes poor, disabled people work harder and suffer more for stuff they need. That's just the way it works. Please speak up and vote in ways to change that.

[locks]

6. You need to know what exactly she's receiving

and her state's coverage. She is on Medicare at 50 if she has been disabled long enough and receiving disability. Problem is, although you receive more money, Medicaid generally covers more health care, meds etc. than Medicare. Some of these problems have been helped by Obamacare but each state is different. She needs a good case worker or technician to explain her options; some companies like Johnson and Johnson do help with meds if she qualifies.