Ask The Advisor - Help! My Disabled Son Is Getting Transferred To A Medicaid Managed Care Plan.

Ask The Advisor – Help! My Disabled Son Is Getting Transferred To A Medicaid Managed Care Plan.

Q: My adult son has cerebral palsy and gets his healthcare through both Medicare and Medicaid.  I recently received a letter from the state that his former fee-for-service coverage is ending and that he has been assigned to a managed care plan.  The letter says we can’t opt out. My son currently lives at home with us instead of a nursing home and gets care from his sister during the day through a family caregiving program.  Will the new plan cover this as well?  — Susan G.


A:  It’s hard for me to say whether the new plan will cover the family caregiving programs, so I recommend that you call the contact number on your letter about the change.  In the state of Virginia, for example, the family caregiving program will not be affected by the transition, but each state is different.

Medicaid is the federal and state healthcare program for low-income Americans that includes coverage for retirees and disabled adults.  Medicaid pays for 60% of all nursing home stays as well as other types of long-term care services and supports, like the family caregiving program you mentioned.  Medicaid also pays for your son’s Medicare premiums and cost sharing if his income is low enough to qualify.

In 2017, 39 states rely heavily on “risk-based” managed care organizations to provide coverage to Medicaid beneficiaries — including a growing number of people with special needs like your son.  States are seeking to maintain or even decrease costs while improving health outcomes.  But it is too early to say whether managed care plans, many of which are owned by the big insurers like United Health, Aetna, Humana, and Anthem Blue Cross Blue Shield, will be able to save money for the states and still provide access to quality care and benefits not covered by Medicare.

People with special needs have complex healthcare conditions and require more ongoing services and supports than other Medicaid enrollees.  They often are the most expensive Medicare enrollees to insure.  Critics of privately-owned managed care plans wonder how long private sector insurers would be willing to provide care, if costs turn out to be higher than expected, or Medicaid budget cuts lead to lower re-imbursements.  Private insurers have pulled out of contracts with the federal government in the past, leaving people, especially in rural areas of the country, with few or even no health plans.

I suggest you learn as much as you can about your choices.  How many plans does your son have to choose from?  How do they differ?  Is there informational material available?  Can your son switch plans if you have problems?  If so, when can he do so?  Does your son’s new plan assign a “care coordinator” who will help you find doctors, hospitals, and the services your son needs?  Have you called your son’s plan and spoken to that person yet?

The letter you received should list your state Medicaid contact number to call for more information.  In addition, you can get free one-on-one counseling from your State Health Insurance Assistance Program (SHIP).  Many of these programs operate through local Area Agencies on Aging or senior centers.