Need Help?

Insurance is ridiculously complicated. And what saddens me is that the people who need it the most, are the ones least capable of obtaining it. Even if they can afford it, it’s just really hard to know who to turn to for answers. Hec, it’s not even easy to figure out what the questions are supposed to be.

Help Me!

Lately, I’ve been expanding my contracting in the states I’m licensed in. And that means I’ve been doing all sorts of additional training. My goal is to offer best of class healthcare coverage in every county. Life insurance is easy by comparison. It’s by state. If I’m licensed in your state, counties don’t matter. You’ll be covered. Health Insurance – that’s a different beast. First, there is the type you need. Then there is where you need it. What county do you live in? And then there is the type of network you want. Will you lose your doctor, or a much needed specialist if you change plans? Will your drugs all be covered? And what about if you have a chronic illness? What if you’re terminal? What if you’re in a nursing home? What if you are very poor and can’t afford standard healthcare?

With all these questions, you would be right if you guessed that it’s a little more complicated to provide a health plan than a life insurance policy. And to be honest, it doesn’t pay me as much. Many of my peers in the insurance business avoid it because it is a lot of work.

But I can’t do that. My inescapable reality is that I have a bleeding heart and it’s the people that need my help the most, that cry out for attention. I want to help them. The rich have more than enough helpers. The seriously infirm, the marginally qualified, those with special needs, those who might qualify for Medicaid and Special Needs Programs, those who need translators – these all need better support than they now have. And most don’t know how to ask for it. On a daily basis, I find that I’m like a sponge soaking up all I can to prepare myself to help. And be ready next time someone calls for it.

It can be distressing. Look at the lingo. According to the Centers for Medicare and Medicaid Services (CMS), those who qualify for dual special needs programs, (where they could get Medicaid and the state to pay for all or part of their Medicare expenses), are classified into the following five possible types. When I help them apply, I’ve got to classify them correctly. Tell me if this all sounds clear as mud to you.

FBDE – Full Benefit Dual Eligible only

  • Full Medicaid coverage refers to the package of services, beyond coverage for Medicare premiums and cost-sharing, that certain individuals are entitle to when they qualify under eligibility categories covered under a state’s Medicaid program. Some of these coverage groups are ones that states must cover (for example, Supplemental Security Income [SSI] beneficiares), and some are groups that states have the option to cover (for example, the “special income level” institutionalized group for individuals or home-and community-based waiver participants and “medically needy” individuals).
  • These indivudals get Medicaid only, are enrolled in Medicare Part A and/or B, and qualify for full Medicaid benefits, but not for Medicare Savings Program c ategories. However, the state may pay for their Part B premiums.
  • Beneficiaries pay no more than the amount allowed under the state’s Medicaid program for services furnished by Medicare providers.

QMB – Qualified Medicare Beneficiary Only without Other Medicaid

  • Medicaid pays Part A (if any) and Part B premiums.
  • Medicaid pays Medicare deductibles, coinsurance, and copayments for services furnished by Medicare providers for Medicare-covered items and services (even if the Medicaid State Plan payment does not fully pay these charges, the QMB is not liable for them).

QMB+ – Qualified Medicare Beneficiary Plus

  • Medicaid pays Part A (if any) and Part B premiums.
  • Medicaid pays Medicare deductibles, coinsurance and copayments for services furnished by Medicare providers for Medicare-covered items and services (even if the Medicaid State Plan payment does not fully pay these charges, the QMB is not liable for them).
  • Get “full Medicaid” coverage in addition to coverage for Medicare premiums and cost-sharing.

SLMB – Specified Low Income Medicare Beneficiary Only

  • Medicaid pays Part B premiums.

SLMB+ – Specified Low-Income Medicare Beneficiary Plus program

  • Medicaid pays Part B premiums.
  • Get full Medicaid coverage in addition to coverage for Medicare Part B premiums.

2023 & 2024 Qualified Benefit Levels & Qualifications

So what does all this mean?!

What this means and what to do about it are two different questions. What it means is some people qualify for extra help as spelled out above. Any US citizen falling on or below the poverty line is likely to qualify for state Medicaid. Even if they are as much 20% above the Federal Poverty Level (FPL), they can at least qualify to get their Medicare Part B premium covered. When people are on a low fixed income, every dollar counts.

What you can do about it is help me help people. Get them onto Medicaid, if you can. If not, see what they qualify for by helping them pay their bills. See if you can help them prove their income at their local Medicaid office.

If you’ll do that, I’ll do this

It takes a village. Having a bleeding heart is sweet, but I’m about maximizing the good I do. I know that if I spend my time tirelessly helping people get onto Medicaid and helping them with their bills, that I won’t be able to help those who have already taken those steps and now just need to get plugged into the best dual special needs plan for their needs so they can get to their doctor. Let me focus on the insurance side of the problem. Let their church friends and family help them with their Medicaid applications. Then let me know immediately what they’ve qualified for once they are approved. What is their individual or family income? Have they been approved for FBDE, QMB, QMB+, SLMB, or SLMB+? If you’re not sure which is which, call me. I can decipher bureaucracy-speak.

NOT AFFILIATED WITH OR ENDORSED BY THE GOVERNMENT OR FEDERAL MEDICARE PROGRAM.

Participating sales agencies represent Medicare Advantage [HMO, PPO, PFFS, and PDP] organizations that are contracted with Medicare. Enrollment depends on the plan’s contract renewal. 

I do not offer every plan available in your area. Currently I represent 6 organizations in Tallahassee which offer 42 plans and other organizations with numerous but not all plans in six total states, including Florida, Georgia, Texas, Arizona, California and Virginia.

My Seasons

Dual Special Needs Plans
Dual Special Needs Plans

Most of my friends know that I’m a veritable insurance mall. I handle Medicare, dual Medicaid/Medicare plans (D-SNPs), and both traditional, supplemental and Medicare Advantage plans. I also offer Marketplace (Obamacare/ACA), as well as private and specialty health plans. And if that wasn’t enough, my core business – when we’re not in a Medicare or Marketplace open season – is life insurance. I represent numerous life insurance carriers and plans so that I can match individual needs with the plan that fits best.

Use this code to schedule me

It’s January 10th. As I post this, there are only six days left of open season for the Marketplace. If you are under 65 and have significant preconditions and don’t have a very high annual income, the Marketplace may be the best match for you. You can probably avoid premiums. Just be aware that having no monthly premiums to pay does not mean you get free healthcare. And think about it. If you have preconditions, that will likely matter a lot. Always check to see what your annual deductibles will be. And count up your most likely copays and costshare. Most “free” healthcare plans only pay 70-80% and that’s only after a huge annual deductible is out of the way. Don’t get me wrong. A lot of thes out-of-pocket expenses may be subsidized, as well. But then maybe not. I’m here to help my clients figure that sort of thing out and direct them to the plans that will save them the most money.

As you might imagine, my goal is to help as many people as possible. To do that, I’ve got to manage my time super well. I’m happy to educate people, but I also like to make sure they’ve followed my advice. If I don’t have the best plans for your needs, I’ll let you know. I don’t mind that at all. What gets me down is when people end a conversation saying they want to shop around some more, and then I find out they’ve chosen a plan that will cost them more.

Life in the nursing home. Who is there to love them? Who becomes family when family leaves them?
Who becomes family when family is gone?

One thing that is particularly difficult for me emotionally is helping the seriously sick and poor with their health insurance. They are often incapable of providing the paperwork needed to prove they qualify for Medicaid or Low Income Subsidies (LIS). I will literally go the extra mile to help people who don’t know how to help themselves, sometimes driving far out of town. If a person needs Medicaid, their friends should know it. We need to be one human family and look out for one another. Managing bills when you’ve had a stroke and live alone can be near impossible. Imagine if you were alone and growing old. Who would help you? Be that friend. Step up. Let each person do what they do best. Make sure your friend has help. Bring them to your local Health and Human Services office and help them get them enrolled in Medicaid. Help them with their bills. They need you. Then once they are enrolled, they need people like me, to set them up with D-SNPs.

SOA

Qualifying for Medicaid triggers a special enrollment period for a D-SNP. That means I can help your friend outside of the normal enrollment periods most any time of year. I can work over the phone or face to face. Usually, the only limitation is that you will need to schedule at least 48 hours ahead of time using a Scope of Appointment form to schedule me once you’ve helped them enroll in Medicaid.

SOAp2

I’m sure you know your friend will also need legal representation if they can’t answer questions for themselves. Sometimes a non-family member can obtain a temporary power of attorney to help make insurance decisions on their behalf. Medical Power of Attorney, Living Wills and Advance Directives are related and sometimes critical to obtain to help people when they need it most. That said, I’m not an attorney and this is not legal advice. Downloadable forms can be obtained for free online for these purposes and you can personalize them. Then you would need to get your friend to sign them in front of a notary, but I would strongly suggest you consult with a local attorney before doing anything.

The seasons of our lives change. In the fall, I go into full Medicare mode. In the winter, I do both health and life. In spring and summer I focus on life insurance. And throughout the year I think about how I can help as many people as possible, especially those most incapable of helping themselves. Please help me help your friends. Understand that I can’t speak with you about their medical conditions or about any possible health plans without a scope of appointment that is properly authorized. And that means you may have to obtain a Power of Attorney so you can act on their behalf. If you are helping them gather the information they will need to apply for Medicaid, you will likely need a POA for that too.

  • NOT AFFILIATED WITH OR ENDORSED BY THE GOVERNMENT OR FEDERAL MEDICARE PROGRAM.
  • Participating sales agencies represent Medicare Advantage [HMO, PPO, PFFS, and PDP] organizations that are contracted with Medicare. Enrollment depends on the plan’s contract renewal. 
  • I do not offer every plan available in your area. Currently I represent 6 organizations in Tallahassee which offer 42 plans and other organizations with numerous but not all plans in six total states, including Florida, Georgia, Texas, Arizona, California and Virginia.