Speaker 1: Hello, everyone, this is Francine Crawford, and I am your host of Autumn is Here. And I'm so glad to have again with me, Mr. Frank Polanco from MJHS. And he's here to help us to clarify some things about Medicaid and Medicare and different things like that. And these are questions that people have asked asked us. And we're just going to find the information to give it to the audience. So please welcome Mr. Polanco to the show.

Speaker 2: Thank you, Francine. It's a it's a pleasure to be back on your show and do the best I can to answer the questions that your that your community has about Medicaid or Medicare Advantage. As you mentioned, my name is Frank Polanco. I'm the Senior Vice President of Growth for MJHS. That's a little different than before. You know, I was mostly all my years been in charge of the health plan. My responsibilities have expanded a little bit more to include hospice and palliative and home care. I'm just learning about all those things. So don't ask me any questions about that just yet. But but as far as a Medicare Advantage and Medicaid, I'll do the best I can to give you as much information as possible. And again, I'm happy to be here with you and the community.

Speaker 1: Awesome. Well, that's great. Because these are questions that I could not answer. So I'm sure that there's something that you can help with with answering this or getting some information out there. So let's just start with people were saying that they are being denied Medicaid because they have family support. Now, how does that hurt your qualifications for obtaining Medicaid?

Speaker 2: I mean, Medicaid has, you know, income levels. And I'll give you an example. You know, for for an individual, single individual, their monthly income cannot exceed $1,752, or $31,000, approximately a year. You know, these numbers change every year. So I mean, if you ask me again, in January might be a little different. And for instance, a married couple, the income level is 2300 and change and assets can exceed $42,000. So when when Medicaid considers your eligibility, they take household income into consideration. So although one, you know, the person applying for Medicaid might have income that suit that fits the criteria, the entire household's income is considered by by the state. So that's how someone's application might be affected if if others in the household have higher earnings.

Speaker 1: Okay, so it's the household income? Yes, yes. Okay. Okay. All right. So are, are you familiar with spend down program? Because people have asking about that? How does that work spend down program?

Speaker 2: So I just mentioned to you that there are limits, you know, we said that the individual limit was $1,752. Now, let's just keep it real simple. Let's say your income is $1,952. And you're over by $200. The state of New York will allow you to spend down those $200. And you'll cut the state a check every month for $200 so that you could have your Medicaid. And if you're enrolled in a managed care plan, like let's say home first managed long term care plan, we will bill you those $200 so that you can keep your your Medicaid active.

Speaker 1: Oh, okay. So you actually have to pay them the extra? Is that

Speaker 2: what yes, you have to pay down, you have to that's what he used the term spend down, you have to spend it down, pay that $200 or whatever, whatever the differences between what your income is, and Medicaid eligibility limit.

Speaker 1: Okay, so let's say if you can't get Medicaid, can you get a managed care plan? Is that is that does that work in that way?

Speaker 2: Yeah, so you should think about it that there's there's Medicaid managed care, and then there's Medicare managed care, you know, Medicare managed care is typically Medicare Advantage, which is elder plan elder plan is a is a Medicare Advantage plan. And, you know, typically, you know, Medicare Advantage is the alternative to traditional Medicare. And if you if you just had traditional Medicare, you would Medicare would cover in basically 80% of your cost, you would be responsible for 20%, you would also be responsible for some premiums, you'd be responsible for some deductibles. Now, depending on the Medicare Advantage plan that you choose, some of those some of those deductibles and some of those premiums may go away. Every plan is different. But the idea is, is that instead of where Medicare only covers 80%, a Medicare Advantage plan might give you the kind of like the peace of mind of knowing that you have specific copays, maybe you have a zero copay for a PCP, maybe you have a $40 copay for a specialist, instead of being responsible for 20%, you'd be responsible for a defined copay that you can budget and manage. And also, there's certain benefits that traditional Medicare does not cover like dental vision, hearing, and Medicare Advantage plans typically cover those benefits. And they also sometimes have transportation or have OTC. So if you if you do not have Medicaid, which would cover that 20% for you, it does make sense to check out a Medicare Advantage plan, like elder plan where you have multiple different products that might make sense for you, help you save money and provide you some additional services that you wouldn't have had.

Speaker 1: Okay, okay. So do you know if Medicaid or Medicare covers meals? And if, if not, are there any programs that do cover meals for seniors and elderly?

Speaker 2: You know, there are a lot of there are a lot of places in the community where seniors can get meals. But yes, Medicaid does cover typically cover meals, you know, and I'm sure you've heard of Meals on Wheels or God's Love We Deliver. There are a lot of services out there that do work with Medicaid to provide meals for seniors. So typically, yes, Medicaid does cover meals.

Speaker 1: Okay, okay. And there are other programs out there.

Speaker 2: Yes, there are there are a lot of programs besides, you know, God's Love We Deliver. And like I said, Meals on Wheels are good examples. You know, you'll find that in, at least in the communities that we service here in the five boroughs of New York City, there's a lot of opportunities in senior centers where meals are typically provided on a daily basis. So I would there's really no reason why a senior should go without using these days.

Speaker 1: Okay. Does Medicare pay for Medicaid pay for home care? And can you use Medicare to help with home care?

Speaker 2: Well, let's let's let's start by the last part of your question, which is Medicare does not cover long term home care. Just for the short term. Medicare does not Medicare does not it covers short, short term, you know, after you get at a hospital, you know, for 90 days, Medicare will cover some, some home care, some certified home care, but it's really not a part of the Medicare benefit. But it is a part of the Medicaid benefit. So yes, Medicaid does cover home care does cover a home attendant. So if you if you qualify for full Medicaid, and you require long term care to stay at home in the community, yes, it is covered by by New York State Medicaid.

Speaker 1: Okay, and who decides like if you qualify for for home care? And how do they do that? Do you know how that how that happens? And who decides that? Is it something that it's a rule? As far as the federal government? Or is it individual? You know, with different organizations?

Speaker 2: You know, it's, it really comes down to an assessment. And it gets it gets a little complicated a UAS assessment. But, you know, a senior citizen or anybody who doesn't have to be a senior citizen, anybody who requires long term care to stay safely in their home, could join, they need to have full Medicaid. And, and most of the folks that require home care like that are are assigned to can choose or assigned to a managed long term care plan like home first. So basically, if you we receive a referral from somebody who, who needs home care, and the first thing that happens is that the state conducts an assessment to determine eligibility. Once the state determines that the person is eligible, then the health plan goes out and and does their own assessment and provides a plan of care. So yes, Medicaid does pay for it, but not everyone is eligible. So the state determines eligibility, then the plan comes out and does an assessment. And the plan then determines what the plan of care is, which you know how many hours the person will receive and, and so on.

Speaker 1: Okay, so if you are denied, is there any How do you how do you challenge that? Or can you challenge that? Is there a period of time that you can challenge it? Or can you challenge it at all?

Speaker 2: There's an there's a there's an appeal. If you are denied, you could appeal. If you if you come on to the program, and you feel like you don't have enough hours, you have the opportunity to appeal that also. And you appeal to the plan, a plan could deny or grant your appeal. And, and if they deny your appeal, you can appeal again, and you can go to in front of a judge and, and they'll do a fair hearing. So yes, there is a there's an appeal process.

Speaker 1: Okay, well, that's, that's good to know. That's good to know. Are you familiar with the NHTD program, and the guidelines, the nursing home transition waiver?

Speaker 2: Yes, the NHTD program is a is a Medicaid waiver program. And it's an it's another way to receive home care. Traditionally, people who are in this NHTD program require a lot of home care, like live ins or split shifts, and and it is managed by the state. And it's really, it's the last resort before you would go into a nursing home. But it's it's managed. Yes, it's managed by the state. It's not part of the managed long term care plans. It usually provides 24 hour care really for, you know, the sickest in the community.

Speaker 1: Okay, is that just New York State? Or is it all over?

Speaker 2: Well, it is a New York State waiver program. I mean, it's possible that other states, you know, have similar programs, you know, Medicaid is very individual by state to have different, you know, levels, different programs. So when we're talking about this NHTD program, at least when I'm talking about the NHTD program, I'm talking about New York State's version of it.

Speaker 1: Okay, so as far as who runs these things, and who owns who says what's the qualifications are? Is it the federal government that has one regulation for all states? Or do states have leeway to make some of their rules?

Speaker 2: When it comes to Medicaid, you know, the states make their rules. I mean, the states fund a portion of the Medicaid program and the federal government funds the other portion, but but each state's Medicaid program is individual to the state. So what you might be accustomed to in New York will be very different in the state of Florida or the state of Texas, the programs that are available, the services, the levels will all vary from state to state. As far as Medicare goes, Medicare is the federal government's health insurance plan. And those rules are the same regardless of the state that you're in. So, you know, what you know, who whether you pay, pay their premium for a pay the premium for B, you know, when you're eligible, it's all the same, regardless of what state you're in when it comes to Medicare.

Speaker 1: Okay, okay, that's good information. Okay, so let me ask you, if you are a veteran, is there different benefits or more benefits or something else that people don't know if they're veterans to look into that may help them?

Speaker 2: I mean, the veterans have their own set of benefits, the veterans are able to go to the VA, and they're able to access their benefits at the VA, active duty has TRICARE. So, you know, there are a whole separate set of benefits that are available, you know, to people who are veterans to VA. Now, typically, you can you can access all your VA benefits at the VA at the VA and join a Medicare Advantage plan like elder plan, and it really just supplements your benefits. Now, there are some active duty service members or people who have TRICARE who will need to be very careful and probably should not enroll in a Medicare Advantage plan because it might affect some of their other benefits. But normally, a retired veteran, normal guy out in the community who served, you know, could still go to the doctor at the VA, if that's what they want to do, enroll in a Medicare Advantage plan benefit from all those additional services that might they might receive. So they have the opportunity to really get both. So it's for a veteran, it works, they should they could it might make sense for them to investigate a Medicare Advantage plan, they might have additional services that that they'll be happy with.

Speaker 1: Okay, okay. Okay. Well, thank you. These are questions that people are asking. There. I know it's a it goes all over the place. But there's sometimes when you have Medicaid or Medicare, whatever, and your needs change, and you may need to know what other support is out there, or if there is something else a program for you, because your needs have changed. So thank you so much for this. And also, is there anything else that you would like to add to this?

Speaker 2: You know, the one thing that I would add is that, you know, we talk about Medicaid, and Medicaid, obviously, is very, very important. But I would also say for those, you know, seniors, that there are two other programs, and I don't, we probably shouldn't go into detail about the two programs. But there are two programs that maybe we could touch on next time. And one is a low income subsidy, which is a federal program that helps with the cost of prescription drugs. And the other and the other one is the Medicare savings program, which is run by the New York by New York State Medicaid, which helps people with the cost of, of Medicare cost sharing. So and those are two very important programs, people qualify for them based on income and assets. And it really does help with out of pocket costs associated with drugs or with healthcare. So I know Medicaid is the big one. And I know we always talk about, you know, care and home and home attendance. I know that's very, very important. But, but once you get beyond that, there's still other opportunities for seniors, for lower income seniors to get help with some of the out of pocket costs. And maybe that's something we could touch on next time. I like a little teaser.

Speaker 1: Well, thank you. Thank you. We love having you, Frank, you give us so much information. And we appreciate MJHS for all their services and what they've done. And congratulations on your new responsibilities. And you have to let us know how that goes. Maybe there's something else you can add to this.

Speaker 2: I hope so. I think the idea Francine is that we can kind of bring together the synergies from, you know, from the years of experience on the managed care side, and you know, and help in other parts of the organization. So I'm looking forward to it. And I hope that it could just add more content to our future conversations.

Speaker 1: Absolutely. Absolutely. Well, thank you so much for sitting here and giving us information on Artemis here. So I'm hoping that, you know, people will listen. And now things will be a little bit more clearer for them as they go through this process.

Speaker 2: I just remember Francine, I mean, and for your community, these things change often. So we might be having this conversation next year. And, and there'll be different information. So this stuff is, is fluid, it changes. It's a very complicated topic.

Speaker 1: But it only changes in a year's period of time, right?

Speaker 2: Correct, correct, correct. So these, these amounts, these limits, they usually change every year.

Speaker 1: Every year. Okay. Okay. Yes. All right. Well, thank you so much. I really appreciate it.

Speaker 2: Thank you. You have a great one.

Speaker 1: Transcribed by https://otter.ai