Tricare and Medicaid

[Bann]

Could use some input on this weird situation. (or at least it is for me)
Long story, but here is the background:

Thing1, who is now 25, used to be the dependent of his retired military father. He was covered by the military health care insurance, Tricare, until his 21st birthday, when he lost it due to his aging out of the system. (this was before the ACA, and no, he was not eligible to be carried until he was 26). However, because he is disabled, he was also eligible to continue to receive the military healthcare benefits, HAD his father taken the proper steps to make sure this happened. He didn't. Anyhoo, 4 years later, I have finally gotten those steps taken care of, met all the requirements of BUMED, and Thing1 is now covered under Tricare. (until he has to re-submit the information all over again to meet the requirements, which is standard procedure in medical situations such as his).

During the last 4 years, he has been covered under Medicaid. He met the requirements due to his receiving DDA funding. I was told and did research to verify, that Tricare will be the "first payer" and then Medicaid will pay. (because he still has DDA funding, he is automatically eligible to receive Medicaid) Recently, I go to get his perscriptions filled, and I'm not going to take them to the Navy Base since it's so far away. Since he has TWO insurances, I figure the amount he pays will be less or the same as Medicaid. (which is $1.00 per script). Apparently, this is not the case. The pharmacist and staff are excellent where I go and they ran it through several times, but he still had to pay $2.05 for 1 script.

Does this make sense? Does anyone know how this convoluted system works? $2.00 doesn't break me, but if I were gone and he had to live in a residential home setting, every dollar of his would need to go as far as it could. It's just crazy to me that if he has Medicaid his meds are $1.00, and with 2 insurances, he would still pay more than if he had only Medicaid.

 

[ferdberfel]

By law TRICARE pays before Medicaid does, this was done in 2005 as part of the Deficit Reduction Act to ensure Federal funds were conserved. The law cut back on a lot of medicaid services, passed the Senate in a Dick Cheney tiebreaking vote. While Medicare and TRICARE are both federally subsidized programs, Medicare is subsidized to a greater degree due to most Medicare beneficiaries either being disabled and not having any income, or too poor to pay any costs/copays.

If you didn't have TRICARE your costs would be less. I don't know if you could get the same level of coverage.

TRICARE says it is the primary payer in Medicaid cases: http://www.tricare.mil/Plans/OHI.aspx

 

[ferdberfel]

Medicare and Medicaid are two very different beasts!

So you are paying medicare part D premiums? If so see http://www.military.com/benefits/tricare/medicare-part-d-and-tricare.html it says

For nearly all TRICARE-Medicare beneficiaries, under most circumstances, there is no added value in purchasing Medicare prescription drug coverage if you have TRICARE. The exception to this general rule may be for those with limited incomes and assets who qualify for Medicare's extra help with prescription drug plan costs.

Also on http://www.military.com/benefits/tricare/outpatient-prescription-drug-coverage-comparison.html it says "Medicare is the primary payer if the individual is enrolled in a Medicare drug plan." and that page goes on to attempt to explain the crazy rules about deductibles, etc.

TRICARE is increasingly going to force long term maintenance prescriptions to be filled either at a military pharmacy or through the mail. So that is another thing you may want to consider.

 

[Bann]

Bann, I know this won't be helpful and I don't know how it works on the outside because all of my son's many prescriptions get filled at Patuxent River but are you sure Tricare is primary because I've been told that it was secondary and that he had to have the Medicaid in order to have the Tricare.

Was your son found to be Incapacitated Dependent permanently incapacitated prior to age 21? If so every four years all you have to do is provide a notarized letter that breaks down all his expense and state that you provide at least 50% support.

Thanks, Dixie. Tricare is definitely the primary payer. If I'm not mistaken, Medicare might be first, but Medicaid is not.

Yes, he was incapacitated before age 21. We will have to provide the breakdown as you describe, although it has to show that his father provides 50% of his support. (which he does, per the court order I obtained in 2014) The other documentation which will be required is a current vocational assessment because he is capable of *some* work, as well as a Life Skills Assessment.

 

[Bann]

By law TRICARE pays before Medicaid does, this was done in 2005 as part of the Deficit Reduction Act to ensure Federal funds were conserved. The law cut back on a lot of medicaid services, passed the Senate in a Dick Cheney tiebreaking vote. While Medicare and TRICARE are both federally subsidized programs, Medicare is subsidized to a greater degree due to most Medicare beneficiaries either being disabled and not having any income, or too poor to pay any costs/copays.

If you didn't have TRICARE your costs would be less. I don't know if you could get the same level of coverage.

TRICARE says it is the primary payer in Medicaid cases: http://www.tricare.mil/Plans/OHI.aspx

Thanks, I knew all of those things about Medicare vs. Medicaid and first payers, etc. His level of coverage, should he need to be hospitalized, or have a lengthy illness will definitely be higher with the two insurances, which is why I pushed to get it through. I just don't know why it would cost more.

He doesn't qualify for Medicare. He gets a Medicaid waiver due to being funded by DDA in the state of MD.

 

[Bann]

Medicare and Medicaid are two very different beasts!


TRICARE is increasingly going to force long term maintenance prescriptions to be filled either at a military pharmacy or through the mail. So that is another thing you may want to consider.

Sure, I explained in my first post that my son is on Medicaid. I unerstand the different programs, as my mom had Tricare For Life and also Medicare.

The problem at the pharmacy submitting the prescriptions through the different insurances was NOT with Tricare. It was with the insurance company that handles his Medical Assistance (Medicaid), which is Amerigroup. The Pharmacist said that Amerigroup would not allow a "split pay" option on that particular medication. However, on others it went through. She was scratching her head about it, and was going to look into it more.

So it wasn't Tricare that was the problem. If I were forced to get his scripts filled at a military facility or through mail order, I would gladly pay a dollar or 2 more not to go through that hassle.

 

[Bann]

I should have said I'm happy to hear that your package went through - it's a hassle - so I'm happy your package went through! I've got a sinking feeling that my son is losing that privilege. He gets both Social Security and child support and although every penny is used for his benefit and I met the 50% support requirement - a lot of his money is used for things like swimming lessons, bowling, movies. I just sent off his four year letter and I'm not sure the Navy will approve. To top it off, Chris Christy just signed a bill that will strip him of child support in February and make him once again eligible for the Navy program - ONLY I think I have to once again prove all the conditions that made him eligible that he will never lose, all over again and wait all over again. Meanwhile, he will lose his neurologist at Walter Reed and prescriptions that I get from Patuxent and I will have to begin paying. He takes 33 pills a day for seizures - I can't imagine where I'm going to get a neurologist and how I'm going to pay for the pills Then Social Security switched him to Medicare and apparently he will have to pay Medicare Part B. It's confusing as all get out.

Without getting into your bizness too much, (feel free to PM me if you'd like) here's what I did and maybe you can do this, too.

If your divorce was in NJ, get your divorce decree registered in Maryland. Mine was in Florida, and I got it registered in MD. Maryland (and most states, although I am not familiar with the law being pass by Christie) doesn't take too kindly to parents financially abandoning their adult disabled children any more than they do their minor children. There is a statute in many states which covers this.

Unfortunately, I had to take Thing1's father to court in order to have child support for Thing1 continued. The Ex apparently thought Thing1 quit eating, and needing necessities like clothing, housing, etc. when he turned 21.

And oh, by the way, he also neglected to insure that his son didn't lose his military healthcare benefits by going in to PSD and taking care of this way before his 21st birthday (even though we talked about him doing that very thing). I dropped the ball by not keeping up on things and checking on whether he was doing what needed to be done.

However, in my own defense, I had lost my sister to cancer in April 2011, and by October that year, I had become my mother's primary caregiver. I had the conversation with the Ex about benefits and CS in late 2011 and *thought we had a verbal agreement. My mother was terminally ill by April 2012, and was in hospice care, so imagine my surprise in June, 2012 to not only have a son without healthcare, I also discovered the CS allotment was substantially less that month because he stopped over half of it without even telling me he was stopping it. My mom passed away the next week.

I called an attorney, and took the Ex to court. It was a 2 year process, mostly because we gave him time to answer to various legal phases. (Strongly worded letters, etc). By the time I got to court at the end of March, 2014, I received not only every penny I asked for, I also got the arrears he owed, AND my court costs*.

The total amount he pays now adds up to about $50 MORE than the CS and half the alimony he was paying back then. (I guess he should have kept his agreement with me, instead of listening to his buddies and girlfriend at the time.) The CS now gets garnished from his pay and sent to me thru the CS Bureau. He cannot refuse to pay part of our son's support in the state of Maryland. Another thing I also had in my son's favor was the stipulation in the marital settlement agreement AND ordered by the divorce decree was that if Thing1 was unable to be self-supporting at age 21, then we would both be responsible for him 50/50. Oopsie. I guess he forgot about that little detail as well before he went and stopped his allottment. That is another reason I was able to get back CS for those 2 years. He violated the Court Order.

It is not hard to have your divorce decree registered in MD. The Family Law section of the MD Courts website has all the forms. Let me know if you need help.

*I had to provide documentation of different sorts and also a bugdet of expenses for my son (which is the same one I submitted to the Navy, by the way)

 

[Roman]

Bann, and Dixie, I admire both of you. I wouldn't know where to begin if I had to go through with this. My hat is off to both of you. Your children are lucky to have you not only as their parent, but also as their advocate. I have a question. Both young men are disabled, and will need care probably for the rest of their lives. Why is it that the fathers don't have to pay cs for the rest of their lives? So they expect you to pull money out of your butt to care for them 100%? That just doesn't seem fair. Regardless of their ages, they still need food, shelter, clothes, medicine, and a ton of other stuff that goes along with life, and living.

 

[Bann]

Sounds like you had more than good reason to divorce him.

I already checked with NJ and the way the law reads is that I would be allowed to collect child support because he is disabled up until age 23 but after that it cuts off for everyone regardless of circumstances. My son will be 25 in two weeks. Several years ago I tried to have the case switched to Maryland figuring it would be easier to manage in my home state. Social Services informed me that Fritz (St. Mary's County DA) turned it down flat stating that my son was 19 and that I had no business getting child support for him. I asked Social Service if Fritz was aware that he was mentally disabled and would never be capable of self support and was informed that he knew but didn't care the law was the law. I know they were speaking for him but I firmly believe that is what he said. He's a jackass.

So... I'm going to social services some time in the next few weeks - I mean his Social Security is $790.00 per month - I think there are probably options - someone mentioned something called QMP for low income people that goes hand in hand with Medicare - which might be helpful with his prescriptions and I still haven't given up hope that the Navy still might approve that I'm covering 50 percent.

Meanwhile I think I better locate a local neurologist and speak to him before the shoe falls.

I really am happy you got the Tricare through - I know you had to fight for everything.

Thank you, Dixie. I appreciate that.

Please reconsider this information and contact the Woman's Law Center who could give you a free consultation. They have hotline numbers: http://www.wlcmd.org/services/family-law/hotlines/

I have no idea how FRITZ can turn down anything as far as you registering your divorce decree in the state of Maryland. I believe it is a fairly routine matter. I filed a "Petition To Enroll And Enforce Final Judgment of Dissolution of Marriage With Dependents Or Minor Children" and it was accepted without any question whatsoever. My son was 23. Once Maryland's court recognized the Divorce Decree and child support order - then I proceeded to petition the court to Modify the CS Order. You can call the Woman's Law Center and check out what they suggest. I live in Calvert, and they do have a very good CS department, so maybe that is the difference. However, you do have a leg to stand on according to the following information.

As for the Adult Disabled child support - it's called by various names in different states. Here is a link to a very helpful website: Termination of Child Support- Exception for Adult Children with Disabilities What it says about New Jersey is this:

New Jersey


Child support will terminate at age 19 unless the child has a physical or mental disability, as determined by a federal or state government agency, that existed prior to the child reaching the age of 19 and requires continued child support.

It gives the Citation as "2015 SB 1046", which is Senate Bill 1046 passed in 2015, which reads:

1. a. Unless otherwise provided in a court order or judgment, the obligation to pay child support shall terminate by operation of law without order by the court on the date that a child who is less than 19 years of age marries, dies, or enters the military service. A child support obligation shall also terminate by operation of law without order by the court when a child reaches 19 years of age unless:

(1) another age for the termination of the obligation to pay child support is specified in a court order;

(2) the parents of the child consent and the court approves the continuation of support until another predetermined date; 1[or]1

(3) the court extends the obligation to pay child support based on an application by a parent or 1[the child] guardian1 filed prior to the child attaining the age of 19 1; or

(4) the child receiving support is in an out-of-home placement through the Division of Child Protection and Permanency in the Department of Children and Families1.

b. A parent or 1[child may petition the court for] guardian may submit a written request to the court with supporting documentation, including a projected future date when support will terminate, if appropriate, seeking1 the continuation of child support beyond 19 years of age in the following circumstances:

(1) the child is still enrolled in high school or other secondary educational program;

(2) the child is participating full-time in a post-secondary education program;

(3) the child has a physical or mental disability that existed prior to the child reaching the age of 19 and requires continued support; or

(4) other exceptional circumstances as may be approved by the court.

As for finding another Neuro Doc, it is best to be prepared, I agree. I know we might have discussed this before, but does your son receive funding through Developmental Disabilities Administration? (DDA) He should be eligible, I would think. You can get information through DDA Resource Coordination here for St. Mary's County: http://www.smchd.org/individuals-with-disabilities/

I would definitely give them a call, because your son might qualify for Medicaid throught DDA. (again, a confusing process, so it's easier just to call the Resource Coordination Dept) DDA can also help you if you would like a Provider Agency (Such as Center for Life Enrichment, The Arc, Spring Dell Center, etc.) to help with your son during the day. They have Day Programs, with transportation to and from in a lot of cases, with a lot of activities and community integration and inclusion opportunities. They can give you more information about all that, too. Good Luck, Dixie -if you ever have any questions, please feel free to PM me!

 

[Bann]

Bann, and Dixie, I admire both of you. I wouldn't know where to begin if I had to go through with this. My hat is off to both of you. Your children are lucky to have you not only as their parent, but also as their advocate. I have a question. Both young men are disabled, and will need care probably for the rest of their lives. Why is it that the fathers don't have to pay cs for the rest of their lives? So they expect you to pull money out of your butt to care for them 100%? That just doesn't seem fair. Regardless of their ages, they still need food, shelter, clothes, medicine, and a ton of other stuff that goes along with life, and living.

You would have done the same thing, I'm sure. Just from what I've read of your posts.

I am his mother, but I am first his advocate, now. That's the truth. I have a lot of hats, but that's the main one. I go after anything and everything I can for him. It's paid off, he has learned advocacy as well, and he puts that information to good use in a self advocacy group he belongs to for Disabled Adults. I think it's probably the most important thing he's ever learned.

As for the father, yeah - well, what can I say except "if you only knew". He's an idiot which is truly putting it mildly, but I do accept in hindsight that I made a poor choice picking him. However, I have held him accountable every step of the way. The adult child support in this case IS required in the state of Maryland, and it's a good dang thing I looked into it. Fool me once, shame on you - fool me twice shame on me. He's obligated for life to this CS and it's a garnishment, so it will continue as long as he works. And if he doesn't work, then it will come out of his military and government retirement pays. Until he dies.

 

[itsbob]

Thanks, Dixie. Tricare is definitely the primary payer. If I'm not mistaken, Medicare might be first, but Medicaid is not.

Yes, he was incapacitated before age 21. We will have to provide the breakdown as you describe, although it has to show that his father provides 50% of his support. (which he does, per the court order I obtained in 2014) The other documentation which will be required is a current vocational assessment because he is capable of *some* work, as well as a Life Skills Assessment.

Interesting.. Opposite of what I thought..

 

[Bann]

Interesting.. Opposite of what I thought..

How so? Tricare is (and would have been had he not lost it to begin with) his primary insurance.