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» Hatrack River Forum » Active Forums » Books, Films, Food and Culture » Medicaid Limits and Fiscal Responsibility

   
Author Topic: Medicaid Limits and Fiscal Responsibility
DDDaysh
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I saw that the debate in he Republican Candidate thread has touched a bit on health care reform and what it means. I have to say that I personally had become more interested in the possibility of a single payer system than I was in the past. Then something that happened yesterday reminded me of all the concerns about I've had about it.

I learned that Medicaid, at least in my state, will generally not approve more than two medications for each adult that is on the program. Adults are typically on Medicaid because they are disabled, including psychiatric disability. This makes absolutely no sense to me, not only because I question how this will impact the quality of life for those on the program, but also because I question how it will impact our public budgets.

How can this possibly be a reasonable thing to do? Yesterday, the situation came to my attention because I have a brother who lives in a group home due to being Mentally Retarded. This brother, unfortunately, is not JUST retarded and also suffers from epilepsy and psychological issues that make him irrational and sometimes violent. He has had issues this spring that sent him to the state hospital to get his medications worked out. Now, mind you, while he is IN the hospital, Medicaid covers his prescriptions because he is an inpatient. He is now out, and they will only cover two of the five he needs. If he doesn't get those medications, he'll end up back in the hospital which costs taxpayers considerably more per day than his group home situation, which is why this policy confuses me so much.

Because my brother can't be the only one. Most people with psychological issues like my brother aren't in group homes, so they're not monitored even as much as he is. We already have a huge problem in this country with getting appropriate mental health care to those who need it. We've already realized that when those people aren't appropriately treated they become a massive drain on society since even a small proportion of them ending up in prison is incredibly expensive. It's hard enough to get them to take the medication when the medications are provided free of cost, but now we're going to severely limit the medication cocktail options and hope that works out well?

I simply can't understand this policy. Beyond what it means for my family, and luckily we're in a position to make sure he is getting all of his medications every month, it just seems like a good way of costing taxpayers way more money, but hiding it by changing the category of the expense.

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GinetteB
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quote:
Originally posted by DDDaysh:
I learned that Medicaid, at least in my state, will generally not approve more than two medications for each adult that is on the program.

Isn't there an opening in the use of 'generally'? What would happen if you write Medicaid what you just posted here? I mean, you're so right, it sounds absurd to only cover two of the five he needs.
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MrSquicky
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What state are we talking about? Medicaid implementation varies a lot from state to state. In the situation you describe, I'd recommend talking with an expert in your state's programs.

I'm no expert, but looking at it, Medicaid mandates coverage of at minimum two drugs per class. So, it possible that straight medicaid in your state only covers that. Even if that is the case, there are other programs to help.

One that you'll probably want to look at is the Medicare Low Income/Extra Help subsidy. From my brief reading, if your brother qualifies for full Medicaid, he's automatically eligible.

I'm not sure the specifics of this, but there is also the possibility that he is eligible for Medicare Part D drug coverage. Again, there are people out there in your state who do know about this and are there to answer your questions. I highly recommend getting in touch with them.

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Samprimary
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quote:
Medicaid covers his prescriptions because he is an inpatient. He is now out, and they will only cover two of the five he needs. If he doesn't get those medications, he'll end up back in the hospital which costs taxpayers considerably more per day than his group home situation, which is why this policy confuses me so much.
It's just an individual snapshot about why our system sucks, and will eventually catch up with the social medicine systems of literally every other modernized nation on earth. We're stuck in these perverse, overly expensive situations because so many people in this country are terrified of universal and complete health coverage, and fund these systems only enough to have them be desperately reactive, which costs us more overall and provides less benefit.

See: pretty much the entire rest of our medical system, and why our privatized system is pretty much the last of its kind, and won't last.

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DDDaysh
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quote:
Originally posted by GinetteB:
quote:
Originally posted by DDDaysh:
I learned that Medicaid, at least in my state, will generally not approve more than two medications for each adult that is on the program.

Isn't there an opening in the use of 'generally'? What would happen if you write Medicaid what you just posted here? I mean, you're so right, it sounds absurd to only cover two of the five he needs.
Well, as far as I understand it, that is the "rule". Most programs have a way to get an exception though, and I guess I just was hoping that if a person was actually going to die without the medication they'd pay for more than 2. But, no, I don't know of any cases where they actually are paying for more than 2.
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DDDaysh
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Texas. I've only just started looking into it, but I do know that our Medicaid switched over to a "managed care" system about 8 years ago. I only was able to get to the tip of the ice berg yesterday because I was just stunned by running into this when I was talking with his case worker.

Maybe it is only two in every class, but I don't think so. One of his medications is for cholesterol, and the bottle had a price on it so it's clear that they were paying out of pocket for that one. (Not too bad since, thankfully, the generic version of that works for him.) Even though that particular medication is cheap, if it was a "class of drugs" situation, it seems like it would be in a different "class" than his psychiatric drugs, and therefor covered.

quote:
Originally posted by MrSquicky:
What state are we talking about? Medicaid implementation varies a lot from state to state. In the situation you describe, I'd recommend talking with an expert in your state's programs.

I'm no expert, but looking at it, Medicaid mandates coverage of at minimum two drugs per class. So, it possible that straight medicaid in your state only covers that. Even if that is the case, there are other programs to help.

One that you'll probably want to look at is the Medicare Low Income/Extra Help subsidy. From my brief reading, if your brother qualifies for full Medicaid, he's automatically eligible.

I'm not sure the specifics of this, but there is also the possibility that he is eligible for Medicare Part D drug coverage. Again, there are people out there in your state who do know about this and are there to answer your questions. I highly recommend getting in touch with them.


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DDDaysh
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That's the thing that drove me the most crazy about this. I mean, sure it's personal for me here, but we'll get something worked out for my brother.

But I just have to wonder if one day we're going to hear on the news about some poor little girl who gets murdered because the homeless man who hangs out near her school couldn't afford his meds and had a psychotic episode. And things much less dire too, just the constant in and out of the ER stuff that alot of these people go through that costs an arm and a leg. I'm going to have to look more into it, because it just seems so entirely irrational.


quote:
Originally posted by Samprimary:
quote:
Medicaid covers his prescriptions because he is an inpatient. He is now out, and they will only cover two of the five he needs. If he doesn't get those medications, he'll end up back in the hospital which costs taxpayers considerably more per day than his group home situation, which is why this policy confuses me so much.
It's just an individual snapshot about why our system sucks, and will eventually catch up with the social medicine systems of literally every other modernized nation on earth. We're stuck in these perverse, overly expensive situations because so many people in this country are terrified of universal and complete health coverage, and fund these systems only enough to have them be desperately reactive, which costs us more overall and provides less benefit.

See: pretty much the entire rest of our medical system, and why our privatized system is pretty much the last of its kind, and won't last.


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Samprimary
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quote:
Originally posted by DDDaysh:
But I just have to wonder if one day we're going to hear on the news about some poor little girl who gets murdered because the homeless man who hangs out near her school couldn't afford his meds and had a psychotic episode. And things much less dire too, just the constant in and out of the ER stuff that alot of these people go through that costs an arm and a leg. I'm going to have to look more into it, because it just seems so entirely irrational.

There's a boulevard in Denver where the homeless transfer in and out of medical care constantly; the cost to taxpayers climbs up into the millions per individual. It would cost significantly less to house, clothe, and medicate them permanently as indefinite wards of the state. We're not interested in that, though. Instead, we do things like this.

It's rightfully agitating, because we're essentially paying twice as much money into our system to float a process which is miserable in comparison to universal healthcare. Entirely because of holdover mentalities, and the delusional narrative that we have the "best healthcare in the world." What keeps me less bothered about it is that it's doomed. National universal health services will be around well before I'm a senior.

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MrSquicky
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I went looking for Texas information. From what I can tell, this may be the relevant page.

Here's the part most pertitent:
quote:
Medicare will cover most of your necessary prescriptions. Specific information on the prescription medicines each drug plan covers is available from the plan itself. All Medicare Part D prescription drug plans must cover “all or substantially all” drugs in key categories such as antidepressants, antipsychotics, anticonvulsants, anticancer, immunosuppressants, and HIV/AIDS categories of drugs. There are certain categories of drugs Medicare Part D will not cover including over-the-counter medications, barbiturates (sedatives), and benzodiazepines (anti-anxiety agents). There will be no monthly limits to the number of prescriptions you can get through your Medicare Part D prescription drug coverage.
I obviously don't know your brother's specifics, but from everything I can tell, if he fully qualifies for Medicaid, he is eligible for and really should be enrolled in Medicare Plan D. If that is not the case, you'd probably do well to find out why.

---

Also, as I mentioned before, there is a Low Income/Extra Help subsidy available through the Social Security office, which I believe he would qualify for. If he's not on that, this is another thing to look into.

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Kwea
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I work with this population as a nurse at a facility in FL, and Medicare covers more than 2 per patient here, even outpatient. Also, there are all sorts of low to no cost clinics that offer major discounts on a lot of those drugs. I'd keep checking into it if I were you.
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