Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

OP - On your mother's behalf, you may want to talk to an elder care lawyer well versed in setting up trusts to help one qualify for Medicaid to see if there is a legal option to make her eligible. The goal would be to protect her financial assets now so she can have a life and qualify for the medications that she needs to be able to do so.

Don't other with a lawyer, its jut a money grab. The threshold is very low and it doesn't sound like she's low income.

Again, attempting to shift assets to qualify for Medicaid is not for amateurs and if done incorrectly can leave the person with neither the assets nor the Medicaid. Get your legal advice from a competent elder law attorney, not some poseur on a discussion board who doesn’t have a clue.

OP here - I am 100% certain my mom won't transfer her assets in order to accomplish getting this medication. It's too complex and too many things can go wrong. It is not a life-saving medication rather one that improves the quality of her daily life. The other issue is that because she doesn't have a diagnosis getting any kind of assistance with this just won't happen. I appreciate all of the feedback I've received with my question. Such a great knowledge base!

Anonymous wrote:

Anonymous wrote:

OP - On your mother's behalf, you may want to talk to an elder care lawyer well versed in setting up trusts to help one qualify for Medicaid to see if there is a legal option to make her eligible. The goal would be to protect her financial assets now so she can have a life and qualify for the medications that she needs to be able to do so.

Don't other with a lawyer, its jut a money grab. The threshold is very low and it doesn't sound like she's low income.

Again, attempting to shift assets to qualify for Medicaid is not for amateurs and if done incorrectly can leave the person with neither the assets nor the Medicaid. Get your legal advice from a competent elder law attorney, not some poseur on a discussion board who doesn’t have a clue.

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:What's the medication?

I believe that's for Medicaid patients, my mom is on Medicare

Take a look at this article.

https://www.azaleahealth.com/blog/340b/

340B Patient Eligibility
Regardless of insurance type or lack of insurance coverage, covered entities can provide all of their patients with 340B drugs. It is often misunderstood that 340B pricing only applies to Medicare or Medicaid patients.

340B lowers the price for what the hospital acquires it for, they generally don’t pass on the savings to the patient.

If every drug in the category works for her, then her Part D plan should cover at least two of them — the law says a plan must cover at least 2 drugs per category/class. And every plan must submit their formularies to the government for review and approval every year.
If she is paying $6000 for a drug that is on her plan formulary, then it must be a VERY expensive drug and she is getting benefit from her plan, including a 70% manufacturer discount during the gap phase and 5% cost sharing once she hits the catastrophic cap, which she should reach very quickly at an out of pocket cost of $6000. She would then pay the reduced amount for the rest of the year.
In 2025 the cap will be $2000 after which she will pay nothing, so positive change is coming.

Anonymous wrote:

OP - On your mother's behalf, you may want to talk to an elder care lawyer well versed in setting up trusts to help one qualify for Medicaid to see if there is a legal option to make her eligible. The goal would be to protect her financial assets now so she can have a life and qualify for the medications that she needs to be able to do so.

Don't other with a lawyer, its jut a money grab. The threshold is very low and it doesn't sound like she's low income.

Also, nearly all Part D plans are required to cover at least one drug in each class. I’d be surprised if there are no insurers at all that cover the medication she needs. (It would in fact be against the law).

Yes. She needs to purchase a Part D plan with a true OOP (troop) cap. And one that counts non covered expenses in the troop.

Also, talk to someone at a SHIP about whether she might qualify for Medicaid via the medically needy pathway. (But there’s still an asset test, so she’d need to spend down her assets, excluding the house that she lives in).

OP: have you looked into a better Part D plan? Typically costs are x, then go up in the “doughnut hole,” and then go down again once “catastrophic” coverage kicks in.

Anonymous wrote:

Anonymous wrote:

OP - On your mother's behalf, you may want to talk to an elder care lawyer well versed in setting up trusts to help one qualify for Medicaid to see if there is a legal option to make her eligible. The goal would be to protect her financial assets now so she can have a life and qualify for the medications that she needs to be able to do so.

This is the way to go. Or she needs to give you her assets and add someone with zero income to her household (jut on paper) so that she becomes low income herself.

Doing this without competent legal advice is a recipe for disaster.

Anonymous wrote:

OP - On your mother's behalf, you may want to talk to an elder care lawyer well versed in setting up trusts to help one qualify for Medicaid to see if there is a legal option to make her eligible. The goal would be to protect her financial assets now so she can have a life and qualify for the medications that she needs to be able to do so.

This is the way to go. Or she needs to give you her assets and add someone with zero income to her household (jut on paper) so that she becomes low income herself.

A quick trip to Canada?

OP - On your mother's behalf, you may want to talk to an elder care lawyer well versed in setting up trusts to help one qualify for Medicaid to see if there is a legal option to make her eligible. The goal would be to protect her financial assets now so she can have a life and qualify for the medications that she needs to be able to do so.

Anonymous wrote:For example, the pharmaceutical company is unaffiliated with this foundation that helps people afford medication. There is a low income restriction of $67,000 but no asset test.

https://www.amgensafetynetfoundation.com/assets/pdf/AMGEN-SNF-Application-Prescription-Editable.pdf

But even at $67K, a medication that's $6K a month is an absolute impossibility.

Anonymous wrote:

Anonymous wrote:What's the medication?

I believe that's for Medicaid patients, my mom is on Medicare

Take a look at this article.

https://www.azaleahealth.com/blog/340b/

340B Patient Eligibility
Regardless of insurance type or lack of insurance coverage, covered entities can provide all of their patients with 340B drugs. It is often misunderstood that 340B pricing only applies to Medicare or Medicaid patients.

For example, the pharmaceutical company is unaffiliated with this foundation that helps people afford medication. There is a low income restriction of $67,000 but no asset test.

https://www.amgensafetynetfoundation.com/assets/pdf/AMGEN-SNF-Application-Prescription-Editable.pdf