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Should My Husband Switch From Medicare Advantage to Original Medicare Once He Is Approved for Medicaid?

  • October 9th, 2018
I need to find out if I should switch my husband, who is in a nursing home, to original Medicare now that Medicaid has approved him for benefits. We have a Medicare Advantage HMO plan that covers his medications. Also, does Medicaid cover the same prescriptions as the Medicare Advantage plan? In New Jersey, Medicaid coverage is through an HMO plan, so if I keep the Advantage plan he would have two HMO plans. 

The nursing home or the New Jersey Medicaid agency should be able to advise, but here’s how it should work. It depends on whether or not you are receiving your husband’s income. A nursing home resident on Medicaid must pay the bulk of his income (less a small monthly income allowance) to the nursing home. There are two common deductions. First, if the nursing home resident is paying medical insurance premiums then the cost of those premiums can be deducted from the payment obligation to the facility. For instance, if your husband’s income is $2,300 a month, without any deductions, he must pay the full amount (less the small monthly income allowance) to the nursing home. But if he’s paying $300 a month in health insurance premiums then he only has to pay $2,000 a month to the facility. The result is the same – either way he’s paying out his full income. If he drops the insurance, then he has to pay more to the nursing home.

The second possible deduction from your husband’s income could be a spousal allowance for you if your income is low. For instance, you may be entitled to $1,000 of your husband’s income to get your own income up to a minimum guaranteed by the Medicaid rules.

Local Elder Law Attorneys in Ashburn, VA

Margaret O'Reilly

Margaret A. O'Reilly, PC
Herndon, VA

Loretta Williams

Hale Ball Carlson Baumgartner Murphy PLC
Fairfax, VA

Judith Mitnick

Needham Mitnick & Pollack, PLC
Falls Church, VA

But here’s where things can get really complicated. It’s possible that your own income is so low, or your own care needs are so high, that you’re entitled to all of your husband’s income and nothing has to be paid to the nursing home. If that’s the case, you’re almost certainly better off dropping your husband’s Medicare Advantage plan because you’re, in effect, paying for it out of your own pocket.

Your second question has to do with whether the coverage is the same. It should be, but this can get complicated with respect to Medicare Part D coverage. The nursing home should be able to advise you on this -- it should not be an unusual question for them.


Last Modified: 10/09/2018

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