I just had to vent. I have basically wasted several hours over the past few weeks with a guardian who demands I research her childs Medicare Part D plan to find ways to get over the counter and vitamins covered, to find a way to "work the system" to get a tiered drug co pay reduced but not change the drug and to basically find ways to circumvent the rules so she does not have any out of pocket expenses for the childs mile long grocery list of meds and vitamins.
My patient population all receive services through a Medicaid funded waiver and therefore qualify for Medicare Part D drug benefits also. These plans vary considerably about which drugs are on which tier but they all exclude vitamins except for prenatals and fluoride supplements. This mother has a masters degree but tells me she can't read the evidence of coverage or formulary and comprehend it. She insists nurses know "all about insurance stuff". Really? I guess I missed that class. Because everything I have learned has been since I began my real world career and I had to seek it out just like everyone else.
I am not seeking solutions. I just had to vent because I have had a lot of these conversations over the years in various forms and it still blows me away that the general public honestly believes "nurses know all about insurance coverage". In addition I personally am all for saving money but to quibble over paying $20 to $30 a month for vitamins and co pays for someone who takes 9 prescription meds and 5 vitamins and OTC antihistamines irks me. To me that seems like an awesome bargain. I wish my prescription plan covered that many items for the same amount of money.
OK, all better now lol. I just had to get that off my chest.
Thanks for the input and thoughts. Let me clarify a little. This is a community based waiver program centered around group homes. People receive Medicaid not due to financial issues but due to disability issues. The particular family member I mentioned has 1) a Masters Degree in Social Work 2) has sufficient income to take a minimum of 4 major world spanning vacations a year plus maintain two homes 3) her child of whom she is the legal guardian has a medical care trust fund from which the monthly co-pays are dispersed so this is not coming from her personal finances nor does it pose a hardship for the client. Her desire to "work the system" comes from a sense of entitlement, not financial necessity.
Regarding the referral to a social worker. As I said the mother is a social worker herself. My branch office is small and the non medical caseworkers are no more knowledgable about the individual differences in co pays, drug tiers etc. than I am. I appreciate the idea of pointing someone to the person in the know but on occasion we(the nurse) are the only person "in the know". My vent was the stance that by sheer virtue of having a nursing license I am automatically expected to know all about over a 100 different private plans, Medicaid and Medicare. My point was the public needs to educate themselves about their own individual health care coverage or that of anyone for whom they have assumed legal responsibility. It is like expecting your auto mechanic to know whether or not your car repairs are covered under your auto insurance and what your deductibles are and any related benefits.
As I said just a vent. I viewed this entire experience as time taken away from more pressing issues which do require a nurses expertise.
Specializes in LTC, assisted living, med-surg, psych.
"Working the system" is exactly why there are so many rules and regulations........when people abuse the system, it just makes it harder for honest folks to use it for its intended purposes. Good for you for standing up to this!
txredheadnurse, BSN, RN
349 Posts
Thanks for the input and thoughts. Let me clarify a little. This is a community based waiver program centered around group homes. People receive Medicaid not due to financial issues but due to disability issues. The particular family member I mentioned has 1) a Masters Degree in Social Work 2) has sufficient income to take a minimum of 4 major world spanning vacations a year plus maintain two homes 3) her child of whom she is the legal guardian has a medical care trust fund from which the monthly co-pays are dispersed so this is not coming from her personal finances nor does it pose a hardship for the client. Her desire to "work the system" comes from a sense of entitlement, not financial necessity.
Regarding the referral to a social worker. As I said the mother is a social worker herself. My branch office is small and the non medical caseworkers are no more knowledgable about the individual differences in co pays, drug tiers etc. than I am. I appreciate the idea of pointing someone to the person in the know but on occasion we(the nurse) are the only person "in the know". My vent was the stance that by sheer virtue of having a nursing license I am automatically expected to know all about over a 100 different private plans, Medicaid and Medicare. My point was the public needs to educate themselves about their own individual health care coverage or that of anyone for whom they have assumed legal responsibility. It is like expecting your auto mechanic to know whether or not your car repairs are covered under your auto insurance and what your deductibles are and any related benefits.
As I said just a vent. I viewed this entire experience as time taken away from more pressing issues which do require a nurses expertise.