View Full Version : Medicaid Drug Coverage

06-02-2009, 11:57 PM
Let's say a homeless person had Medicaid and the drug he was taking wasn't helping much, so the doctor prescribed a newer, hopefully more helpful drug. But this drug probably isn't on formularies of recommended (and cheap) drugs and it's not generic, so it's expensive.

My understanding is that while the exact amount covered varies from state to state, that all except a co-pay of probably no more than $5 would be covered. Is this correct?

06-03-2009, 12:03 AM
Don't know about homeless, but when I was a kid my dad was on Medicaid and they paid everything on his medical expenses. (100% disabled and drawing Social Security disability at the time)

One problem in certain areas with drawing benefits homeless is that to get a check (like for Social Security) you have to have a physical address and bank account - obviously a homeless person would not - and they don't allow shelter addresses as the physical. I'm not sure how that affects Medicaid, but it might be something to think about.

06-03-2009, 01:25 AM
Medicaid is at the state level, whereas medicare is federal. The state things vary so much and they change so rapidly (at least here) that the updates every few weeks to months can be twice as thick as the phonebook. A 5 dollar copay is believeable, homeless and on medicaid less so, but it would be a state thing and maybe California or a few others allow it?

06-03-2009, 01:28 AM
I see, so if he couldn't provide a valid address (other than a shelter) he might lose his health benefits entirely? That would be a really horrible way to do it, but actually might work for my story.

06-03-2009, 02:03 AM
I see, so if he couldn't provide a valid address (other than a shelter) he might lose his health benefits entirely? That would be a really horrible way to do it, but actually might work for my story.

Medicaid picks up the tab when someone can't pay. In my Dad's case, it covered what Medicare didn't (so it was like supplemental insurance.). California has Medi-Cal instead of Medicaid, so other states may have similar programs under other names.

06-03-2009, 02:10 AM
Hmmmm, it takes a lot of paperwork to get NC Medicaid. Bank and employment records and things. I have no idea how they'd handle a homeless person, but I suspect he couldn't 'prove' himself like you have to.

It's $3 here and non-generic drugs are generally covered. You have to offer more proof if you need over a certain number of prescriptions, so I'd bet there are drugs expensive enough to bring a review requirement.

06-03-2009, 03:13 AM
There are other charitable resources available to those with no income, homeless etc. for medical purposes. Most hospitals have a charity fund that cover the cost of medical treatment if the recipient can't pay. There are forms to fill out etc., but asking your local hospital about their programs might shed some light on it. And you can't discount free clinics that give away medications. They are usually in sample packs, but it's amazing how many sample packs a doctor or nurse can shove in a brown paper bag.

Medicaid co-payment depends on the cost of the medication. My friend has elderly clients whose co-payments are up to fifteen dollars for one medication. You'd have to figure out the price of the drug and then calculate the percentage of co-payment based on the state in question's requirements, etc. And, in some states, medicaid won't cover things that aren't considered "necessary". Such as dental treatments, for just one example. Only certain dental work is covered by state insurance for adults. Extractions, antibiotics, sure, but forget having someone get a filling or a cap because it's "cosmetic". And there are others who can't get coverage at all unless the disease or illness is life threatening. There are so many different loops and so much jargon with state insurance, it's not even funny. Children under 18 are completely covered for anything except plastic surgery (and they'll even pay for it if it's a necessary case IE car accident, animal attack etc).

A homeless person would more likely go to a free clinic and get free meds, though. State mandated insurance wouldn't be something he or she could get. A valid identification card, birth certificate, Social Security Card, proof of income, proof of residence are only a few things he or she would need in order to get an insurance card. States differ, though, so it might be best to find out exactly what your state (or the state the book is set in) requires. There may even be provisions for the homeless. I don't really know. With our Blue Cross coverage, it's around 900 dollars a month for the family plan we have and it covers 80% of everything. If our bill is two grand, we pay four hundred. With state, the percentage is much smaller, but it shouldn't be hard to figure it out. Hope this helps a little bit.

06-03-2009, 03:25 AM
I'd think about making your character a veteran (and maybe disabled). A lot of the homeless are veterans and the health insurance is then covered by the veterans administration, which is relatively simple and straightforward to get on. Cost for drugs, depending upon the level of coverage, can be free.

Best of luck,

Jim Clark-Dawe

06-03-2009, 07:14 AM
It covers it. All of it. Name brand, generic, whatever.

Co-pays are only if you do not qualify for Medicaid but do qualify for another sponsored program.

My daughter is disabled and on it. Since my husband lost his job and I can't work in my former line of work, not to mention a shortage of other jobs here, the rest of the kids are, too. Here you automatically get Medicaid if you get SSI, as well.

When I was on Medicaid there were a few drugs that I needed that had no generic alternative. Medicaid covered it all.

EF- Are you sure that your elderly friend doesn't have Medicare? My mother calls it Medicaid all the time. I've never heard of a co-pay with Medicaid and I've lived in quite a few places with friends that had it at one time or another.

06-03-2009, 07:35 AM
and they don't allow shelter addresses as the physical.

This probably varies state to state, but I don't think that this is the case everywhere.