Stanford Med · Unit 5B Medicine·Day shift·Mon · 9:42 AM

Coverage & Resource Matching

Michael Johnson · BlueShield MA Advantage HMO

Coverage-funding waterfall · Michael Johnson

BlueShield MA Advantage HMO · MEDICARE ADVANTAGE

Unresolved · Patient co-pay ability + OOP willingness

gross $1,158 → residual $1,113 / 30d

✓
Real-time eligibility (X12 270/271)fundsT0 auto
Coverage active · BlueShield MA Advantage HMO.
X12N 270/271 (CAQH CORE)
◑
Insurance · primary plan (benefit + PA)partialT1 auto+notify
Plan covers most; residual patient responsibility $1,158 over first 30 days (copays / coinsurance / benefit-day limits).
42 CFR §409.30 (SNF benefit) + plan formulary; medical necessity per InterQual/MCG
✓
Manufacturer / foundation assistance (drugs)fundsT1 auto+notify−$45
PA-required specialty drug — manufacturer PAP (NeedyMeds/PAN/RxAssist) removes $45/mo of drug cost; residual now $1,113.
NeedyMeds + PAN Foundation + RxAssist
◐
Patient co-pay ability + OOP willingnessunknownT2 hard-gate
Residual $1,113 · co-pay ability not captured (no budget on file). Written cost estimate + documented acceptance required (T2).
HFMA Patient Financial Communications

→ Next action: Close "Patient co-pay ability + OOP willingness": Residual $1,113 · co-pay ability not captured (no budget on file). Written cost estimate + documented acceptance required (T2).

Matching resources

Ranked by payer fit · capacity · quality · caregiver distance · preference

11 candidates

Resource / provider	Type	Distance	In-network	Capacity	Quality	Preference match	Documents required
Bayview Skilled NursingBest match	SNF	4.2 mi	In-network	open	★ 4.2	Top match	SNF referral packet · Auth approval · MD orders
Hillcrest Rehab & Nursing	SNF	7.8 mi	In-network	limited	★ 3.8	Alternate	SNF referral packet · Auth approval
Marin Manor Post-Acute	SNF	12.4 mi	In-network	open	★ 3.5	Alternate	SNF referral packet
VNA Bay Area	Home Health	—	In-network	open	★ 4.4	Top match	HH referral · F2F encounter note
Lincare Home OxygenWalker + scale	DME	—	In-network	limited	★ 4.0	Top match	CMN form 484 · Rx
Apria Healthcare (backup)	DME	—	In-network	open	★ 3.9	Alternate	CMN form 484 · Rx
ModivCare NEMT	Transport	—	In-network	open	★ 3.9	Top match	Transport auth
CVS Pharmacy — Mission St	Pharmacy	1.4 mi	In-network	open	★ 4.1	Top match	Rx · PA approval
Walgreens — 24th St	Pharmacy	2.1 mi	In-network	open	★ 4.0	Alternate	Rx · PA approval
Mission Meals (CHF diet)Low-sodium	Community / SDOH	—	Out-of-network	open	★ 4.2	Top match	SDOH referral
Stanford Cardiac Rehab Phase II	Community / SDOH	5.3 mi	In-network	limited	★ 4.6	Alternate	Referral · Stress test

Financial assistance · what to apply for

9 programs matched · ordered by tier

CA · MEDICARE_ADVANTAGE

Hospital charity care / discount payment (501(r) + CA AB-774)Pre-screenedCharity careConfigured rulesT2

Every 501(c)(3) hospital must offer a FAP; screen via financial counselor.

Apply: Patient financial counselor screens via the hospital FAP; AB-774 mandates the offer ≤400% FPL.

Basis: IRS 26 CFR §1.501(r); CA Hospital Fair Pricing Act (AB 774 / AB 1020) · API: Hospital FAP policy (public; HCAI / IRS Form 990 Schedule H)

Part D Low-Income Subsidy (Extra Help)Pre-screenedMedicare cost-shareComing soonT1

Screen for Extra Help (≤150% FPL); dual-eligibles auto-qualify.

Apply: Apply via SSA (ssa.gov) or county; dual-eligible (Medi-Cal + Medicare) auto-enrolled.

Basis: 42 CFR §423.773 (Part D Low-Income Subsidy) · API: SSA i1020 (online application)

Program of All-Inclusive Care for the Elderly (PACE)Pre-screenedLong-term servicesComing soonT1

Integrated Medicare+Medi-Cal long-term care alternative to nursing home; nursing-home level of care + community-safe.

Apply: Enroll via a local PACE organization; eligibility = age ≥55 + NF level of care + community-safe.

Basis: 42 CFR Part 460 (PACE) · API: CMS PACE plan finder

Medicare Savings Programs (QMB / SLMB / QI)Needs lookupMedicare cost-shareComing soonT1

Income not captured — screen for QMB ≤100% / SLMB ≤120% / QI ≤135% FPL.

Apply: Apply via county Medi-Cal (CA administers MSP); auto-enrolled for many dual-eligibles.

Basis: 42 CFR §400.200 (QMB/SLMB/QI); SSA dual-eligible rules · manual referral

In-Home Supportive Services (IHSS)Needs lookupLong-term servicesComing soonT1

Requires Medi-Cal eligibility; pair with a Medi-Cal application.

Apply: County IHSS office assessment (can start while inpatient); authorizes personal-care hours.

Basis: CA Welf. & Inst. Code §12300 et seq. · manual referral

Community-Based Adult Services (CBAS)Needs lookupLong-term servicesComing soonT1

CBAS is a Medi-Cal managed-care benefit; confirm plan + eligibility.

Apply: Referral through the patient's Medi-Cal managed-care plan; CBAS center eligibility assessment.

Basis: CA Medi-Cal CBAS benefit (1915(b)/(c)) · manual referral

Copay assistance foundations (PAN / HealthWell / Good Days)Pre-screenedMedicationComing soonT1

Disease-specific copay foundation may cover insured patient's drug copays (12-month rolling grants).

Apply: Pharmacy/financial counselor checks disease-fund availability (PAN, HealthWell, Good Days) and submits.

Basis: 501(c)(3) charitable copay foundations (insured patients only) · API: Foundation disease-fund lookup (web; some APIs)

Manufacturer Patient Assistance Programs (PAP) + copay cardsPre-screenedMedicationComing soonT1

Specialty drug present; PAP/copay card as a parallel path.

Apply: Prescriber enrolls via the manufacturer PAP; NeedyMeds / RxAssist directories aggregate options.

Basis: Manufacturer PAPs (non-statutory); copay cards (commercial insurance only — not Medicare) · API: NeedyMeds / RxAssist (directories; partial APIs)

Community resource navigation (findhelp / 211 / ADRC / AAA)Pre-screenedCommunity / SDOHComing soonT1

Universal, no income gate — match housing/food/transport/utility/legal needs to local resources.

Apply: Social worker submits closed-loop referral via findhelp; 211 warm handoff; ADRC/Area Agency on Aging for 90-day coordination.

Basis: Community-based organization network (no statutory eligibility) · API: findhelp API (closed-loop referrals); 211 directory API

Eligibility uses cited % FPL bands (501(r)/AB-774 ≤400%, Medi-Cal ≤138%, MSP ≤100/120/135%, LIS ≤150%). Depth chips disclose which sources are configured rules vs. not-yet-wired live feeds — see the data-source registry.

Demo data · no PHI · mocked Epic + payer endpoints