INSURANCE questions. Confused, stressed and worried.

[swramsay]

Dear Group,
If there are other forums for this topic, please direct me. I searched for insurance without finding the info I need. I hope someone can clarify this for me. I have spent much time looking at Medicare information, talking with Medicare, Social Security and my own employer insurance company (Boeing Regence Blue Shield). Recently, I spoke with one (of many) Boeing Regence person who told me that they could become secondary and Medicare primary. I am pretty sure I made it clear that I was asking about changing now (before the 30 months). Maybe that wasn't clear and she was explaining how it works when they are secondary. I have thought all this time that I could electively switch to Medicare before the 30 month period was up. Is that incorrect?

The problem is I will max out my lifetime allowance in 13 months. My insurance company has been paying $45,000 a month for dialysis!!!!! Is that legal? How can it possibly cost that much money? Hopefully, if I can't switch sooner, I will be able to switch to medicare when my insurance is maxed out. BUT Medicare only covers 80% plus the $94/month premium plus the deductible. How do all of you pay the 20%? At the current charges, that's $9000/month. Normally, I would have my employer insurance as secondary to cover that, but it will be at zero by then.

This is very worrisome for me and very stressful. I continue to fight bladder cancer. I have fought so hard for so long to be alive and here for my son. I truly believe I am alive today in large part because of the non-questioning coverage that my employer insurance has provided over the years. They have always paid 100% for many out-of-the-box treatments for me. No premiums either. I fear this will not be the case with Medicare and I have watched friends die because of either poor insurance coverage, delays in treatments due to insurance companies or the stress and depression caused by it all.

Is there ANY WAY to switch to Medicare as primary and retain my employer insurance as secondary before the end of the 30-month coordination period and before my benefits run out?

If I sound a bit excitable, I am.   
Thank you.
Wendy

[glitter]

 First of all, dialysis centers hose private insurance companies- they are only allowed to charge medicare so much and are only allowed to bill you 20% of that, they cant bill either medicare or you the difference. and its under 1500.00 a month and probably more like half that. There are people here who know the exact math...I'm sure they will post.
  Also if your in a non-profit dialysis center they will/can write off the 20 % you have no insurance for.

can you switch before the 30 months? I dont know- but someone here will. 

dont stress- IHD people will explain how it works-

[okarol]

When Medicare Coverage Begins
When you first enroll in Medicare based on ESRD
(permanent kidney failure) and you are on dialysis
your Medicare coverage usually starts the fourth
month of dialysis treatments. For example, if you start
getting your hemodialysis treatments in July, your
Medicare coverage would start on October 1.
If you are covered by an employer group health plan,
your Medicare coverage will still start the fourth
month of dialysis treatments. Your employer group
health plan will pay first on your health care bills and
Medicare will pay second for a 30-month
coordination period. See pages 15-17, “How
Medicare Works with Employer Group Health Plan
Coverage.”

If you don’t have Employer Group Health Plan
coverage, there are other types of insurance and
programs that may help to pay some of your
health care costs (see pages 43-46.)

There Are Three Ways You May Be Able to Get
Medicare Coverage Sooner.

1. Medicare coverage can start as early as the first
month of dialysis if . . .

• You take part in a home dialysis training
program in a Medicare-approved training facility,
to teach you how to give yourself dialysis
treatments at home;

• You begin home dialysis training before the third
month of dialysis; and

• You expect to finish home dialysis training and
give yourself dialysis treatments.

2. Medicare coverage can start the month you are
admitted to a Medicare-approved hospital for a
kidney transplant, or for health care services
that you need before your transplant if . . .
• Your transplant takes place in that same month or
within the two following months.

3. Medicare coverage can start 2 months before
the month of your transplant if . . .
• Your transplant is delayed more than 2 months
after you are admitted to the hospital for the
transplant or for health care services you need
before your transplant (see Example, below).
Example:
Mrs. Perkins was admitted to the hospital on May
25th for some tests she needed before her kidney
transplant. She was supposed to get her transplant
on June 15th. However, her transplant was delayed
until September 15th. Therefore, Mrs. Perkins’
Medicare coverage will start in July, two months
before the month of her transplant.

this info is from www.medicare.gov/Publications/Pubs/pdf/esrdcoverage.pdf

[swramsay]

Thank you okcarol. That is the same info that I have in front of me in paper. I have Medicare part A already. I need to know if I can switch to medicare part b before the 30 month coordination period. Doesn't look like it.

How can dialysis centers charge so much more for private insurance companies? It's no different than robbery.

[paddbear0000]

OMG. Medicare is secondary for 30 months if you have private health insurance?? Another question. I'm getting conflicting info from different sources. If I have Medicare and private insurance, is Medicare going to pay the 80%, then my insurance pays the remaining 20%, or my insurance  company pays their amount and Medicare will pay my copay, so that I won't have to pay anything out of pocket? All we'd have to pay is our private insurance's deductible and monthly premium (which is deducted from my husband's  paycheck), and Medicare's deductible and monthly premiums? I have a medicare booklet, but the info goes right over my head. I need it explained in dummy english!

[dialysisbiller]

don't panic if you exhaust your lifetime benefits, Medicare will be billed conditionally if/when that happens and they will pay. You really don't have a choice about deciding when Medicare becomes primary tho.

Medicare only pays as secondary if you've exhausted your benefits (either yearly or lifetime) or the primary coverage pays less than what Medicare would have approved(which almost NEVER happens)

I'm going to guess your insurance company does not have a contract with the dialysis company you're with because that about 80% of the gross charge(Medicare only allows about $120-160 on average per hemo tx, not including medications.

Be sure to talk to a COB specialist (Coordination of Benefits) at the dialysis company. They can give you the best information since they specialize in that stuff.

[Bill Peckham]

Dear Group,
If there are other forums for this topic, please direct me. I searched for insurance without finding the info I need. I hope someone can clarify this for me. I have spent much time looking at Medicare information, talking with Medicare, Social Security and my own employer insurance company (Boeing Regence Blue Shield). Recently, I spoke with one (of many) Boeing Regence person who told me that they could become secondary and Medicare primary. I am pretty sure I made it clear that I was asking about changing now (before the 30 months). Maybe that wasn't clear and she was explaining how it works when they are secondary. I have thought all this time that I could electively switch to Medicare before the 30 month period was up. Is that incorrect?

The problem is I will max out my lifetime allowance in 13 months. My insurance company has been paying $45,000 a month for dialysis!!!!! Is that legal? How can it possibly cost that much money? Hopefully, if I can't switch sooner, I will be able to switch to medicare when my insurance is maxed out. BUT Medicare only covers 80% plus the $94/month premium plus the deductible. How do all of you pay the 20%? At the current charges, that's $9000/month. Normally, I would have my employer insurance as secondary to cover that, but it will be at zero by then.

This is very worrisome for me and very stressful. I continue to fight bladder cancer. I have fought so hard for so long to be alive and here for my son. I truly believe I am alive today in large part because of the non-questioning coverage that my employer insurance has provided over the years. They have always paid 100% for many out-of-the-box treatments for me. No premiums either. I fear this will not be the case with Medicare and I have watched friends die because of either poor insurance coverage, delays in treatments due to insurance companies or the stress and depression caused by it all.

Is there ANY WAY to switch to Medicare as primary and retain my employer insurance as secondary before the end of the 30-month coordination period and before my benefits run out?

If I sound a bit excitable, I am.   
Thank you.
Wendy

You could switch to a nonprofit provider and get charged about a third of the $45,000

[dialysisbiller]

Bill, could you provide a link to a few? might help

[BRANDY]

simular question. If you are already getting disability SS,  How do I get help in the 20% and for D  also? Is there a cut off amount  with DSS or is it a life time deal.?  Im worried about the payments also.  The center I will be going to is a Davita center.  Help ease my mind please.

[Bill Peckham]

Northwest Kidney Centers

[dialysisbiller]

simular question. If you are already getting disability SS,  How do I get help in the 20% and for D  also? Is there a cut off amount  with DSS or is it a life time deal.?  Im worried about the payments also.  The center I will be going to is a Davita center.  Help ease my mind please.

speak to the Social Worker at your center, let him/her know of your concerns regarding the 20% after mcare pays.... you may qualify for emergency medicaid in your state or you may have options to get a supplimental secondary coverage, i have centers in Virginia and North Carolina and i have many patients with either medicaid as a secondary plan or a BCBS secondary.

[Savemeimdtba]

I'm on SSI and my medicare just started - I was worried about that 20% as well (and the $96 a month premium).  I called social security and they assured me that since I am on SSI, the state pays those amounts for me and I don't have to worry about it.  I also got medicare part D at no cost .. you can always call the Social Security help line and they can try to answer your questions or set you up with an appointment. 

[swramsay]

Thanks for ALL the help and info. Here's a little update since my first post on this in March.
My insurance was paying $1500 per dialysis session because the Puyallup Davita center was not contracted. Hmm. On my own, I found out the Federal Way unit a few miles away is contracted with my insurance. Their rates (quoted to me by my insurance and twice by Davita) are 85.50 for home dialysis and $220 for in-center...a far cry from $1500! Interestingly, the insurance coordinator wasn't aware of the contract and no one at Davita claimed to know EXCEPT the big wigs somewhere.

Still perturbed about all the unecessary charges against my lifetime max, I see my insurance company is now paying $621 per session instead of the thrice quoted $85.50 for home dialysis. Sure, it's a whole lot better than $1500 but as far as I can figure, it's still $400/session too much! I have called the billing dept for davita several times and was told "they have been instructed not to talk to me" with no reason given. ?? The insurance coordinator did find out that the $85.50 rate for home dialysis is for home PD not home hemo. Apparently there is no separate contract for home hemo and she has no idea why. Even if home hemo pays the in-center rate, it should be $220 not $620 each run.

So, Davita billing says I need to go through a social worker (who doesn't want to get involved in billing) who will talk to a 'guest services specialist' who will talk to billing. Ha. Ha. Can you believe it? I have asked 3 easy questions. Guess how many answers I've gotten?  NONE. Any one want to guess how long this will go on??

[hurlock1]

I KNEW IT WAS A BIG RACKET! I was worried about the 20% and "all that" when I first got started. The propensity for insurance companies and medical facilities to gouge the government is shameful.  It's like  everybody with the will is grabbing every thing they can get their hands on, and then some. But! They told me not to worry about it, so I don't. I just pray that everything turns ou alright.

[dialysisbiller]

Thanks for ALL the help and info. Here's a little update since my first post on this in March.
My insurance was paying $1500 per dialysis session because the Puyallup Davita center was not contracted. Hmm. On my own, I found out the Federal Way unit a few miles away is contracted with my insurance. Their rates (quoted to me by my insurance and twice by Davita) are 85.50 for home dialysis and $220 for in-center...a far cry from $1500! Interestingly, the insurance coordinator wasn't aware of the contract and no one at Davita claimed to know EXCEPT the big wigs somewhere.

Still perturbed about all the unecessary charges against my lifetime max, I see my insurance company is now paying $621 per session instead of the thrice quoted $85.50 for home dialysis. Sure, it's a whole lot better than $1500 but as far as I can figure, it's still $400/session too much! I have called the billing dept for davita several times and was told "they have been instructed not to talk to me" with no reason given. ?? The insurance coordinator did find out that the $85.50 rate for home dialysis is for home PD not home hemo. Apparently there is no separate contract for home hemo and she has no idea why. Even if home hemo pays the in-center rate, it should be $220 not $620 each run.

So, Davita billing says I need to go through a social worker (who doesn't want to get involved in billing) who will talk to a 'guest services specialist' who will talk to billing. Ha. Ha. Can you believe it? I have asked 3 easy questions. Guess how many answers I've gotten?  NONE. Any one want to guess how long this will go on??

send me a message with your center name and location.... i work in billing for SAID company.... i KNOW i can help with this... plus i want to know WHY someone told you that they will not speak to you, that's BS

[swramsay]

Federal Way Davita.
I got some other gal on the phone the other day. She said she would mail me an itemized printout.

I would still love to find out why they were 'instructed not to talk to me'.
I think it's BS too. The 'guest services specialist' won't find out for me. She said I would have to go through someone else at Federal Way to file a grievance. Who needs this.

[dialysisbiller]

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