Medicare as secondary insurance - how does it work after transplant?

[pelagia]

If you can help with this question from experience, thank you!

We originally enrolled in Medicare Part B (medical insurance) as the "safety net" for Stephen's donor.  Stephen qualified because of ERSD. We are paying over $1000/year in premiums.  I am not sure if Stephen is covered by Part A (hospital insurance) because he had a transplant after dialysis for only 7 weeks and was never on disability.

For our family we have primary health insurance through my job.  The state pays most of my coverage and I pay a monthly premium to cover my family. 

We just yesterday (6 months later) received the statement of coverage for Stephen's transplant from our primary insurance and a bill for the part not covered by the primary insurance ($6,000) from the hospital.  The insurance company has been going back and forth with the hospital for months because they deemed his admission the day before the surgery was "not medically necessary."  It appears that the hospital has decided to bill Medicare for part of the charges.  I'm sure we have already met our "out of pocket" expenses for the primary insurance (like within 5 minutes of the transplant...).  But there is nearly $6,000 that the primary is not paying.  I have talked with the primary insurance company in the past about the bill and they told me that since the hospital is a BS/BS provider, they agree to the terms set by the insurance company.   I was under the impression that we will not be responsible for any additional charges unless we signed some sort of waiver.  I don't think we did, but I am not 100% sure.  But, now the hospital has added this complication of billing Medicare.

Medicare Part B is medical insurance, not hospital insurance, so I don't think it will cover hospital charges.  I don't know if Stephen has Part A because he had the transplant only 7 weeks from the time he began dialysis and he was never on disability (he's away this weekend and we haven't talked about this yet).  The paragraph below indicates that Medicare does cover hospital bills as secondary for someone with ESRD, but how does it work after transplant?.

Medicare and other health benefits: your guide to who pays first

http://www.medicare.gov/publications/pubs/pdf/02179.pdf

Medicare and Group Health Plan Coverage for People with End-Stage Renal Disease (ESRD) (permanent kidney failure)

If you are eligible to enroll in Medicare because of End-Stage Renal Disease, your group health plan will pay first on your hospital and  medical bills for 30 months, whether or not you are enrolled in Medicare and have a Medicare card. During this time, Medicare pays second. The group health plan pays first during this period no matter how many employees work for your employer, or whether you or a family member are currently employed. At the end of the 30 months, Medicare pays first. This rule applies to most people with ESRD, whether you have your own group health plan coverage, or you are covered as a family member.

I guess we will have to start calling everyone tomorrow.  I can barely handle the thought of trying to deal with Medicare after all these months when my memory of everything is going to be really bad. 

If anyone can share any insights, thank you. 

[willieandwinnie]

pelagia, medicare should pay what your primary insurance didn't. That's how it worked for us. If the hopsital is BS/BS provider they have agreed to accept the amount that BS/BS is willing to pay and they can try to get medicare to pay more but I don't think it will happen. Medicare usually pays less then BS/BS. I can't stand dealing with insurance companies. Drives me nuts.  As long as you have met your deductibles and co-pays, you should be good to go. Let us know how it goes. 

[pelagia]

OH, W&W, thank you sooo much for the information.  While you were posting I was working on the info below.  I am going to leave it there anyway for reference.  Maybe it is all mute and Medicare will tell the hospital they are bound by the original agreement with BC/BS.  But it drives me crazy that they send us a bill because if I ended up paying it by mistake, would they actually reimburse me?

I am a bit crazed about money right now and that makes it hard for me to think clearly about this.  We just FRIDAY finished paying off the home equity loan we had to take out in 2003 in order to finish repairing our house after a hurricane.  And now that my husband is back to work after a year off, I thought we would actually have some extra dollars again. Then this bill arrives on SATURDAY.  And it's just a little over a month before Christmas and about the same until my son's college room and board bill for the spring is going to be due.     

*******
I just found this in an online Medicare document that is specifically about and Medicare ESRD.

http://www.medicare.gov/Publications/Pubs/pdf/10128.pdf

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. this would be true for Stephen

...  When Medicare Coverage Ends
 
If you have Medicare only because of kidney failure, your Medicare coverage will end:

•    12 months after the month you stop dialysis treatments, or

•    36 months after the month you had a successful kidney transplant. this would not yet be true for Stephen

... Important:
Remember, in order for Medicare to pay for kidney dialysis and some transplant services, you need both Medicare Part A and Part B. If you don’t pay your Medicare Part B premium or if you choose to cancel it, your Medicare Part B will end.
 

Now, I am thinking that he must have Part A, because otherwise they wouldn't let him apply for Part B, right?

If Medicare does end up paying a part of the hospital bill, what would that mean for what we have to pay in terms of out of pocket, co-pay, etc?

From what I am reading it sounds like 20% of doctors services (which are covered by Part B) after paying a deductible of $135.

For hospital services I found this:

Hospital Services: For 2008 in Original Medicare, you pay the following: $1,024 deductible and no coinsurance for days 1–60 each benefit period





 

[okarol]

The financial coordinator at your transplant hospital should be able to help you with this.

When a bill arrives my husband checks with the provider to see if it has been submitted to Medicare and Blue Shield before he even considers paying it. There is a ton of paperwork but somehow he keeps on top of it. I am so grateful he handles it because its all so confusing to me.
Here's another document about Medicare - but may have the same info you have seen www.medicare.gov/publications/pubs/pdf/esrdcoverage.pdf

I did notice while looking over the info that Medicare will pay for a "Kidney Regisrty Fee" - I don't remember ever seeing that before. Interesting.

[willieandwinnie]

pelagia, I never pay a medical bill until I get at least 3 statements from them showing what other insurance has paid and then I call them and find out why we are being billed at all. I made this mistake with Washington Hopsital Center once and it took 3 months to get reimbursed our money. Yes, if Stephen has Part B that you are paying premiums on then he has Part A. Don't let them screw you. Try to enjoy some of your Sunday and don't worry about insurance crap. 

[pelagia]

   Thanks, I will not pay the bill until I see how it plays out.  They took 6 months to send it to me.  I think we should get at least 6 months to figure it out!

(note: I deleted some text, but you are all still invited to come stay at my B&B)

[lola]

I'm in the same position, wondering WHAT we will need to pay now that Otto lost the kidney, but they can all wait till after Christmas. Also after I get home from Linda and Stephen's B&B hehehe

[paris]

I will meet you there, Lola!!    

[Rerun]

We may complain about Medicare but we as "kidney patients" are very lucky.  If we were not covered under Medicare.... only those over 65 would get the secondary coverage.  Plus after a transplant Medicare helps cover meds for 36 months.  Some people don't think that is long enough and I do see their point.  Dialysis is more expensive then the meds per year.

The only problem I find with medicare is now that Medicare is "primary" for me.... no doctor will take me other than my Nephorlogist.  Great!


                         

[pelagia]

I'm in the same position, wondering WHAT we will need to pay now that Otto lost the kidney, but they can all wait till after Christmas. Also after I get home from Linda and Stephen's B&B hehehe

I will meet you there, Lola!!    

My house is always open to friends!  Let's have an IHD party!