Primary/Secondary Insurance question...

[tiredandthirsty]

Hello all,

hope you are doing well and keep on doing well forever.

so i am back with another questions.  this one is about money :-). 

i have United HC through my work (90/10) and then i have medicare.  I was wondering if Medicare picks up the 10% for all services or for none or for some?  i recently had to re-do the tests for the transplant list since it has been a year and i just received a bill for one of those tests.  The hospital billed the insurance for  the tests and they billed me for the 10%.  is there anyway Medicare can pick that up? or no?  if there is, what do i need to do to make this happen? 

any kind of help, suggestions, advice, tips would be greatly appreciated as usual.  as you all know, money is probably one of the biggest problems most of us all face and i could use some advice on this.  thanks a lot in advance.

Hope you are all doing well and keep on doing well forever.

[jeannea]

I get confused on this. Most transplant teams have someone assigned to help you with the financial issues. Call and ask for that person. They are usually Medicare experts.

[tiredandthirsty]

Hi Jeanna,

thank you very much for your response.  much appreciated.

i was actually going to talk to financial coordinator or whatever they are called but i wanted to arm myself with some knowledge before i did that.  so i am better prepared to argue my side in case they throw some curve balls at me. 

I am totallly clueless on this primary/secondary bs.  everytime i go somewhere i show them both my insurance card and medicare card and they ask me what is primary and what is secondary.  i have absolutely no idea.  i just tell them UHC is primary, medicare is secondary. who makes this decision anyways?

[cattlekid]

Tiredandthirsty, when you start dialysis, you qualify for Medicare both Parts A and B (after the fourth month if you are in-center, sooner if you start training for home hemo).  If you are still employed or not on Social Security, you will get quarterly bills for the Part B premium.

For the first 30 months, your employer group health plan or other health insurance is primary, Medicare is secondary.  You will need to call the Medicare Coordination of Benefits group for your state and make sure that this is noted or there may be issues with bills not being paid by either insurance (just found that out two weeks ago!) 

After 30 months, the situation reverses and Medicare becomes primary and the other health insurance becomes secondary.  Again, you will probably need to call the Medicare Coordination of Benefits group for your state and make sure that the flip happens so that there is no issue with payments. 

When I go to any health care provider, I am always VERY careful to tell the front desk staff that my EGHP is primary and Medicare is secondary.  Otherwise, the bills won't go to the insurances in the right order.  I found that out last year when both insurances paid as primary for some tests.  At least the hospital was organized enough to send back the money that they got from Medicare. 

It's gotten to the point now where I have created an Excel spreadsheet to track everything so that I don't inadvertenly pay a bill that may have slipped through the cracks.

[frankswife]

Not sure how it works for others, but here's Franks and my story: I pay $370 a month through my employer for private health insurance for me and Frank. Frank will pay another $105 starting in March out of his SSDI check for Medicare A and B. For all the info I can gather, this will cover NOTHING. We are just handing them the extra hundred bucks now so we dont have to pay a 10% penalty later. I am still going to be racking up $25 copayments 3 times a week ($9000!) until Medicare becomes primary. As I said, they basically do nothing for the money we pay. Nice, huh? I really don't understand the Medicare program.

[jeannea]

Frankswife, something isn't right there. See your social worker for help.

[WishIKnew]

frankswife, please check with your social worker.  That's not how it worked for me.  Hope it works out better for you!

[frankswife]

This IS the info from the SW. It's also the info I got from the Office for the Aging, who my HR person at work suggested I call since no one else has a clue. The way it was explained, my insurance is primary for 30 months. Frank HAS to take Medicare now because if he doesnt A), My insurance  could drop him and B), we will have to pay a 10% penalty for every 12 months he doesnt have Medicare and C), My insurance company can and likely would refuse to pay for a transplant if he was eligible for Medicare and refused it. Now, my insurance seems to be pretty good, but I do have $25 copays for dialysis. Medicare DOES NOT cover them. Medicare is paying for nothing. There is nothing my insurance is not picking up. I have no deductibles to meet, no coinsurance, just the copayments. So thats why I'm saying we are paying the government $105 for nothing. We cant afford it. Plus the first month they are taking 4 months of Medicare premiums which wipes out about half his check. For what? I still have the hospital collection office calling me for money and I'm afraid they'll stop his dialysis because I cant pay the $75  every week. So thats my Medicare story. Im glad it  worked out better for some of you, I wish I knew how.

[jeannea]

Is your Social Worker really saying tough luck if you're going broke on dialysis but it's not our problem? That's inappropriate. There are ways to help you and it's their job to figure it out.

[Sydnee]

frankswife that is how it worked for Ed last year. we paid the $300 a month through Ed's work for BCBS and $99.90 a month (last year) for medicare. Medicare picked up NOTHING. We owe over $7000 in medical bills that have gone to collection from last year (hospital and doctors would not work with us).

[KarenInWA]

I have Anthem BC/BS through my work, and I didn't sign up for Medicare until shortly before my transplant. Here is my timeline:

Started dialysis: April 22, 2011
Medicare Eligibility Date: July 1, 2011
Signed up for Medicare: Sometime in Sept/Oct 2011
Transplant: November 11, 2011 (Medicare was squared away at this point as my secondary coverage) My first statement was for time from July 1, 2011 - Feb 29, 2012
Have had no co-pays for numerous dr visits and 2 hospital stays

This past November, I received a bill from my dialysis clinic, for co-pays during the time I was not covered under Medicare. The cost was $450. My co-pays are $15, so that was for 30 treatments. I paid the bill, because it was low compared to what others have been billed.

From my experience, Medicare pays the co-pays for dr visits and hospital stays. I have never paid anything for a CT, ultrasound, or lab draw, although that is part of my medical plan, also. I would double-check and then triple-check everything. The only things Medicare will not cover are things your primary coverage will not cover. Medicare should pick up all or most of your co-pays.

KarenInWA

[Cowdog]

Read this: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/msp105c03.pdf
If you have primary private/work insureace with Medicare as you secondary.
Each procedure/treatment has an Medicare approved payment amount. If the primary insurance pays more than that approved amount Medicaare won't pay any additional and the provider cant bill you for any additional. While Medicare was my secondary the additional amounts I did not have to pay far offset the cost of the Medicare premium. I did have a couple of providers I had to "teach" the rules to. With work insurance as primary and Medicare as secondary the only expense I had was co-pay on meds.
Now with Medicare as primary I occasionally get a small bill after Medicare and Ins have paid but usually very small. Example: Recently had fistulagram and angioplasty. Bill was about$5000. Medicare approved amount was about $2500. Medicare paid, insurance paid, I was billed $25.

[Cowdog]

BTW - Social worker was zero help on any of this. She did/does not know or make the effort to find out.

[blondie1746]

I have Medicare and private insurance.  Since our private insurance is not provided by work (i.e. not a group plan) and we pay for it ourselves, Medicare is primary in my case, and my private insurance is secondary.  That also has to do with the fact that I do PD at home.  I was covered from the time I started training for PD.  But, my social worker found a grant that helps pay my Medicare premium and my portion of my private insurance premium.  Also, I have never been balance billed by my dialysis clinic for anything not paid by Medicare or private insurance.  Sounds like you might need a new social worker.  That is their job to help you through this, mentally, and financially.

[brandi1leigh]

Also check out the American Kidney Fund. They help dialysis patients pay for insurance premiums. They will even reimburse you for the cost of both private insurance and Medicare if you qualify. The financial coordinator at my center helped me fill out the paperwork, but if yours won't help here's a link.
Www.kidneyfund.org/patient-programs

[tiredandthirsty]

oh wow!! so many responses.  apologies for coming in late but this past week was a busy one at work.  didn't get to do much with that and treatment. 

let me read the responses and i'll respond to each and everyone of them if needed.

thank you so much for taking the time to help me out.  i am very grateful.

 

[tiredandthirsty]

Tiredandthirsty, when you start dialysis, you qualify for Medicare both Parts A and B (after the fourth month if you are in-center, sooner if you start training for home hemo).  If you are still employed or not on Social Security, you will get quarterly bills for the Part B premium.

For the first 30 months, your employer group health plan or other health insurance is primary, Medicare is secondary.  You will need to call the Medicare Coordination of Benefits group for your state and make sure that this is noted or there may be issues with bills not being paid by either insurance (just found that out two weeks ago!) 

After 30 months, the situation reverses and Medicare becomes primary and the other health insurance becomes secondary.  Again, you will probably need to call the Medicare Coordination of Benefits group for your state and make sure that the flip happens so that there is no issue with payments. 

When I go to any health care provider, I am always VERY careful to tell the front desk staff that my EGHP is primary and Medicare is secondary.  Otherwise, the bills won't go to the insurances in the right order.  I found that out last year when both insurances paid as primary for some tests.  At least the hospital was organized enough to send back the money that they got from Medicare. 

It's gotten to the point now where I have created an Excel spreadsheet to track everything so that I don't inadvertenly pay a bill that may have slipped through the cracks.

hi cattlekid, thank you for your response.  hope you are doing well and keep on doing well forever.

yes i did read somewhere on here that insurance is primary for the first 30 months and medicare is secondary and it reverses after 30 months.  i also do pay a premium every three months, something like 330 or so.  it's like a gut punch everytime i have to write that bloody check hehe.

but i am trying to find out how it actually works in non-dialysis situations.  such as doctor appointments for example.  i have a 40 copay for neph every time i go to him.  i am not sure whether that can be or is covered by medicare of not.  do i still have to pay out of pocket for that? also, i recently had to repeat the listing tests since it has been a year for me on the list.  so had to repeat all the tests.  i am quite sure the hospital will charge the insurance for it and insurance will pay 90, but can medicare cover the remaining 10% of it?  this is the type of information i am trying to collect so when i go to the social worker or financial coordinator she can't bs me around.  :-). 

thank you once again for your response and hope you are doing well and keep on doing well forever.

[tiredandthirsty]

Not sure how it works for others, but here's Franks and my story: I pay $370 a month through my employer for private health insurance for me and Frank. Frank will pay another $105 starting in March out of his SSDI check for Medicare A and B. For all the info I can gather, this will cover NOTHING. We are just handing them the extra hundred bucks now so we dont have to pay a 10% penalty later. I am still going to be racking up $25 copayments 3 times a week ($9000!) until Medicare becomes primary. As I said, they basically do nothing for the money we pay. Nice, huh? I really don't understand the Medicare program.

hi frankswife,

thank you very much for your response.  i really appreciate it. 

i am totally clueless on the medicare piece as well.  i still pay 330 dollars every three months just to make sure i don't get caught with my pants down if something happens and i no longer have insurance through work.  back up.  it is so bloody convoluted.  i am sorry you hare having to pay so much out of pocket.  i wish i had something mind exploding to say to you for your situation.  but i am in the same boat as you, almost. 

[tiredandthirsty]

I have Anthem BC/BS through my work, and I didn't sign up for Medicare until shortly before my transplant. Here is my timeline:

Started dialysis: April 22, 2011
Medicare Eligibility Date: July 1, 2011
Signed up for Medicare: Sometime in Sept/Oct 2011
Transplant: November 11, 2011 (Medicare was squared away at this point as my secondary coverage) My first statement was for time from July 1, 2011 - Feb 29, 2012
Have had no co-pays for numerous dr visits and 2 hospital stays

This past November, I received a bill from my dialysis clinic, for co-pays during the time I was not covered under Medicare. The cost was $450. My co-pays are $15, so that was for 30 treatments. I paid the bill, because it was low compared to what others have been billed.

From my experience, Medicare pays the co-pays for dr visits and hospital stays. I have never paid anything for a CT, ultrasound, or lab draw, although that is part of my medical plan, also. I would double-check and then triple-check everything. The only things Medicare will not cover are things your primary coverage will not cover. Medicare should pick up all or most of your co-pays.

KarenInWA

thank you very much KarenInWA for sharing your story.  very helpful indeed. 

it's good to know that co-pays are covered.  those things add up quite fast.  however i recently did pay a LabCorp bill for some blood tests for my liver that the liver transplant clinic asked for.  i gave labcorp my insurance and medicare and i still received a bill.  how do i check whether this is a mistake or not? when i didn't have medicare, i still had to get these tests done and i did receive similar bills and i paid them from my FSA account.  however with medicare i was thinking maybe it will be taken up by medicare. 

thank you once again for your time and your response.  hope you are doing well and keep on doing well forever.

[tiredandthirsty]

Read this: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/msp105c03.pdf
If you have primary private/work insureace with Medicare as you secondary.
Each procedure/treatment has an Medicare approved payment amount. If the primary insurance pays more than that approved amount Medicaare won't pay any additional and the provider cant bill you for any additional. While Medicare was my secondary the additional amounts I did not have to pay far offset the cost of the Medicare premium. I did have a couple of providers I had to "teach" the rules to. With work insurance as primary and Medicare as secondary the only expense I had was co-pay on meds.
Now with Medicare as primary I occasionally get a small bill after Medicare and Ins have paid but usually very small. Example: Recently had fistulagram and angioplasty. Bill was about$5000. Medicare approved amount was about $2500. Medicare paid, insurance paid, I was billed $25.

thank you Cowdog for your response.  i really appreciate it.

your fistulagram charge was 5K? heck my doctor charged my insurance almost 10K for the same thing.  and the first time he did one, 21K!  first time he found some stenosis, second time there was nothing. 

thank you for the link as well. very useful. 

hope you are doing well and keep on doing well forever.

[tiredandthirsty]

Also check out the American Kidney Fund. They help dialysis patients pay for insurance premiums. They will even reimburse you for the cost of both private insurance and Medicare if you qualify. The financial coordinator at my center helped me fill out the paperwork, but if yours won't help here's a link.
Www.kidneyfund.org/patient-programs

hi brand1leigh,

thank you for your response.  i really doubt i will be able to qualify for such a help at this point.  my private insurance is through my work and i am the only person on it (as opposed to a family, one of the only few perks of being single) so it's about 60 dollars per paycheck.  i am not going to take help for that.  someone in more need could use it.

hope you are doing well and keep on doing well forever.

[tiredandthirsty]

I have Medicare and private insurance.  Since our private insurance is not provided by work (i.e. not a group plan) and we pay for it ourselves, Medicare is primary in my case, and my private insurance is secondary.  That also has to do with the fact that I do PD at home.  I was covered from the time I started training for PD.  But, my social worker found a grant that helps pay my Medicare premium and my portion of my private insurance premium.  Also, I have never been balance billed by my dialysis clinic for anything not paid by Medicare or private insurance.  Sounds like you might need a new social worker.  That is their job to help you through this, mentally, and financially.

hi blondie1746,

thanks a lot for writing.  you buy private insurance?  wow, i have always heard for people like us it costs an arm and a leg and an another additional appendage that cannot be mentioned here (medical term: gonad (male), particularly the left).  that is if they are ready to take us on in the first place.  pardon my intrusion, but could you please share how you managed to get personal insurance? i might have to consider this option in the future that's why. 

hope you are doing well and keep on doing well forever. 

[cattlekid]

Once you are on Medicare, it covers everything, as long as you let the provider know that you have it.  Medicare will pick up all of the remainder as long as there is a remainder to pick up.  One of the benefits of being on Medicare secondary is something called "assignment".  If a provider accepts assignment, they cannot bill you for anything over what Medicare would pay.  So let's say they bill your insurance $200 for an office visit.  Let's say the Medicare fee schedule for the office visit is $100.  Your insurance will process any provider discount and then pay out the 80% of what's left (at least that's how mine does it).  Then if there is anything left that is under the Medicare fee schedule, then it would flip over to Medicare and they would pay the remainder.  However, most insurances pay much more than Medicare would pay so I am not seeing anything flipping over to Medicare for me.  But I am also seeing much smaller bills than I would have seen in the past, if anything.  The point is that Medicare insulates us somewhat from unexpected bills that aren't covered by our primary insurance.  I think it is more helpful for those with high deductibles or out of pocket maximums.  For me, it's kind of pointless.

I do want to reiterate that you will need to identify your Coordination of Benefits organization for your area and contact them to let them know of your other insurance.  I was told that if you don't do so, both insurances will think they are primary and no one will end up paying properly.  If you go to the Medicare website (www.medicare.gov), you can find the COB contractor for your area.

Good luck!

hi cattlekid, thank you for your response.  hope you are doing well and keep on doing well forever.

yes i did read somewhere on here that insurance is primary for the first 30 months and medicare is secondary and it reverses after 30 months.  i also do pay a premium every three months, something like 330 or so.  it's like a gut punch everytime i have to write that bloody check hehe.

but i am trying to find out how it actually works in non-dialysis situations.  such as doctor appointments for example.  i have a 40 copay for neph every time i go to him.  i am not sure whether that can be or is covered by medicare of not.  do i still have to pay out of pocket for that? also, i recently had to repeat the listing tests since it has been a year for me on the list.  so had to repeat all the tests.  i am quite sure the hospital will charge the insurance for it and insurance will pay 90, but can medicare cover the remaining 10% of it?  this is the type of information i am trying to collect so when i go to the social worker or financial coordinator she can't bs me around.  :-). 

thank you once again for your response and hope you are doing well and keep on doing well forever.

[frankswife]

Again, Medicare does not pick up copays and copays are what are killing us. By the time Medicare becomes primary in 30 months, we will owe $9000 in dialysis copays. We cant pay it. I thought you were covered if you were on dialysis and had medicare. I'm not asking for a free ride. I just dont understand how this can be.

[cattlekid]

Frankswife,  I am really at a loss to understand what is going on in your situation.  May I ask a few questions?  What is your out of pocket maximum on your insurance?  I know ours is $2000 for each individual.  Is yours higher than that?  Do you know if your dialysis clinic accepts Medicare assignment?  Is your social worker helping you make sense of all this?  There are programs available to help.  The social worker should be addressing all of this with you.  If he or she is not, I would complain to the Facility Administrator and then to the ESRD network for your area.  This just doesn't seem right from everything I have read and experienced in my own situation.

Again, Medicare does not pick up copays and copays are what are killing us. By the time Medicare becomes primary in 30 months, we will owe $9000 in dialysis copays. We cant pay it. I thought you were covered if you were on dialysis and had medicare. I'm not asking for a free ride. I just dont understand how this can be.