Primary/Secondary Insurance question...

[jeannea]

I understand what frankswife is saying about copays. Your out of pocket maximum does not count copays. The failure here is with the social worker. If you go to her and say We cannot afford these copays then she should find a way to help you. She could ask the facility to waive the copay, she could help you apply for American Kidney Fund assistance, there might be other options. You may have to go to someone else like the Facilities Administrator or maybe your doctor.

State calmly but firmly that you cannot afford to keep your husband on dialysis. Ask directly what they can do to help.

[cattlekid]

I am now more confused than ever.  How can a copay not count against an OOP maximum?  I know in my situation, I have to pay the 20% that my insurance does not cover for all office visits, tests and hospitalizations up to $2000 per year per covered person and after that, everything is covered at 100%.  Is that 20% considered a copay?  Or am I missing some subtle distinction? 

[tiredandthirsty]

hi cattlekid

i believe the term you are describing is "co-insurance".  the 20% that you have to pay is your co-insurance payment.  meaning you are responsible for 20% of the risk and the insurance is responsible for 80% of the risk.  Risk is spread between you and the insurance provider. in my case it is 90/10.  that number once it reaches 2000, same for me, the insurance picks up the entire risk of 100%.  the co-pay is a set payment you have to pay for office visits.  for me, it is 20 for general, 40 for specialists, 100 for ER etc.  these payments are considered as co-pays and do not count towards your out of pocket maximum for the  year. 

anyone, please correct me if i am wrong and hope this explanation helps. 

[cattlekid]

Okay, that makes sense.  I have never had an insurance plan with copays that never end, always just the co-insurance with a maximum total out of pocket expense.  I can see where never ending copays would be a problem.    Either way, I do agree with others that the social worker should be getting involved and possibly the financial coordinator as well with escalations up the food chain as necessary.

hi cattlekid

i believe the term you are describing is "co-insurance".  the 20% that you have to pay is your co-insurance payment.  meaning you are responsible for 20% of the risk and the insurance is responsible for 80% of the risk.  Risk is spread between you and the insurance provider. in my case it is 90/10.  that number once it reaches 2000, same for me, the insurance picks up the entire risk of 100%.  the co-pay is a set payment you have to pay for office visits.  for me, it is 20 for general, 40 for specialists, 100 for ER etc.  these payments are considered as co-pays and do not count towards your out of pocket maximum for the  year. 

anyone, please correct me if i am wrong and hope this explanation helps.

[KarenInWA]

All I know is, ever since I started paying for Medicare, I don't get billed or co-pays anymore. Right now I am lucky and only have $15 co-pays for ALL doctors. I never did understand the higher co-pay for a specialist. Isn't needing a specialist punishment enough???

KarenInWA

[frankswife]

Cattlekid, without checking with my HR person for sure, I believe out of pocket is $3000. Clinic does accept medicare assignment. Social Worker is leaving and training new person to take over. Her idea of helping was to hand Frank an application to get a reduced payment plan for the copayments from the hospital. Right now we are semi- ok while I am still working. However I work for an auxiliary company on a university campus and we are laid off May to August. Normally this too was ok while Frank was still working but now we are going to have to live on his SSDI check from May through August. It equals ONE QUARTER of what our combined incomes used to be. I'm not ashamed to tell you I'm terrified. I've already gotten rid of one of our trucks and put our camper up for sale. We are officially poverty stricken. I'm trying to save as much as I can till then so copays are OUT. Is there help anywhere for us?

[brandi1leigh]

Frankswife check out my previous post in this thread. I posted an organization that provides help!

[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.

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.

My husband and I have worked for small companies that do not provide insurance for the past 23 years.  Since that time, we have always had to purchase individual health insurance, sometimes through Blue Shield, sometimes Blue Cross, depends on who has the best rate.  We have been with our current company since before my diagnosis, so I don't believe they could cancel us.  We carry a high deductible ($7000) to keep our monthly premiums down some.  And our rates have increased due to my health issues.  But since it is not employer-provided, (and because I do PD at home) we don't have to wait the 30 months.  Medicare became primary as soon as I started my PD training.

I hope you are doing well and continue to, as well!  Good luck with this.  And I believe American Kidney Fund might be where my SW got the grant to help pay my premiums.

Shrei