Medicare Primary, insurance secondary

[mrstrekkie84]

My husband has been on staff-assisted home hemodialysis for almost 3 years. His insurance has been paying the costs. Last month, his social worker said we would have to switch to Medicare because commercial insurance stops being the primary payer after 33 months. After that, Medicare pays 80% and insurance pays 20%.. I'm afraid that he won't get the same benefits on Medicare as he did with his insurance. Will we lose staff-assisted home dialysis? Furthermore, the deadline is approaching and we have not heard back from Medicare yet. Will the insurance company and the dialysis center cut him off if we can't pay?

[Simon Dog]

Once he's on Medicare, Medicare will directly pay 80% of the allowed dialysis charge, but will not pay the extra for the home assist.   The dialysis clinics are good about managing the transition, and tolerating a delay while Medicare gets its act together.  I don't know if they will cut you off if you can't pay the 20% (directly or via a supplement plan).

Any chance you or he could learn to do dialysis yourself?   You would probably have the option of NxStage if you don't feel like dealing with the extra time of setting up and taking down the traditional machine.

[mrstrekkie84]

Thank you for your help. I will talk to the insurance company and the dialysis unit to see what the next step is. I just feel like having Medicare is a big pain in the butt

[obsidianom]

Actually medicare and a supplement insurance pay 100% of all costs. It works well. If you are low income the Kidney Fund will pay your second insurance too. So there are no costs. Talk to your social worker about that . Medicare is the greatest deal for the money as it covers so much for only about $105 per month.

[Simon Dog]

Medicare is the greatest deal for the money as it covers so much for only about $105 per month.

It's a bit more if you work.  I pay an income redistribution penalty of about $45/month on top of the $105 premium since I still work.

[cattlekid]

Be very careful about how your husband's commercial insurance coordinates with Medicare.  Some will be a true supplemental and pick up the 20% that Medicare doesn't pay and some won't. It depends on how they are set up to coordinate.

For example, I have medical insurance through my employer and I am on Medicare primary as I am still in the 3 year post transplant period.  My employer's insurance pays less for claims than Medicare pays because of the significant discounts they have negotiated with most of the local provider networks. 

If I go to the doctor's office for a basic follow up appointment, Medicare is billed first and pays their contracted amount.  This is subtracted from the total amount that the doctor's office billed and then this leftover amount is compared to what my insurance would have paid if they were primary.  Since my insurance would pay less, they do not pay anything.  I am responsible for the 20%.  The co-pays do accumulate towards the out of pocket maximum for my employer insurance so if there were catastrophic bills, I do have a backstop that caps my personal outlay at $4000 for the year.

I will be so happy in April of 2016 when I can finally tell Medicare to take a hike. 

[Bluebutterfly]

What is name of secondary insurance to get?

[Michael Murphy]

I am retired and as of January I passed the three year mark, I was on Aetna one policy from my last employer and my wife's companies Aetna policy.  For three years I was completely covered.  Then I had Medicare and my wife's Aetna and I had about 600 dollars a month charged to me until I hit the 2500 dollar deductible.  In June my wife retired and her company wanted her to switch to Medicare because the costs are lower.  They created a special Medicare advantage program with Aetna that covers every thing. Costs me 300 a month but I have no additional costs. Since I am now on Medicare the donut hole appeared to be a additional cost but it turned out Aetna bill the donut hole to my wife's company.  So noe my costs are fixed at about 450 a mont paying Aetna And Medicare.  I would contact your private insurer and see if three is a Medicare advantage policy that helps you.

[cattlekid]

Be careful with the Medicare Advantage plans.  One of the ways they keep the premiums down is to have very narrow networks (just like Marketplace plans).  So if you have very specialized needs or live in a rural area, Medicare Advantage can be problematic. 

I am retired and as of January I passed the three year mark, I was on Aetna one policy from my last employer and my wife's companies Aetna policy.  For three years I was completely covered.  Then I had Medicare and my wife's Aetna and I had about 600 dollars a month charged to me until I hit the 2500 dollar deductible.  In June my wife retired and her company wanted her to switch to Medicare because the costs are lower.  They created a special Medicare advantage program with Aetna that covers every thing. Costs me 300 a month but I have no additional costs. Since I am now on Medicare the donut hole appeared to be a additional cost but it turned out Aetna bill the donut hole to my wife's company.  So noe my costs are fixed at about 450 a mont paying Aetna And Medicare.  I would contact your private insurer and see if three is a Medicare advantage policy that helps you.

[Michael Murphy]

Yes the nice thing about the plan I am on is the goal is to save money for the company by paying Medicare rates.  When I checked about availability for my mountain home Aetna created a network that would cover Fulton county in the Adirondacks.  So far I see my doctors and go to my clinic with 100% coverage.

[PrimeTimer]

When you have Medicare as your primary and employer insurance as secondary, does Medicare require a referral to see a specialist? 

Hubby's employer insurance plan does not require a referral but now that he has Medicare as his primary, we wonder if that changes things. Of course we will have to make the necessary #@% phone calls first but wanted to ask if any of you have experience in this. Thanks in advance.

[nursey66]

We ran into the same issue . I had my husband on my insurance through work when his kidney gave out . We used mine as primary, Medicare was secondary until the required months then it switches to Medicare as primary and Private (my work insurance) was secondary . That worked fine , all his bills were covered. Until I wanted to retire ! It was almost impossible to get him on a supliment since he only had straight Medicare. He still had a poorly working transplant that as on its 11th year and ready to go out. Most supplements won't take a dialysis patients.  We found an agent that found one that would take him with a Dr note that he had a working transplant . We were so relieved 😌, I thought I would have to work forever ! His transplant failed 7 months later.

[kickingandscreaming]

This is why we need single-payer.  Here's a good article about the many reasons for single-payer:
https://www.facebook.com/kurt.eichenwald.1/posts/1448157071889590

[Tío Riñon]

When you have Medicare as your primary and employer insurance as secondary, does Medicare require a referral to see a specialist? 

Hubby's employer insurance plan does not require a referral but now that he has Medicare as his primary, we wonder if that changes things. Of course we will have to make the necessary #@% phone calls first but wanted to ask if any of you have experience in this. Thanks in advance.

To answer your question, I'm in a similar situation.  I have NOT requested a referral to see other specialists and the bills have been paid by Medicare and then anything left over is covered by my secondary policy.  Normally there is nothing left for me to pay after the two plans have processed the bills. 

Good luck with your appointments!

[PrimeTimer]

Thanks guys for responding. Hubby hasn't seen his Podiatrist since having Medicare as his primary and we got to wondering about their rules. Shame we have to deal with and pay for two insurance plans now but because he has ESRD and under 65, his employer insurance insisted he sign up for Medicare. We know he wasn't required to but they aren't very nice about things as it is.

[Tío Riñon]

I just finished working with a podiatrist for my father and learned a few items about Medicare.  He has both kidney disease and diabetes; therefore, he is eligible for have his feet trimmed and checked as preventative care every 62 days.  One pair of specially fitted custom diabetic shoes are covered annually.  The doctor may write a prescription for medical compression socks, if needed.  I'm not sure how many pairs are covered.

Check into this with your podiatrist when you go in for an appt.

[PrimeTimer]

I just finished working with a podiatrist for my father and learned a few items about Medicare.  He has both kidney disease and diabetes; therefore, he is eligible for have his feet trimmed and checked as preventative care every 62 days.  One pair of specially fitted custom diabetic shoes are covered annually.  The doctor may write a prescription for medical compression socks, if needed.  I'm not sure how many pairs are covered.

Check into this with your podiatrist when you go in for an appt.

Thank you so much for all the tips,Tío Riñon! We check his feet every nite. To help him relax and to keep his feet from drying out, I rub Gold Bond foot cream on them but am too afraid to trim his nails. He lets them get a bit long and so I hope the Podiatrist will trim them. He also stubbed his big toe the other week and a small blood blister formed below the skin surface. Not like the usual blood blister on top of the skin. It almost looks like a tattoo. It hasn't gotten any bigger but not going away and that scares me so want the doc to look at that too. Hubby will be glad to hear your news, thanks again! 

[PrimeTimer]

Yuuge relief! Hubby saw the podiatrist (no copay) with Medicare primary, Aetna secondary. The spot on his toe was just a dried blood blister which the doc quickly shaved off. Also took off a couple calluses and trimmed his nails. Doc felt his pulse at the bottom of his feet and was surprised by that. Said he has good circulation. Wants him to come in every 3 mos for nail trimming. He asked who had been trimming them for him and hubby replied "my wife" and the doc said "oh, you've got a nurse!" 

Anyway, at his next appt he might try on some tennis shoes and inserts since Medicare covers that every 3 years. Hubby is on his feet all day with his job so might be worth looking into, whether it's covered or not. Gotta have good souls to be one!

[Charlie B53]

I quit clipping (and biting) my nails in my teens.  I got tired of having so many ingrowns from them being too short.  I bought me a nice long triple-cut metal file and fille all nails shorter and once finished shaping I 'round' the corners carefully.  Gently filing from across the front all around the cornet to the side making for a very smooth curve around every corner.  This way as the nail grows out there is never any corner 'point' that may catch and dig into the skin creating an in-grown nail.  This has worked pretty well for 40 odd years.  I must be Blessed.

Grandson has a couple already. Aged 10.  I am going to have to buy him a file and teach him how to trim correctly.  He clips them too short.  Wrong!

[Mothergoose26]

Has anyone run into a problem with secondary insurance? I am on dialysis and have medicare primary and Blue Cross Blue Shield secondary. Medicare pays it 80% but secondary will not pay it 20% of the bill until I hit maximum out of pocket. I called BCBS and they said since medicare paid the 80% they will not pay any more. I cannot see why BCBS should not pay 80% of the 20% that medicare did not pay and I should pay 20% of 20%. Why should I pay the full 20% when I am paying two premiums. If anyone can help me with this I would appreciate it.

[Michael Murphy]

Insurance is not fair they write the policies very tight.  In January last year I was forced to switch to Medicare as primary but my Aetna policy would not cover the 20 % not paid by Medicare.  I had to cover the deductible before they kicked in towards my dialysis. What was stupid is with two insurance coverage (my wife and mine) Aetna was paying 1500 for each treatment and I was not required to,pay a dime.  Now at 320  treatment which is about 1200 less I needed to pay  64 dollars 3 times a week till I hit my deductible limit.  What saved me was a switch to a Form of Medicare advantage from Aetna sponsored by the company my wife retired from.  I took the pricey 300 dollar option but they seem to pay for every thing.  I was hospitalized after a heart attack twice it in volved 4 hospitals, 4 ambulance rides, 2 angioplasties, 1 7 hour operation to insert a ICD and perform a abalation procedure to cure a vtach episode.  Total cost was over 100 thousand dollars even at Medicare rates. Cost me 250 because 1 of the doctors was out of network and the hospital bill did not say the operation was a emergency.  The solution is that a good Medicare advantage program is cheaper in the long run then free insurance from a employer.

[Tío Riñon]

Has anyone run into a problem with secondary insurance? I am on dialysis and have medicare primary and Blue Cross Blue Shield secondary. Medicare pays it 80% but secondary will not pay it 20% of the bill until I hit maximum out of pocket. I called BCBS and they said since medicare paid the 80% they will not pay any more. I cannot see why BCBS should not pay 80% of the 20% that medicare did not pay and I should pay 20% of 20%. Why should I pay the full 20% when I am paying two premiums. If anyone can help me with this I would appreciate it.

I have Medicare and BCBS too.  I am surprised that you are having issues with them paying the 20% balance.  They cover mine once Medicare has processed the original claim.  Unfortunately BCBS varies from state-to-state as well as the types of policies offered.  Why don't you consult with the insurance representative at your clinic to see if s/he can help.  Otherwise, you can try an appeal with BCBS.  They should be happy to pay 20% instead of 80% or 100%.

[nursey66]

We had the same deal . Hubby was on Medicare and he was on my BCBS from my work. All his bills were covered 100%   That was a few years ago maybe 3-4 , so they might of changed it . We are from Minnesota.

[MKFlStrong]

If you have Medicare and Medigap you should be fine with out of pocket costs. My mother had Original Medicare and a Medigap Plan to supplement the costs that Medicare didn't pay.

[cattlekid]

This was the exact situation that I was in.  I had Medicare primary and my employer-provided Blue Cross Blue Shield as secondary. 

I had to pay:
1.  premiums for my employer insurance
2.  premiums for Medicare Part B
3.  the 20% that Medicare didn't pick up until I met my out of pocket maximum

I was told that it was the way that my particular flavor of Blue Cross Blue Shield coordinated with Medicare.  Because Medicare paid more than BCBS would have paid for the same claim, my employer insurance did not kick in.  They were only there as a "backstop" in case I racked up huge bills and hit the OOP maximum.

I was never so happy as to be able to tell Medicare to take a hike after 36 months post-transplant.  I was back to saving the Medicare Part B premium and only having to deal with one insurance company AND had lower co-pays for all of my medical needs. 

Has anyone run into a problem with secondary insurance? I am on dialysis and have medicare primary and Blue Cross Blue Shield secondary. Medicare pays it 80% but secondary will not pay it 20% of the bill until I hit maximum out of pocket. I called BCBS and they said since medicare paid the 80% they will not pay any more. I cannot see why BCBS should not pay 80% of the 20% that medicare did not pay and I should pay 20% of 20%. Why should I pay the full 20% when I am paying two premiums. If anyone can help me with this I would appreciate it.