Medicare Ins. and supplimental Ins.

[karen335]

Not sure where to post this question. How does Medicare A & B work with Medigap or supplimental insurance. I have had an HMO for the last 3 yrs and all my medical expenses have been paid through there (HMO, Cobra) It runs out end of the month (April), They called me, insurance. No advance letter or anything.

My question is, how do I do this and make sure I am selecting full coverage. I can't pay a lot out of pocket. What does everyone else on Medicare do, your suggestion and what you have done would be greatly appreciated.

Thanks All,

Blessings and prayers,

Karen[/b]

[Linda661]

Karen:

Medicare part A is for hospitalization times -- generally everything is covered 100% for things covered under part A. The first 20 days in a skilled nursing facility and hospice care are covered under part A as well.

Medicare part B generally covers 80% of eligible expenses, including out-patient care. All those professional charges that are in addition to a hospital stay, treatments such as chemo/radiation, PT/OT, medically necessary ambulance service, oxygen therapy and other durable medical equipment needs, and days 21-100 in a skilled nursing facility. There are caps on the total amount of part B coverage for therapy and I'm sure caps exist for other things as well.

Rxs are not covered once out of part A situation -- that's where Medicare part D cropped up for folks, beginning as of Jan 1, 2006. Chemo drugs, including shots for anemia are covered under part B (they are so far for us) when administered by a doc. at a treatment center -- I don't know about home administered stuff like pill forms of chemo (Tarceva?) or decadron yet.

I don't know about Medigap. We have supplemental insurance through my dad's retirement benefits where I have to do the submissions once I get a summary statement of what Medicare has paid for. In other words, Medicare picks up it's part of the tab first, then the supplemental picks up the rest of part B stuff. I would imagine other supplementals would work in the same manner: others will chime in if I'm wrong there, I'm sure.

For now, www.medicare.gov (the official medicare website) and www.medicare.org (useful info. resource on medicare as well) should help you get a start on becoming informed. In addition, Medicare should be sending you a booklet all about your benefits and how they work. 1-800-MEDICARE is the official phone number for help on questions, but I have got to tell you that it is no more than folks looking up the answers to your questions (and you never get to the same person twice) -- I have run across reality not working the way the 1-800-MEDICARE "customer support" folks say it will.....still fighting battles over medicare says-you say stuff and the two don't agree.

Feel free to PM me if you have more questions -- I'm not sure at the moment, but we probably have the same organizations handling Medicare processing of claims, if I remember right from some recent digging I have been doing (there will be two: one for durable medical equipment and one for other claims). I certainly don't know everything about all possible Medicare stuff, but I have done a heck of alot with Medicare for both of my parents over the last year including winning appeals on things they wouldn't do at first --

Hope this helps,

Linda

[karen335]

Linda,

Thank you very much. I guess I should look into a supplimentsl insurance. To pick up what Medicare doesn't cover, like maybe Cigna (I have that now HMO) or Blue Cross.

I read somewhere about asking physicians about assignments. It means they accept what Medicare pays them as payment in full. Do you know anything about that?

Appreciate your help,

Karen

[Linda661]

Re: Assignments

Yes, I do. Physicians are not required to accept Medicare assignment as payment in full and that you definitely want to watch out for when out-of-pocket expenses need to be watched closely.

When you stay with a doctor who does not accept Medicare assignment, they will (well they better!) still process the claim to Medicare and Medicare will issue you a check for what they would have paid the doctor. Your medicare supplemental should also give you the balance of part B claims stuff. But.....you are responsible for the doctor's charges.

We ran across this with a specialist (came on board when my dad was first hospitalized) who would not accept Medicare assignment. Was interesting that we did not have to pay extra when the physician was visiting dad in the hospital (part A), but things were different when the follow-up visit hit (we ended up paying about $500 out-of-pocket for just that one follow-up visit for non-acceptance of Medicare assignment). You definitely have to watch that one. All I can figure is that the specialist had some special agreement with the hospital when he saw new patients there, but all bets were off once the patient left the hospital.

Linda

P.S. As much of a paperwork hassle as it has been for me, it really has been worth it to be "in the loop" looking at all of those Medicare summary statements along the way. I have caught thousands of dollars worth of billing mistakes by medical professionals and not one of them have been in the family's favor!!!!! I had no choice since I have to do the submissions to our supplemental insurance......other supplementals will probably allow direct billing by doctor's offices.....just a word of warning to somehow make sure you will get copies of those Medicare summary notices to review for yourself. I guarantee that your supplemental will only pay what they are supposed to and you might be left wondering why you seem to be mysteriously paying something you shouldn't be.

[karen335]

Linda,

Does this mean I have to pay all doctors up front and wait on Medicare and supplimental insurance to pay me back? I am really dumb when it comes to insurance..

What if people can't afford to pay up front. I can, but I shouldn't have to. We already pay enough. We are going to have to go to a National Healthcare System.. The Middle class get taken to the cleaners again. We are doing their job for them (ins. Co's).

[Linda661]

Generally, we pay nothing up-front. The doctor's offices will do their Medicare processing first and then bill us for the remainder (so I have a cash flow issue in my supplemental insurance circumstance, but you might not). If your supplemental will permit direct-bill by doctors, they will probably do that first too.....it all depends on your particulars that get set up on supplemental.

The only place I have had to pay anything up-front is at chemo so far. We have to go ahead and pay what the patient on Medicare is supposedly responsible for at every visit because they can't go ahead and direct-bill our supplemental insurance -- I get to catch up on their errors after the fact on that one. That has got to be a facility policy thing....worth asking about if it is a concern to you on what you get set up.

This was also true on the doctor who would not accept Medicare assignment......it got run through Medicare before we got the bill.

The only "Medicare paybacks" you will get will be for those who don't accept Medicare assignment -- Medicare will pay your docs. directly if they accept assignment. Your supplemental might very well pay them direct as well.....all depends on your particulars.

Linda

[karen335]

Thanks Linda

[KarHart]

Hi Karen,

When Ken was first dx he had only Medicare. He was already on it for a different disability. Anyway, we had to pay the 20% of the Medicare approved charges, no one ever billed the difference.

I was able to add him on to my work insurance last March (Blue Cross HMO). It appears that they are paying the 20%, which is a good thing since each chemo treatment was costing us about $960 after Medicare. Blue Cross is slowly picking these up. I just received a $2,000 bill from Moffitt from the time before we got him on Blue Cross, unfortunately that is all mine.

If you have Medicare and a supplement you are generally in really good shape. The really important thing about getting him on BC was that while he was on Tarceva I only had to pay a $30 copay since it was under my RX coverage.

Karen H

[Larry]

Karen i have a supplemental insurance plan and i have the top level or the F plan that cover's all over charge's that medicare would not normally cover. I am covered by preferred insurance out of whichita Ks and i found them to be much less than the other's such as Blue Cross and Arrp and so forth and my wife was covered by them and they were so polite and prompt to deal with, to give a example of there service i had a problem with a doctor who took over another's practice and they failed to get my insurance info as this doctor was not signed up to there insurance. Well they tried to charge me full amount which was over $700.00. Well i called Preferred and they checked into it and the next time i heard from the Doctor's office they were very Apologetic and Reduced my bill in half. If you want to call Preferred i'll PM you and give you there number.....Larry