Medicare as primary - covered post transplant labs and a Medicare Advantage question

[Pcnet]

Medicare is becoming primary insurance in 2 weeks for my 19 year old son after 30 month coordination of benefits period ends where group health insurance paid everything after deductible. Will Medicare cover labs (he goes every 2 weeks) for RFP, tacro, magnesium, CBC w/diff and viral studies of BK, CMV and EBV?

I got EOBs in the past where Medicare was mistakenly billed and it was a big NO, NO, NO under covered services for all these labs on multiple dates. Any help/advice would be appreciated. Should they be coded a certain way?

We will keep our group health plan initially as secondary but it’s becoming very expensive and cost prohibitive. We are looking at potentially a Medicare Advantage plan from AARP United Healthcare. Does anyone have experience with the Advantage plans and coverage? He cannot get a supplement plan in our state of Ohio because of his age.

I’d appreciate any thoughts, advice, et cetera.

[Bassetmommer]

My best suggestion for you is to find an insurance broker. I have used one for years and it made all the difference in getting the right plan. Unfortunately, I do not think she can help you in Ohio.

[Eyak1971]

You can contact medicare to receive a booklet to identify costs and payments. Also you transplant center can guide you to resources. My own personal choice is basic medicare with a supplement. It may no longer be an option presently but look into it. This option was recommended buy my daughter who worked for a large hospital and was in the insurance billing department. She said the advantage programs were a nightmare to process. Traditional medicare has always paid for my testing for the first 3 years with no questions. I believe after that time period particularly with patients younger than retirement the cost is not covered. So you are looking at private insurance or medicaid. So that at least gives you 3 years to investigate. Note meficare part d covers anti rejection medication but you may have to look for a supplement plan to cover others. I have one of those also. It may seem that advantage plans would be simpler but remember those plans are managed by a private company looking to make a profit so they may limit doctors and procedures with pre-suthorizations and referrals. Never had that problem with traditional medicare. Medicare also sets what medical facilities and doctors can charge. So if any medical provider tries to push for more. Medicare will stop the process. Medicare also subcontracts with a company who will investigate if a patient is receiving subpar medical services. Good luck in your investigation and the best to your son. Congratulations on being a great parent. We need more.

[Pcnet in reply to Eyak1971]

Thank you for the reply and information. I have some questions and was wondering if we could schedule a phone call so I could get more details? Since you’ve experienced this first hand I would appreciate what knowledge you have if possible. And if not, I could pose more questions through this forum. Thank you.

[Eyak1971 in reply to Pcnet]

Thanks for replying. Keeping to the forum would be best so information can flow to all interested parties. I can only relate my experiences and opinion but with such a decision you should have multiple inputs. For me I was retiring if I had chose advantage programs and then years later changed my mind going to traditional medicare it would have been a financial loss due to my health issues and the law. I needed to make the right decision upfront. When private business entered the medicare program it made the whole program more complicated and actually a strain on the program. Thus the constant tv commercials, mailings, and garage of phone calls during enrollment periods. Since your son is young his insurance issues will be different. After the 3 years he will have some tough decisions. This is why after being on medicare for several years, I believe medicare for all is so important at any age. You may call that socialism. I call it caring about others. I remember when I was a teacher 40 years ago and the hardship my family faced with inadequate health insurance. I ca.nnot imagine what young families face today. In some ways I am thankful my daughter and husband did not have children. That is why I have great respect for you to help your son meet and conquer those future challenges. Take care and do hope you find all the answers you need from this community and your support system.

[Pcnet in reply to Eyak1971]

You mentioned a booklet to identify costs and payments. I have the Medicare and You book and don’t see anything in there related to costs and payments. Is there a different book you are referring to?

You mentioned traditional Medicare paid for testing for the first 3 years with no questions. Was that for ALL your labs, including viral studies? What frequency? When was this year wise? Was it Medicare and the supplement that paid? I don’t know why all the EOBs I got said the services were not covered.

I appreciate your info on advantage plans.

Who is the subcontractor that Medicare contracts with to investigate if receiving subpar medical services?

Our transplant center is not a helpful resource, unfortunately. The social worker told me I could withdraw the Medicare application (and just keep our group health plan) - but I explained to her if we did withdraw app, our group health plan when secondary would only pay as if we still had medicare - and she also recommended a fundraising group…those were her solutions.

Again, thank you for all your feedback and kind words. Much appreciated.

[Darlenia]

My hubby, an retired health insurance broker, is also a transplant recipient. I gave him your question re your son and supplemental plans. He answered that this is a complex subject. If possible, keep your son on your plan - that can be done until he's 25 years old since there is a required waiting period for those "on disability" to be on Medicare for two years before further steps can be taken. He added that there may be additional options if can get your son on Medicaid and Medicare (combined) - there is something known as "special needs advantage plans" for certain conditions that qualify. He urges you to call medicare.gov/talk-to-someone for direction and referrals. You can also discuss the matter with the transplant center for their suggestions. By the way, my hubby is on Medicare Parts A, B, D and also the AARP United supplemental plan - total cost runs around $500/mo. For him, it's been a good combination. He has paid nothing in the 2+ years other than prescription meds for insulin which runs around $1K a year. It's interesting in that particular plan is nationwide - many are not. Hope you find direction soon.

[Pcnet in reply to Darlenia]

Thank you for the information. Complex is a good way to describe it. He’s been on Medicare as secondary since Aug 1, 2021, qualifying under his ESRD diagnosis and with my SS credits because of his age. He is ending the 30 month coordination period and Medicare becomes primary and group health second. Unfortunately, group health plan is 2400/mo, our share, for my husband, me and my son. Not sure we can sustain that much longer and probably will go up in June when renews. My husband is only employee and it’s underwritten. It’s crazy. My son is in college and I contemplated getting plan from them but would need to withdraw Medicare application and cancel group health, so school could be primary. The deadline to add is tomorrow for college so not sure if that would work. Can you ask your husband his thoughts on that? Thank you for the other information regarding supplement and what your husband has. Because of my son’s age and being in Ohio, I’m told we cannot get supplement. So at the moment our group health will be secondary as of February. I appreciate the info about contacting Medicare about special needs plan. Our transplant center has not been helpful. Thanks again.

[Pcnet in reply to Darlenia]

Would you also please ask your husband what labs he gets, including viral studies, the frequency, and if they are all covered with his A, B, D and supplement, and the breakdown on charges between Medicare and supplemental, approximately. Thank you.

[Darlenia]

My hubby says please do not switch your son to a student medical plan - the college plans are "band-aid" plans only. He recommends asking your current group carrier if you might be able to alter the plan choice within their "family of plans" to achieve a lower price point. This could mean a higher deductible, coinsurance, etc. The situation here is that you have a one-person business - as such, ACA law stipulates that one-person group plans are only issuable between Nov 15 and Dec 15 yearly for a January 1 effective date. You could wait until the next renewal cycle in 2024 to look at a different carrier - unless, of course, your current carrier is willing to work with you to lower costs. Hang in there, maybe your current carrier will do that. Hubby also says your next best option is to seek a special needs plan if your current carrier refuses to work with you. Hubby added that besides Medicare, Humana and United Healthcare may be able to address that with you and arrange that special needs plan. Hopefully this gives you a bit of direction. Hubby is located in Virginia and is licensed to work with individual and group health plans but not in Ohio. He wishes you the best.

[Pcnet in reply to Darlenia]

Thank you for the information. The college plan is underwritten by United Healthcare and is a gold tier. Premium is 1250 for 6 months, so much more reasonable than current plan. It does say on cover page “not a Medicare supplement plan.” The college has @50,000 students. Would that change hubby’s mind about a band-aid plan? And the reason I’m asking is because if he thought it could work short term, because my son is technically insured with 2 entities, Medicare and group health, I would have to explain to United college plan I’m in process of withdrawing Medicare app and canceling group health, if that’s feasible to be in the process and get their coverage in the meantime.

My husband has an alternative potential job opportunity but has to work 300 hours at company before eligible for insurance. There’s a lot more employees at potential new company so not medically underwritten. Can’t go on COBRA at current company because only one employee. So my thought process was if college plan could carry him for next 6 months - while working out withdrawal of Medicare application and canceling current group health plan - my husband would have a little time to switch companies. It would also mean my husband and I would have to go on Marketplace plan until he would switch companies and get other insurance.

As for asking current carrier to alter plan choice if possible, our current plan has a 5K deductible per person, 10K family, then everything covered 100 percent. Not sure how much more it could increase but worth asking I suppose, keeping in mind and factoring in our huge 2400/month premium.

And suggestion about Humana and United Healthcare for a special needs plan, is that through Medicaid, if my son qualifies, or just through the private companies?

Would he have any referral for someone in Ohio, given the fact he knows what the plans need to have transplant-wise?

Thanks to you and your hubby for all the info, much appreciated.

[Darlenia in reply to Pcnet]

Hubby says to get hold of that college plan and look through it very carefully. My hubby managed to find the United Health Plan available at Ohio State University. (Premium is $1121 for Jan 1 to May 11). There are deductibles and copays and coinsurance but no dollar limit on covered care in that particular plan. Students on that plan use their Ohio State University clinic with protocols/referrals required to go elsewhere. So check the college plan you're interested in against the one you have now - perhaps the premium required for the college plan is equivalent to the portion you're paying for him on your plan now. Depending on your findings, hubby says it might be best that your husband keeps his current plan in place (while negotiating to keep the rate the same or lower) while transitioning into his new job and enduring the waiting period for coverage with another plan there. With regard to your son, hubby says to simply call both Humana and United Healthcare and ask what your son needs to have on hand (e.g. Medicare/Medicaid) to qualify for their special needs plans. They will give you the steps. For a broker in Ohio, he suggests getting a referral directly from Medicare or from the Ohio Association of Health Underwriters. (He isn't in touch with anyone in your state.) Medical insurance is truly a complicated maize to navigate. He hopes you find a great person near you to lead you to a great solution. Thankfully, my hubby hasn't had any problem getting all his labs and visits completely covered by Medicare and/or his United supplemental plan. (He's been in and out different hospitals since the transplant.) To date, since all has gone as expected, he hasn't bothered keeping a spreadsheet.

[Pcnet in reply to Darlenia]

Thank you again for all the info. The college is University of Cincinnati, if your husband is able to take a look at that one and weigh in, I would appreciate it.

[Darlenia in reply to Pcnet]

Oh! That's a large university with a medical school. Call their insurance advisory office and ask if they will provide supportive services for your son if he goes on their plan - for transplant follow ups, for possible complications, etc. Best to address this directly with them. That should give you direction!

[Tashikat]

its been awhile gor me….but Medicare did cover my labs when they were primary for me. You can get an individual plan. I heard more than one that advantage plans have poor coverage. Research them thoroughly. All the best. .

[WYOAnne NKF Ambassador]

Talk to the social worker at your transplant center. That is her job to help you with insurance issues after a transplant.

[Pcnet in reply to WYOAnne]

Unfortunately, she’s the one that guided me into signing up for Medicare when our group health plan was adequate. Now she says I can withdraw my application - just stay on group health plan - but group health plans says no, they will only pay when secondary as if I still had Medicare. And she also gave me a fundraising group recommendation. Those were her solutions. Not really too helpful.

[Eyak1971]

Looks like you are getting plenty of advice. We were all overwhelmed at first and it takes time to find what works for you. When I was working medicare was my secondary for a short time while on dialysis and then it became my primary. At that point I bought a supplement and a part d. Keep in mind these 2 facts. Medicare sets the price of service so when you see a bill the actual payment is far below the billing and most supplement plans provide similar coverage with similar fees because they are paying far less due to the medicare discount. And lastly the phone number for the company that subcontracts for medicare to keep track that services provided by providers is medically on the up and up is 8009904522 or livanta helpline 8722648402. My kidney center subcontracts with a company that provides patient support. I will get the info. And post it later. I agree with others your center should be more helpful. This is a problem your son is going to have to solve when he becomes independent. He will have to grow up fast. Thankfully you will be there. If he were on ssi it would make it simpler. My medicare payments come out of my social security check which many people do not realize. It is not free . And before I forget if your doctor orders any test or procedure it is usually covered by traditional medicare. I can not say thr same about advantage programs.

[Eyak1971]

evergreennephrology.com/

[Bax509]

I second others' suggestions to find an insurance broker - will save you lots of time and energy!

[Oceansideup]

You may be able to get some information from your local SHIP program with any questions related to Medicare for your final 6 months The State Health Insurance Assistance Program in Ohio lists their # as 800 686 1578.

Most states have some form of this program which counsels people regarding their Medicare choices. I live in NC and talking to a SHIP counselor was helpful to me. . .