I am writing this seek some guidance regarding dealing with the insurance. My wife was diagnosed ESRD in 2021. She want on disability for sometime and went back to work while doing PD at home. She had insurance through her employer. SSA enrolled her in Medicare part A and part B. Since she had insurance through her employer, we declined Medicare part B because we did not want to pay premium for two insurances. She had transplant in November. Neither of the insurance is will to pay the bill now. Her work insurance says that she should be on Medicare part B and Medicare should pay for it. Medicare will not pay because she is not enrolled in part B. They would not backdate Medicare part B. If anyone has to deal with this kind of situation, please advise. We are not getting anywhere with her employer insurance and Medicare.
Thank you in advance for your help.
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vijku
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I hope that someone here has had a better experience or has a solution and I hope that I'm wrong.
I have had a similar experience with my employer's insurance (United Healthcare). I even filed a complaint with the California Dept of Insurance and they told me that this is the way it works. I consulted with an attorney and they pointed out that after 36 months, Medicare Part B becomes primary and if you opted out, the insurance company doesn't have to pay as primary. It's a well intended law that was apparently passed to protect ESRD patients and to help the insurance industry with the high cost of dialysis.
I would have asked my employer to pay for my Part B premium instead of paying for United Healthcare, but I did not want my wife and son to be without insurance.
What dumb person would want to add a Part B premium when they get employer-paid insurance. Well that's how it was written, and United Healthcare and other unscrupulous and dishonorable insurance companies are taking advantage of this legal loop. I feel your pain, and I truly wish you the best.
Thank you for your response. You understood our situation perfectly. I was thinking of seeking legal help but it seems like that will be of no use and it will add legal costs on top of medical costs. It seems that it is in the hands of the person who you deal with at you local SSA office and they can backdate it. In fact, for my wife, one of the SSA representative did back date but another representative took over and canceled it. It is so difficult to deal with SSA office.
part a needs to be in place at the time of transplant. It will cost share with the private insurance for the transplant and then be secondary for 30 months. Then in months 30-36 part b will become primary (so you have to have it then) and your private insurance will become secondary. After month 36 you’re back to private insurance and you don’t need part b (or part a really) any more.
Agree. I am surprised that the posters transplant center did not provide this information while on pd. Maybe the founders on this forum can periodically post financial info. For its followers. I know there are posters from other countries who could probably care less because their governments have a different health care system and probably take delight in our frustration with ours.
Thank you both! The PD center did not tell us about this legal loophole and they we should not decline part B. Unfortunately, my wife and I cannot play blame game here because there isn't any documentary evidence to prove one thing or other. When a person is going through such life changing illness, they expect us to also do all the research and identify all the legal loopholes. It is unfortunate.
Keep that idea in mind as you and your spouse travel through your medical experience as well. There are medical professionals who think they have all the answers but do not spend time talking with you to prepare you for medical treatments. More than once, I have been prescribed medication that was in conflict with other medications and treatment that was generic and not fit my needs. One of the things most often in this forum is to be your best advocate. There was a study done with ai that compared multiple ophthalmologist as to their treatment plans. And only one surpassed ai who stored all the information available. Doctors like everyone in any occupation are limited in knowledge and sometimes experience. Do your research and get to know what every test means and how your medications function. The more you know, the healthier you will be.
Agreed, nobody informed me of this, and even my employer's insurance broker knew my situation and he did not say anything about this rule either. As Rupmh said, I'm anxiously waiting for my 36 month post transplant period to end (currently in month 19) to get rid of this problem. I agree with Eyak1971 that maybe this forum could help get the word out.
My transplant center told me my insurance was better than Medicare and I didn’t need it so I never signed up for it. Now I’m learning I may be penalized. Why should I pay for Medicare when mine is free? Also, why should we be using Medicare when we don’t need it and taking away benefits that could be saved since it’s already going bankrupt. Something needs to be done at the federal level about this.
Would suggest you do some research on why the medicare policy for transplant patients originated. Many patients would not be able to afford transplants if it was not for medicare. You may feel secure in your instance but if insrance is tied to employment it could easily be gone if there was a loss of job, particularly due to an accident or illness. And if you are self insured, consistent income falls in the same category. And more importantly you and others have paid for medicare and deserve to take advantage of the program which restricts what health providers can charge for services. Take a close look at your bills and compare payments by your insurance and medicare. There is a reason your transplant center feels your insurance is better than medicare. They get more profit. Do not forget we have a capitalistic health care system in US. Lastly medicare has financial problems for many reasons. Providing Healthcare for transplant patients is not one of them. Ask any retired person on medicare how many calls they get daily from agents pushing medicare advantage or medical equipment from braces to who knows what and you have the answer why medicare has financial problems. Added to this, medical facilities who provide sub par services which promote a constant revolving door of profit to solve a medical problem. There is a reason equity companies are taking over medical facilities. With any problem it's always about perspective. When you retire your perspective I bet will change.
As I said before it takes perspective. Your anger will pass as you age and have a clearer idea how important the benefit of many outways the personal profit of one. I learned this in the military and time and again in every job I had. Money's you feel you have lost will come back to you in time of need.
Understand your frustration. But put your concentration on your transplant. You will face many obstacles at times beyond your control. But always put your health first. All others create stress and that is not good for your health. It is ok to complain about the financial unfairness but there are so many people on this forum who feel that getting a transplant is the most important concern they have. Put the serenity prayer on your night stand and read it regularly.
I don’t know what you are talking about. I am greatful for my transplant. Things can change and should when people aren’t informed about this situation. Stop berating me for no reason and think before you tell people off.
Please stop your defensiveness. Life is too short. Accept that you will not change the rules of Medicare and take this as a learning situation. I am sorry it was a financial costly lesson, but you are now informed, and your story informs others, which is what this forum is about. Sharing our experiences and knowledge. Please take care.
Things change all the time and yes I will be contacting my congressman Yes it’s about sharing experiences, not telling off other people like you are. Stop responding to me because I don’t want to hear your nastiness.
Your wife has Medicare Part A which will cover the cost of the transplant, without Part B you may have issues covering doctors visits post transplant but her work insurance should cover those.
when my daughter who is under my insurance plan via employer had transplant, she signed up for both parts A and B. However, we were told that Medicare parts A and B will remain secondary for 30 months after transplant. The insurance provided via employer remained primary and paid all the transplant related expenses as well as all other medical expenses for the first 30 months. Now she is between 30 and 36 months. So the switch has happened and Medicare is primary. We’re finding it hard now between the 30 to 36 month period because Medicare and anthem BCBS keep rejecting lab work claims. Is your employer sponsored insurance not covering the transplant related expenses because there is clause in their fine print that somehow excludes it? Wish health insurance was a simpler standard process. Good luck to you.
Hi Dakshina, The employer sponsored insurance (Anthem) does not have any fine print anywhere in the policy. We read it multiple times. They are going by the Medicare rules. We are learning that it is mandatory for a person with ESRD to enroll in Medicare. We declined to enroll in part B because we didn't want to pay double premium. We didn't know that Anthem will refer to medicare law (which we were not aware of until it was too late) and use that loophole to decline the claims. Medicare part B can be backdated but it depends on the who you end up dealing with at your local social security office. They claim that not being aware is not a good enough reason. You need to know all the laws. Right...As if we don't have enough on our hands while dealing with such a medical condition.
I agree there needs to be more education on ESRD Medicare when you have an employer sponsored insurance plan. I had my insurance plan through work and put off enrolling in Medicare until my dialysis financial coordinator said I must enroll for it because it was “mandatory”. So I finally did. I too did not like paying two insurance premiums so I ended up downgrading my work insurance to the most elementary plan and paid Medicare until my 36 months after transplant ended. What I am now realizing is how much money I was saving having both plans. There were no copays. I paid a few dollars for prescriptions. Office visit costs were low. Right after my Medicare ended I realized just how much I had saved with Medicare. I upgraded my insurance because I knew my Medicare was ending last year but it’s still not enough coverage. I am now having to pay co-pays and office visits at 20% and it adds up. I think I would have gladly kept paying for Medicare.
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