IVIG and insurance

Hi Jersey Shore! I too am on Medicare with Disability! I know when my husband had me on his insurance at work a few years back that they would pay 80 percent and then Medicare picked up the tab. Most of my bills got covered 100 percent. But most of the time I was seeing a doctor and not a hospital. I know there is a deductible for Inpatient and some Out Patient Care if it is a Hospital Type Facility and every now and then I would be stuck paying a bill but it was never that much. But Medicare does have a deductible.
Now I am on Humana Medicare and on the RX plan they have. I do the Mail Order for my scripts. And have to get approval for any drugs that are high cost. They denied me one medication because the cost was over $400.00 a month and said I could go generic. The doctor then had to call in a diagnoses and why I need this medication. Then I got approved. If I go over the Out of Pocket expenses of $5000.00 then they call it Castrophic and they cover 100 percent of my drugs. There is a loop hole in that too! Stage 1 you pay the Co Pays. Stage 2 you pay 100 percent until you reach Castrophic and then they pay 100 percent.
I do know that Medicare has a deductible and you have to meet that deductible first before they start covering things. Not sure what type of Medicare you have because they changed things when Bush was in Office. Medicare when I first got on did not cover Medications and I had to pay out of pocket for them which was costly. Then they offered the RX Prescription Drug plan which I got into! I have noticed though when I have been in the hospital that Medicare has not covered the drugs they used to treat me with. And got stuck having to pay for them. So I think they changed some rules there. Humana did cover my Rituxan but I had to go to a facility that was a provider and get approval. But that is because I have the Humana Medicare. I had to pay $23.00 extra a month for that service.
My best advice is to call Medicare personally and ask them why and what they would best suggest to get these infusions covered. Tell them you have a Primaryand that Medicare is considered Secondary! See what they would suggest. Also call your BCBS and see what they suggest. Find out what you have to do to get these infusions covered 100 percent. They might know the loop hole and give you the best advice and then have the bills resubmitted. I know when my father took ill and had to be transported by ambulance they refused to cover the bill because they claimed it was not life threatening. My father had a bleed on his brain and that was not life threatening! HELLO! We called his Insurance and they told my mother what to do and she had to get a doctors note to the Insurance claiming my father was in a life threatening state. You may have to do something simular. Call each one and get the facts first and then go from there but make sure you talk to somebody there that has alot of experience like a supervisor that knows the ropes very well!
There may be a loophole around this! I wish you the best of luck here and hope things work out for you! Even let your doctor know the problem. They too might be able to call the drug company that offers your treatment and get you on the Infusions at no charge. Find out those loop holes for their may be some you can use. Hope this helps! Good luck Jersey Shore!
Linda H

Hi Jersey Shore

My experience is a little different. I only have part A, so when I have a hospital bill, the hospital bills medicare first as primary, then my private coverage under my wife’s employer covers 80 % of the co-pays, so I end up only owing a few dollars. The hospital I use is on my wife’s plan network, so whaterver they reduce the bill to is what the hospital must accept. This only applies to “in-patient” services, so it may not help you. Good luck,
Fred

I don’t really know how to navigate through Medicare.

I wanted to recommend you contact the GBS/CIDP Foundation to see if they had any info for you. I’m sure they could point you in the right direction.

I know IG Living magazine has done quite a few articles on Medicare. If you don’t already receive it then you might want to sign up. It’s free & a very good read.

Kelly

Hi Jersey! Make sure when you send everything back in to add a doctors statement that tells them this treatment is medically necessary in order for you to get well. Giving them the diagnoses of why you need this treatment and without it you will become much sicker needing hospital cares and more expenses will then occur!
Bad thing about Medicare. No telling what they have hired there! Could be some Jo Smo that has no knowledge of what CIDP is and might see it as not being covered when it actually might be! So when they look up the reference in the computer they might not even have this disease listed. Causing it to be thrown out as not being covered my Medicare.
I sure hope things work! Let them send he bills and keep bugging you. Don’t let this worry you. Send them 5 dollars a month and say this is all you can pay right now! They can’t harrass you if you send in at least a small payment! I incurred $4000.00 this year alone in medical bills and only pay them what I can! Take it or leave it is what I say! They take it and don’t bother me! Me and my husband though do pay more than $5.00. We pay $200.00 a month. I get the bills down to 1800 and then here comes more! So I never really get caught up. Hugs
Linda H

[QUOTE=Jersey Shore]I’m just wondering if someone on this forum has experience with insurance and Medicare. I had 5 months of IVIG at an outpatient infusion center in a hospital. B/C B/S is my primary and paid their 80%. Medicare wants to pay nothing and leave me with the rest. [/QUOTE]

Medicare should be your primary. The hospital should send the bill to them and nothing to the secondary. Medicare in turn coordinates with the secondary. This is how it worked for me for several years for IVIG without a glitch.

When I have Medicare as my primary insurance they covered 80% for the IVIG under Part B at my neuro’s clinic. The rest was automatically rolled over to my secondary BCBS.
Then 3 years ago Medicare changed their policies. I looked into Part D coverages but decided to keep my State Employees benefits. BCBS benefits pays my IVIG 100% till July 1, 2009. After that date I’ll pay a co-pay that it will be over $ 5,000.00 a year.
Every time you talk to someone get their name, phone number/extension and job title for documentation. This helps when calling back. I wrote dozens of letters and many many phone calls about coverages.Finally got someone who had a clue.
Navigating the system is time consuming and a royal pain. Hospitals write off so much.
It’s true if you pay a small amount. This shows intent to pay and hope will keep credit companies from calling you..
Can your physician’s office help? Your doctor had to write the prescription order for you to receive the IVIG originally.
Good luck.

Medicare wont act as a secondary. Flip BC/BS as your secondary or if they wont do it try to drop them – use Medicare as your primary and apply for medicaid- they will act as a secondary. Pick a part D provider for Medicare and you’re good.

Medicare’s premiums are likely cheaper than your BCBS.

If you do home infusions through Accredo and can’t afford that 20% you can apply for their assistance plan. I had $4000 or so I owed from before I switched to medicare and medicaid and they erased it. I love Accredo.

If you are eligible for Medicaid they will pay those hospital bills retroactively. It all depends on your income though.

If I had a million dollars when I started treatment in 05 I’d be broke now and on Medicaid anyway. Funny.

First of all, do you work or do you have a working spouse and that is why your commerical is primary? If you are not working and you do not have a working spouse and you are 65 and over then medicare would be your primary. There are a lot of regulations re this. Medicare DOES act as a secondary but it is really complicated. IF we get the above straightened out as to who is really primary then we can deal with the next thing and that is if you commercial IS primary, then the outpatient clinic is mandated to take your commericals payment in full and they are not allowed to bill you!!!!!
You cannot chose who is going to be primary and who is secondary, unfortunately. I agree that things would be better if medicare was primary because your bills would be smaller to begin with.
Secondly, we need to talk about apples and apples. Medicare D is a program just for medications and really is not pertinent here because you said that you received txs at a clinic and not at home. I believe your ivig then falls under your medical plan and has nothing to do with medicare D. You do not by any small chance have a medicare HMO do you? These are tricky and rare. I assumer you have traditional medicare A and B. I sure do not know a whole lot about cidp but I do know about this stuff!!! Ha!