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  1. #21
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    Quote Originally Posted by Rich Berkowitz View Post
    Wendy's situation raises an interesting question. If a person becomes CKD5 after Ocrober 14, 2008 when the new Conditions for Coverage (CFC) came into effect and they were supposed to be informed of all options, what if s/he isn't?
    It sounds like NKC informed Wendy of her options. She knew HHD was an option. NKC must have a policy that won't allow a patient with a catheter to do HHD. Facilities can set policies for what they believe offers safe and effective treatment. Other facilities may have different policies. If patients want something their facility doesn't offer, they have the right to change to a different facility and their original facility is supposed to provide information to help them do that.

    NKC and some DaVita clinics offer more frequent dialysis treatments. They can and probably do bill the EGHP for each treatment the patient receives. This can nearly double the cost of dialysis from in-center dialysis which is done 3 times a week. Medicare will only routinely pay for 3 treatments so even with Medicare, a patient could have higher charges for more frequent treatments. However, the more frequent treatments could save money in the long run on hospital bills which can be much higher than dialysis charges.

    Quote Originally Posted by Rich Berkowitz View Post
    If one goes directly to a home modality, Medicare kicks in immediately without the necessity of going through the coordination of benefits period.
    Sadly, this is not true. The coordination of benefits period applies to anyone with an employer group health plan no matter what type of dialysis the patient chooses to do. The difference in treatment type makes a difference when Medicare can start as a secondary payer saving the patient 3 months of EGHP primary payments. Medicare secondary payer does NOT apply to individual plans that are not sponsored or contributed to by an employer.

    Quote Originally Posted by Rich Berkowitz View Post
    Wendy's concern of attaining her lifetime benefits with her insurance is very real. Many policies have what seems to be a high limit even a couple million dollars. One would be surprised how quickly they can reach that number. This becomes even more possible if the coordination of coverage period gets extended yet another reason for universal coverage.
    IMO, extension of Medicare secondary payer would temporarily help facilities but harm patients because it would exhaust the lifetime benefits of more patients. If facilities do a good job taking care of patients and they do well on dialysis, in the long-run, facilities will lose out if their patients exhaust their lifetime benefits.
    Beth Witten MSW ACSW LSCSW
    Medical Education Institute, Inc.

  2. #22
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    Quote Originally Posted by Beth Witten MSW ACSW View Post
    Sadly, this is not true. The coordination of benefits period applies to anyone with an employer group health plan no matter what type of dialysis the patient chooses to do. The difference in treatment type makes a difference when Medicare can start as a secondary payer saving the patient 3 months of EGHP primary payments. Medicare secondary payer does NOT apply to individual plans that are not sponsored or contributed to by an employer.
    Thanks Beth, I somehow get starting initially with home dialysis confused with transplantation. I won't make this mistake again.

  3. #23
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    Beth,
    Thank you for your suggestions which I will follow up on.
    I also had a thought...Does anyone know in the event that my insurance company denies payment for home dialyis, could I switch to Medicare who does cover home dialysis or will I be forced back into in-center or forced to cover the bill for home dialysis myself.

    I also wonder if I could opt out of my husband's employer insurance and then move over to Medicare with the option of opting back in to the employer insurance after the 30-month coordination period. I guess that's a question for my insurance company.

    There's something morally wrong with all this.

  4. #24
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    Quote Originally Posted by Wendy Ramsay View Post
    Does anyone know in the event that my insurance company denies payment for home dialyis, could I switch to Medicare who does cover home dialysis or will I be forced back into in-center or forced to cover the bill for home dialysis myself.
    Your insurance company will pay for home, one way or another--I'd be willing to bet on it.

    You don't have the option to "switch" to Medicare as a primary payer--it's the LAW that you are required to be covered by your EGHP (if you have one) for the first 30 months. You don't get to opt in and out in that way. It's not up to you.

    You DO get to decide if you want to "accept" Medicare when you are eligible for it. Part A (hospitalization) is free. Part B (outpatient services including dialysis) has a premium. Never take Part A without Part B. Doing so can cause all sorts of problems down the road. Accepting Medicare reduces the amount you would need to pay out-of-pocket because dialysis providers can't charge as much to your health plan (which may not cover everything) when Medicare is in place. Most likely, you would save enough to more than make up for the premium for Part B.

    I also wonder if I could opt out of my husband's employer insurance and then move over to Medicare with the option of opting back in to the employer insurance after the 30-month coordination period.
    Sorry, Wendy, but I would strongly recommend against that. The chances that your EGHP would let you back in with the preexisting conditions of cancer + ESRD are basically zero. So, you could quit your job, go on disability, and become Medicare primary--but it doesn't help you to do this. You'd lose the EGHP completely and be Medicare-only, which then makes you much LESS attractive to dialysis providers and other cancer care providers, because Medicare pays less. [EDIT]Oops, it's your husband who carries the policy. Be careful: some employers have managed to force out employees whose care (or loved one's care) is very costly. If "opting out" is an option for him, again--I would strongly recommend against doing it. Opting "back in" will not be an option down the road.

    Is there something wrong with this system? YES! IMHO, medicine for profit and inserting insurance companies between people and their healthcare is an unworkable model. For more on why, see this thread: http://forums.homedialysis.org/showthread.php?t=1998.
    Last edited by Dori Schatell; March 15, 2009 at 09:12 PM.

  5. #25
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    Quote Originally Posted by Dori Schatell View Post
    You DO get to decide if you want to "accept" Medicare when you are eligible for it. Part A (hospitalization) is free. Part B (outpatient services including dialysis) has a premium. Never take Part A without Part B. Doing so can cause all sorts of problems down the road. Accepting Medicare reduces the amount you would need to pay out-of-pocket because dialysis providers can't charge as much to your health plan (which may not cover everything) when Medicare is in place. Most likely, you would save enough to more than make up for the premium for Part B.
    Hmm. Apparently I got Part A back in September after surgery. I vaguely remember filling out forms in the haze of pain meds. I did not get Part B because I have 100% coverage with no premium through our EGHP. Accepting Medicare won't reduce my out-of-pocket because I have 100% coverage no with zero out-of-pocket. Accepting Medicare will increase my out of pocket with the premiums, deductible and 20% copay - none of which I have now. Are you saying that if I accepted Medicare today with my 100%, zero out-of-pocket EGHP, that the dialysis unit could no longer charge my EGHP $45,000/month? They would be forced to charge less even while my EGHP is the primary? If so, paying the extra out-of-pocket for Medicare may be worth it.

    Medicare also states that there is no penalty for not taking Part B if I have an EGHP in place. They suggested in their handbook that I may want to wait paying the Medicare premiums every month if I'm not using them while I have my no cost EGHP. What sort of problems are you thinking about that could arise down the road?


    Quote Originally Posted by Dori Schatell View Post
    So, you could quit your job, go on disability, and become Medicare primary--but it doesn't help you to do this. You'd lose the EGHP completely and be Medicare-only, which then makes you much LESS attractive to dialysis providers and other cancer care providers, because Medicare pays less.
    Losing my EGHP completely and being Medicare-only is EXACTLY what I am afraid of. In less than 12 months, I will exhaust my EGHP completely - Not because I opted out but because the dialysis centers have stolen it from me - almost $1 million worth. I'm new to all of this. How in God's name can an insurance company be forced to pay a $million in less than 2 years for dialysis when Medicare would have paid $33,000 for the same treatment during that same time period? Is there no cap on their charges to insurance companies at all?

    I don't expect you to keep answering all my questions. Obviously, I have more research to do. I just don't get it - especially the fact that there is some sort of law that makes this type of extortion mandatory. Seems as though we EGHP and private insurance people (minority) rake out the $billions for dialysis for the rest of the majority of the population on Medicare while being stripped of insurance for the other critical parts of our life and health. My husband has worked very hard for this coverage for his family for years. This coverage has kept me alive and winning the fight against bladder cancer for 15 years. I pray that Medicare will not change that.

  6. #26
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    Quote Originally Posted by Wendy Ramsay View Post
    Hmm. Apparently I got Part A back in September after surgery. I vaguely remember filling out forms in the haze of pain meds. I did not get Part B because I have 100% coverage with no premium through our EGHP. Accepting Medicare won't reduce my out-of-pocket because I have 100% coverage no with zero out-of-pocket. Accepting Medicare will increase my out of pocket with the premiums, deductible and 20% copay - none of which I have now. Are you saying that if I accepted Medicare today with my 100%, zero out-of-pocket EGHP, that the dialysis unit could no longer charge my EGHP $45,000/month? They would be forced to charge less even while my EGHP is the primary? If so, paying the extra out-of-pocket for Medicare may be worth it.
    First, even if you have Medicare, your dialysis clinic can charge your insurance company what it normally charges. If you had Part B, your dialysis clinic would not be able to charge you any deductibles or copays as long as your plan pays at least 100% of Medicare's allowable. If you don't have any of those cost-shares, you might not need Medicare at all. You may want to disenroll from Medicare Part A to avoid consequences that I describe in response to your next question.

    If you were not informed of the risks of taking Medicare Part A without Part B and if Medicare Part A hasn't paid any claims for you, ask to disenroll from Part A. NOTE: If you are on the transplant list, sign up for Part A and ask Social Security to make it effective the month of the transplant. This will protect your right to have Medicare Part B cover your anti-rejection drugs.

    Quote Originally Posted by Wendy Ramsay View Post
    Medicare also states that there is no penalty for not taking Part B if I have an EGHP in place. They suggested in their handbook that I may want to wait paying the Medicare premiums every month if I'm not using them while I have my no cost EGHP. What sort of problems are you thinking about that could arise down the road?
    The Medicare handbook (Medicare & You) is written for most of the people who have Medicare -- those with Medicare due to age or disability. It refers people with ESRD to a more specific booklet called Medicare Coverage for Dialysis and Transplant Services (Medicare Pub. 10128).
    http://www.medicare.gov/Publications/Pubs/pdf/10128.pdf

    If you had Medicare due to age or disability and did not have ESRD, you would have a "special enrollment period" to sign up for Part B any time you have an EGHP or when you lose it. The Social Security Act does not provide a "special enrollment period" for Part B if someone has ESRD.

    There are a number of problems that can occur when you take Part A and don't take Part B. Social Security representatives are supposed to describe these to people when they apply for Medicare Part A. Here are two common ones:
    -- Having Part A limits when you can sign up for Part B to January 1 -March 31 and Medicare Part B takes effect 7/1 of that year. You'll need to keep track of when your Medicare secondary payer period expires. Sign up for Medicare so it is in effect the July 1 before that date. Otherwise, you could have a gap if your insurance stops paying primary and you don't yet have Medicare Part B in place.
    -- If you don't sign up for Medicare Part B within 12 months of taking Part A, you'll pay 10% more in a premium penalty added to the premium you would have paid. This continues until you have another reason besides ESRD to have Medicare.
    -- If you forget to sign up for Part A in time to have it cover you for a transplant (within 12 months after the transplant), Medicare Part B will never cover your anti-rejection drugs. And according to the law, Medicare Part D couldn't pay for them either because Part B would cover them if you had it.

    Quote Originally Posted by Wendy Ramsay View Post
    Losing my EGHP completely and being Medicare-only is EXACTLY what I am afraid of. In less than 12 months, I will exhaust my EGHP completely - Not because I opted out but because the dialysis centers have stolen it from me - almost $1 million worth. I'm new to all of this. How in God's name can an insurance company be forced to pay a $million in less than 2 years for dialysis when Medicare would have paid $33,000 for the same treatment during that same time period? Is there no cap on their charges to insurance companies at all?
    Believe me, I can understand your frustration and anger. I can't imagine why your insurance company hasn't negotiated a cap on what it will pay your dialysis provider. Is the company small or self-insured? Are you going to an in-network or out-of-network provider?

    How often are you doing dialysis now - 3 or more treatments a week? What medicines do you get during dialysis? How much of the bill the dialysis clinic sends to the insurance company is for dialysis vs. how much is for dialysis-related drugs or other services. Conpare the amount for dialysis alone with about $1730 (100% of Medicare's allowable for 3 treatments a week).

    Quote Originally Posted by Wendy Ramsay View Post
    I don't expect you to keep answering all my questions. Obviously, I have more research to do. I just don't get it - especially the fact that there is some sort of law that makes this type of extortion mandatory. Seems as though we EGHP and private insurance people (minority) rake out the $billions for dialysis for the rest of the majority of the population on Medicare while being stripped of insurance for the other critical parts of our life and health. My husband has worked very hard for this coverage for his family for years. This coverage has kept me alive and winning the fight against bladder cancer for 15 years. I pray that Medicare will not change that.
    I wish people didn't have to live with the situation that you've described. Check into the Medigap option to see if you can buy it any time you want in spite of your pre-existing conditions.
    Beth Witten MSW ACSW LSCSW
    Medical Education Institute, Inc.

  7. #27
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    Quote Originally Posted by Beth Witten MSW ACSW View Post
    If you were not informed of the risks of taking Medicare Part A without Part B and if Medicare Part A hasn't paid any claims for you, ask to disenroll from Part A.

    If you had Medicare due to age or disability and did not have ESRD, you would have a "special enrollment period" to sign up for Part B any time you have an EGHP or when you lose it. The Social Security Act does not provide a "special enrollment period" for Part B if someone has ESRD.

    There are a number of problems that can occur when you take Part A and don't take Part B. Social Security representatives are supposed to describe these to people when they apply for Medicare Part A. Here are two common ones:
    -- Having Part A limits when you can sign up for Part B to January 1 -March 31 and Medicare Part B takes effect 7/1 of that year. You'll need to keep track of when your Medicare secondary payer period expires. Sign up for Medicare so it is in effect the July 1 before that date. Otherwise, you could have a gap if your insurance stops paying primary and you don't yet have Medicare Part B in place.
    -- If you don't sign up for Medicare Part B within 12 months of taking Part A, you'll pay 10% more in a premium penalty added to the premium you would have paid. This continues until you have another reason besides ESRD to have Medicare.

    Believe me, I can understand your frustration and anger. I can't imagine why your insurance company hasn't negotiated a cap on what it will pay your dialysis provider. Is the company small or self-insured? Are you going to an in-network or out-of-network provider?

    How often are you doing dialysis now - 3 or more treatments a week? What medicines do you get during dialysis? How much of the bill the dialysis clinic sends to the insurance company is for dialysis vs. how much is for dialysis-related drugs or other services. Conpare the amount for dialysis alone with about $1730 (100% of Medicare's allowable for 3 treatments a week).
    \


    I've discovered I have been charged $1600 per treatment (dialysis only) because the unit I was at is "out-of-network". I guess the other $35,000/month is all for meds? I'm not taking massive meds. If I had been told to go to the unit a couple miles away, I would have been charged in-network prices of $220 per treatment or $2640/month. When I called my insurance company to check on coverage before I started there, they said it was paid at100%. They did not say 100% of charges that are 7 times greater than if I had gone in-network down the street. As a matter of fact, my insurance company wasn't even aware of the in-network Federal Way unit until I informed them of it yesterday. When I asked the local Davita people (including their insurance 'specialist') why they didn't tell me of the in-network unit down the road, they said they didn't know either until a few days ago when all of this came to light and someone higher up in the company told them. They asked me how were they supposed to know? Hmmm.

    Davita said my insurance company won't contract with them. My insurance company says Davita refuses to contract with them. A patient relations team from my insurance company will be speaking with Davita to try to remedy this mess.

    As far a medicare, apparently, I got on medicare 2 years after claiming disability for my bladder cancer. I had part A Feb 2008. With my employer benefits, I am not penalized for not taking part B as long as I do so within 8 months of my employer benefits ending.

    We have Boeing Blue Cross Blue Shield - a huge insurance company and one that has been excellent always. I am dumbfounded by their stance on Home Dialysis refusing to cover it because it's investigational. They do pay for the Home Dialysis training. Go figure. In-center, I was at 4 x's a week. I wasn't getting heparing for low platelets and clotted every time after 3 hours. I also clotted my catheter (at the time) needing replacement twice. Blood pressures bottomed out also. So...more runs less time (3 hours). Training for home has been wonderful. Now on 15's and have increased flow and dialysate. I think it will make a big difference. When my 'training' is done, I suppose I will have to go back in-center? Just doesn't make any sense at all.

    I have asked Davita for itemized printouts for all my treatments since November.

  8. #28
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    Dialysis clinics only know what insurance companies they contract with. They would have no way of knowing what insurance companies other clinics contract with unless they called every clinic and unless those clinics shared that information with them. The staff at a particular clinic may not even know who their corporation contracts with unless an issue like yours arises. The one who was responsible for telling you who the network providers are is your BCBS plan. The fact that they didn't know is appalling!

    Does the in-network clinic offer home dialysis? Will your BCBS pay for home dialysis there? I still question whether the denial of BCBS coverage relates to frequency of dialysis or perhaps out-of-network provider. Northwest Kidney Centers is the oldest dialysis provider in the U.S. and has been doing conventional (3 times a week or every other day) home hemodialysis for more than 40 years in the northwest. It's really hard to believe that Boeing's BCBS plan denies coverage for home hemodialysis in Seattle where the Northwest Kidney Centers began training and following home hemodialysis patients in the 1960s. Boeing is a large employer in Seattle. Patients can do home hemo at night while they sleep 3 nights a week or every other day and report they feel better than doing 3-4 times a week in-center.

    You may have been told that since you already have Part A, you have 8 months to sign up for Part B without penalty. However, there are quirks in the Social Security regulations that do not allow people with ESRD to have a "special enrollment period" even if they also qualify for Medicare due to age or disability. Here's the policy from the Social Security that explains this. Some terms you'll need to know to read this include R-HI (Part A), R-SMI (Part B).

    F. POLICY — EFFECT OF MSP PROVISIONS ON FILING
    Because Medicare will not be paying full benefits in many cases where there is a group health insurance plan, some individuals may not wish to enroll in R-SMI when first eligible.

    It is important to remember that the special enrollment period (SEP) rules applicable to aged and disabled individuals do not apply to people entitled to R-HI. Therefore, it is extremely important to properly inform ESRD patients (including dual eligibles) who have GHP coverage about their options with respect to filing an application for R-HI. An individual may wish to:

    * File for both R-HI and R-SMI at initial R-HI eligibility even though Medicare can only make secondary payments until the end of the ESRD coordination period. With expenses as high as those for treatment of ESRD, an individual may consider secondary Medicare payments to be well worth the monthly SMI premium.

    * Defer filing for R-HI (and R-SMI) until the end of the ESRD coordination period. This will permit the individual to defer paying for SMI until Medicare becomes the primary payer of benefits.

    ESRD patients with GHP coverage should be discouraged from filing for R-HI while rejecting R-SMI at initial eligibility. Once R-SMI is refused, enrollment can only take place during a GEP, with coverage effective the following July. This will usually mean a gap in coverage between the end of primary payments by the GHP and the beginning of SMI in the month of July. It may also result in a premium surcharge for late enrollment. If an individual with GHP coverage files an application for R-HI in the mistaken belief that Medicare will be primary payer of benefits, the application may be withdrawn as provided for in HI 00801.197.


    https://secure.ssa.gov/apps10/poms.nsf/lnx/0600801247

    According to the Central Office of Medicare (Baltimore), once someone has ESRD (kidney failure), even if he/she had the right to a special enrollment period due to age or disability, that right no longer exists. However, ask your local Social Security office...not the 1-800-772-1213 helpline...about this policy. You definitely don't want to have a gap in primary coverage and the general enrollment period is from January 1 through March 31 each year with Medicare Part B becoming effective July 1 of that year.
    Last edited by Beth Witten MSW ACSW; March 20, 2009 at 01:53 PM.
    Beth Witten MSW ACSW LSCSW
    Medical Education Institute, Inc.

  9. #29
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    Quote Originally Posted by Wendy Ramsay View Post
    \
    I've discovered I have been charged $1600 per treatment (dialysis only) because the unit I was at is "out-of-network". I guess the other $35,000/month is all for meds? I'm not taking massive meds. If I had been told to go to the unit a couple miles away, I would have been charged in-network prices of $220 per treatment or $2640/month. When I called my insurance company to check on coverage before I started there, they said it was paid at100%. They did not say 100% of charges that are 7 times greater than if I had gone in-network down the street. As a matter of fact, my insurance company wasn't even aware of the in-network Federal Way unit until I informed them of it yesterday. When I asked the local Davita people (including their insurance 'specialist') why they didn't tell me of the in-network unit down the road, they said they didn't know either until a few days ago when all of this came to light and someone higher up in the company told them. They asked me how were they supposed to know? Hmmm.

    Davita said my insurance company won't contract with them. My insurance company says Davita refuses to contract with them. A patient relations team from my insurance company will be speaking with Davita to try to remedy this mess.
    I don't understand. How could your insurance company not know which center they have a contract with. From the moment any paperwork went in regardingaVita, BC/BS should have notified you.

    When my wife's EGHP changed from Humana to Cigna, I was told I had to move from one center (RCG) to another (Fresenius) because the center I was with would have been out-of-network. I appealed to no avail.

    What's ironic is that RCG's own EGHP for it's emplyees was with Cigna, which meant if any of their own employees needed dialysis they would have to treat elsewhere.

    Quote Originally Posted by Wendy Ramsay View Post
    \
    We have Boeing Blue Cross Blue Shield - a huge insurance company and one that has been excellent always. I am dumbfounded by their stance on Home Dialysis refusing to cover it because it's investigational. They do pay for the Home Dialysis training. Go figure. In-center, I was at 4 x's a week. I wasn't getting heparing for low platelets and clotted every time after 3 hours. I also clotted my catheter (at the time) needing replacement twice. Blood pressures bottomed out also. So...more runs less time (3 hours). Training for home has been wonderful. Now on 15's and have increased flow and dialysate. I think it will make a big difference. When my 'training' is done, I suppose I will have to go back in-center? Just doesn't make any sense at all.
    It's hard to believe BC/BS is saying home dialysis is investigational, especially since NxStage is FDA approved, Something's fishy.
    Last edited by Rich Berkowitz; March 20, 2009 at 03:45 PM.

  10. #30
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    If you need someone with an economics background, I am happy to help.

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