Insurance Trouble

Hello, my father had kidney failure about 3 years ago and is getting PD. He returned to work on partial disability and had insurance with his job as well as Medicare A & B. Last year he went on permanent disability and kept his work insurance through COBRA; however he dropped Medicare B because he could not afford it and didn’t think he needed it. Now the private insurance says they are not paying but 20% of his dialysis cost from 2004 until now because he should have kept Medicare. This was not in his benefits book from the company and no one from the clinic, Social Security Agency, or his insurance company has told him until now when he has amassed over $200,000 in charges. Has anyone else had problems or experience with this?

You can’t imagine how much I hate to hear about these situations. I don’t know what he was told. However, he should have been told that his insurance only had to be his primary payer for 30 months from when he first could get Medicare which would have been the first of the month he started PD unless he didn’t start PD training in the first 3 months.

He also should have been told that having Medicare, whether primary or secondary, limits how much a healthcare provider that can charge the patient. In most cases, commercial insurance pays at least what Medicare allows. If so, clinics can’t charge a patient anything. This can save the patient hundreds of dollars a month–which makes the Medicare premium look like a bargain.

I suspect that your father stopped paying premiums and that led to cancellation of his Part B. He should have gotten multiple notices from Social Security warning him that his benefits would be terminated. Does he remember getting these? Depending on how closely the billing department kept in touch with the clinic, it’s possible the clinic staff didn’t know that he didn’t have Part B. I’ve talked with social workers who were notified very late that someone had huge charges because they dropped Part B and their commercial insurance stopped paying primary.

When your father stopped working and took disability leave, he should have received notice about his COBRA rights and how long he’d be able to keep COBRA. This is at least 18 months. Since he is disabled, he should have been able to request extension of COBRA to 29 months. I don’t know if anyone told him this. If he wasn’t given this information about COBRA, he should call the Department of Labor.
http://www.dol.gov/ebsa/newsroom/fscobra.html

In the meantime, he might want to talk with Social Security to see if he can backpay overdue premiums for Part B o get his coverage reinstated as far back as possible to cover the dialysis charges his COBRA plan didn’t cover. I am not sure if their policy allows this, but it’s worth asking.

If someone from Social Security told him he could apply later when his commercial coverage went to secondary status and he can remember the person’s name, he could ask for “equitable relief” based on being ill advised by Social Security. Because he has kidney failure, he doesn’t have a special enrollment period that people that have Medicare due to age or disability have.