Hi, Beth,
This is a question for my friend. She is new transplant patient.
She has medicare a and b as primary and insurance from work as secondary. she has no medicare D. Her work insurance policy states that the insurance does not coordinate it’s prescription drug benifit with medicare Part B.She would like to know does it mean that she can only use medicare B alone or work insurance alone although medicare is primary, but not both ( medicare and work insurance) to purchase immunosuppression medicine? In such situation, she has to pay for either medicare’s copay or work insurance copay? Thanks
cath
I don’t have enough information to know if your friend’s Medicare is truly primary or secondary.
If someone has an employer group health plan, Medicare is secondary to that plan for the first 30 months the person is eligible for Medicare. If the person’s first treatment is a transplant, he/she would be eligible for Medicare the month of the transplant and in certain cases a couple of month before. If the person’s first treatment is dialysis, when Medicare eligibility starts depends on whether the patient chooses to do in-center dialysis or not. If so, Medicare eligibility starts the third full month of dialysis. If the person starts a home training program before the first day of the third full month of dialysis, Medicare eligibility starts the first of the month that dialysis started.
If her employer plan is her primary payer because she hasn’t been eligible for Medicare for 30 months yet, that plan would be responsible for paying for any covered drugs as long as she goes to a pharmacy on her plan. If that pharmacy accepts Medicare, it could bill Medicare second.
If Medicare is primary because she’s been eligible for Medicare for 30 months or longer and she has Part B, then I’d advise that she get her immunosuppressants from a specialty pharmacy that knows how to bill Medicare correctly for transplant drugs. Patients report that they have few problems with specialty pharmacies. Her transplant program should be able to tell your friend where most of their patients get their drugs under Medicare Part B.
If Medicare is primary, her employer plan would probably not want to be the primary payer for her immunosuppressants so she probably has no choice for which coverage to use for the transplant drugs. I’d recommend that she call the state insurance department and talk with a health insurance counselor to find out if state regulations allow employer group health plans to refuse to pay secondary to Medicare for Part B covered drugs.
Hi, Beth
Sorry for not give you enough information. My friend started dialysis in center January 2007 until the day she got a transplant. She had transplant Octorber 2011. She is eiligible for medicare based on ESRD only. We think having a transplant would not trigger a new COB.
IS it correct that her medicare should be continuing to be primary after her transplant?
Thank you very much for your help
cath
It sounds like she fulfilled the 30 month Medicare secondary payer period while she was on dialysis. Therefore, Medicare would be primary for the transplant too.
If her employer plan’s policy states that it will not pay anything on drugs for which Medicare Part B pays 80%, if paying 20% of those drugs will be a hardship, I’d suggest she talk with the transplant team about resources. One that I’m aware of that helps to pay insurance or copays for transplant recipients is the HealthWell Foundation:
This site has information about financing a transplant:
http://transplantliving.org/beforethetransplant/finance/finance.aspx
thank you Beth for your help.
cath