I’ve been here for two days and am still confused as to who is primary and who becomes secondary when dialysis kicks in.
First, I work full-time in Md and will more than likely go right into home hemodialysis training. I currently have BC/BS Open Access. As I will not be going to a clinic, do I assume, Medicare kicks in as primary and the BC/BS will become secondary?
Thanks again for all your assistance.
Hi Jo, and welcome! If you register, you will get an email notice when someone responds to your posts, which can be handy.
We have a free booklet that explains all of this pretty well, at: http://www.lifeoptions.org/catalog/pdfs/booklets/employment.pdf. In a nutshell, it works like this:
– If you have an employer group health plan (your BC/BS) in place when your kidneys fail, it is primary for the first 30 months. This is called the “Coordination of Benefits” (COB) period.
– Medicare is secondary during the COB period, and then becomes primary.
– Once Medicare is primary, it pays 80%, so it’s still best to have another plan.
– If you take Medicare as soon as you are eligible for it, it will limit the amount that dialysis providers can charge you. Part A (hospital care) is free; there is a premium for Part B (outpatient care including dialysis). But you can save much, much more than you might pay–not necessarily even in out-of-pocket expenses, but in how fast your lifetime BC/BS coverage is used up… Don’t take Part A without Part B just because A is free; it can have some bad effects down the road that cost you more.
Beth can no doubt add to this.
Dori:
I read somewhere on this post, that if you go right into a home hemo training facility, NOT A CLINIC, when you start dialysis that you can CHOOSE medicare first and make the employer insurance secondary. Per the post, it stated that you do not have to go through the Coordination of Benefits - you can start Medicare right away as your primary. I believe it was a gentleman by the Rich that stated this - he’s a regular posted here.
Dori:
Here is the post I cut and paste out of what I thought I was reading into:
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? If one goes directly to a home modality, Medicare kicks in immediately without the necessity of going through the coordination of benefits period.
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.
NxStage 2/06
In-Center 3/03
Rich Berkowitz
This is what I thought I was reading that if you go into a home hemo training facility (not a clinic), such as Northwest Home in Woodlawn, MD, (this is not a clinic), you could apply for Medicare immediately, and then have my BCBS as secondary. Can you confirm this?
I may have misspoken. If one has Employer Group Health Policy, the Coordination of Benefits period apparently starts and one would have to wait 30 months instead of 33 months before Medicare becomes primary.
Nope. If you have no other insurance, the benefit to going home instead of doing in-center is that Medicare will kick in right away instead of after 3 months. But if you DO have an employer group health plan, you do NOT have the option of having Medicare be primary until after the COB is done. That’s the law.
Thanks guys for the clarification. Now I have to sit down and find out what my maxiumum is on the health insurance. I don’t think the Employer is gonna like this conversation. Thanks all again for the clarification.
As Dori said, when you have an employer group health plan, Medicare pays second for the first 30 months you’re eligible for Medicare (whether you take Medicare or not). For a patient who chooses to be trained before the 1st day of his/her third full month of dialysis, the clock starts the first of the month dialysis starts. For an in-center patient, the clock starts the first day of the 3rd full month of dialysis. Doing home dialysis means your employer plan would not be primary as long.
I recently read that a GA court allowed Blue Cross Blue Shield to cut its reimbursement to an out-of-network dialysis provider 88% because it determined those charges were “excessive.” The clinic was charging BCBS $2,000 for each dialysis treatment alone, not counting drugs or other charges. BTW, Medicare’s average allowable per dialysis treatment is around $134 nationally (varies some across the country). In spite of this reimbursement cut, the dialysis facility still makes over $100 more than what Medicare allows on average per dialysis treatment and the court noted that it was still making more than it would from Medicare.
So…The plan pays 12% of the facility’s customary charge per treatment. Because the plan limits it’s payment, this means that the patient’s lifetime benefit is reduced significantly less each month.
This is where having Part B as a secondary payer could save you money. If the dialysis provider wanted to bill patients the difference between $240 and $2000 per treatment and if a patient has Medicare Part B, a dialysis facility that accepts Medicare assignment (all do) is prohibited by Medicare from billing the patient anything if the insurance plan pays at least 100% of Medicare’s allowable charge, which BCBS is still doing.
This happened in GA, but I have heard that some insurance companies have started reviewing dialysis charges and reducing their payment for dialysis to closer to Medicare’s allowable.
I just read this thread and have another question. Dori said:
“-- If you take Medicare as soon as you are eligible for it, it will limit the amount that dialysis providers can charge you. Part A (hospital care) is free; there is a premium for Part B (outpatient care including dialysis). But you can save much, much more than you might pay–not necessarily even in out-of-pocket expenses, but in how fast your lifetime BC/BS coverage is used up… Don’t take Part A without Part B just because A is free; it can have some bad effects down the road that cost you more.”
I found out I got Medicare part A in Jan 2008 with disability related to metastatic cancer not kidney disease. I wasn’t even aware of this until the past month or so. During the months I was being charged $1500 per dialysis session (since last October) should those charges have been limited because I had Medicare even though I was and still am in the coordination period? I did not inform anyone that I also had medicare because I wasn’t aware of it myself and then I probably wouldn’t have thought it was important because my insurance pays 100%. Could it be possible that my insurance could file to recover some of those charges?
Also, the story about BCBS taking a provider to court to reduce their charges is very interesting. Although my insurance seems to care less that I am saving them $22,000 a month, maybe I should pursue some formal action to recover $130,000+ back onto my lifetime max.
You must have Medicare Part B to limit what your dialysis facility can charge YOU. Having Part B doesn’t limit what the dialysis facility can charge your insurance company.
If you’re considering legal action, one question would be whether you could get your insurance company reimbursed for payments it made since 1) those happened in the past before any court decision could be rendered and 2) the insurance company isn’t objecting. That would be something to discuss with a lawyer. Also discuss whether you as the insured (and injured party…due to the loss of a larger than necessary portion of your lifetime benefits) have “standing” if your insurance company doesn’t care. It might be something to discuss with your insurance company to at least protect future patients from “unreasonable” charges.
Beth, you make some interesting points. I’m not an attorney, at least professionally. But always thought of myself as a pseudo-lawyer – enought to get me in trouble, But it stands to reason that a dialyzor would have cause to sue. 1) lifetime benefits are diminished with higher and unreasonable charges to their insurance. 2) Subsequent insurance costs will undoubtably be charged to the EGHP, which one would have to bear part of. A good attorney could make a caso of about anything and this wouldn’t be an exception.
We don’t tend to be big fans of lawsuits in general, Rich, but the challenge is generally to get an attorney to take on a case on a contingency basis (where they are paid from the proceeds IF there is a win). A case has to be pretty much a sure thing for that to happen, and there are very few sure things in life. If an attorney won’t take a case on a contingency basis, then someone has to pay the fees–and at $200/hour, even a SIMPLE case can cost $10-20K. Most folks don’t have that to spend.