Author Topic: Medicare  (Read 13142 times)

ellieas

  • Full Member
  • ***
  • Posts: 154
Medicare
« on: June 23, 2014, 05:45:37 PM »
Hi-when I was first diagnosed, 4 years ago, I was still working and my insurance covered everything but the co-pay. Now, I have retired, not on disability and have Medicare and a very good supplement insurance. I am now in a new area and found a doctor who only does Sjogrens. It is a University hospital group. I use this center for oncology and all my other doctors. They always take my insurance cards and I have had no problems. When I got this appt.--for October- they said bring your insurance card too because Medicare doesn't really pay. Has anyone else had this problem? When I searched for all rheumys in the area for Medicare, nothing came up. But, many people over 65 have arthritis conditions.They must have medicare.

Any thoughts on this?
Thank you
Lesley
sjogrens dx'd 2010, non hodgkins Lymphoma(1999), fibromyalgia, age 65, keep trying Plaquenil, Zoloft, Forteo, ibuprofen, love being near my kids

cccourt1942

  • Hero Member
  • *****
  • Posts: 1532
  • Suffered from numerous symptoms for about 25 years
Re: Medicare
« Reply #1 on: June 23, 2014, 06:14:24 PM »
Medicare pays a larger portion than my supplemental.  My suppleme tal is a group....one of the largest groups in America.
« Last Edit: June 24, 2014, 04:53:16 AM by cccourt1942 »
Sjogren's, Psoriasis, Hashimoto's, Osteoporosis, Osteoarthritis, Cold hands/feet,  fatigue,  pilocarpine-25 mg , Restasis, Plaquenil, Low dose Prednisone (2-3 mg daily) Xylimelt, Citrucel, Alcon-Naturale, Tears,Omega 3, Vit.D, Caltrate+D3, Fosamax, CoQ10, Zinc, Oxtellar. Levothyroxene

Breia Lee

  • Guest
Re: Medicare
« Reply #2 on: June 23, 2014, 07:10:38 PM »
I have Medicare only, I see my rheumatologist regularly (every 6 months) and I have no problem with it paying him.  My portion is only $14--nothing yet for the bloodwork.  I'm not sure what they are talking about, unless they don't really understand Medicare, which is definitely possible.

Jasper

  • Hero Member
  • *****
  • Posts: 1009
  • P SJS; SFN; Sensory Polyneuropathy/Ganglionopathy
Re: Medicare
« Reply #3 on: June 23, 2014, 07:22:39 PM »
I have Medicare.

Not all doctors accept Medicare. Be sure you check to be sure that they do take Medicare and that they will accept what Medicare approves as the payment. Also check to be sure they take your supplemental insurance.

Medicare pays about 80% of the "approved amount." The "approved amount" is the amount of the bill that Medicare approves for payment. It is usually considerably less than the actual amount the doctor billed.  The supplemental insurance picks up part or all of the remainder of the approved amount.

The approved amount is a fraction of what the doctor bills. So, if the doctor bills $350, Medicare may approve only $100 in payment. The rest is discounted and, if the doctor has agreed to accept Medicare, then the doctor gets none of the discounted amount and the doctor also cannot bill you for it.

However, if the doctor does not accept the Medicare assignment, then you may have to pay the entire bill. But you can check this before you go just by asking if they accept Medicare assignment.

I always make sure they accept Medicare and my supplemental insurance.

PS: If the group of physicians accept Medicare then I am sure they all would because it is the group that makes the rules. My doctors are all in a University Medical group, University of Minnesota Physicians. The entire group accepts Medicare so I always know that any physician that I see in that group will accept Medicare assignment (the amount approved by Medicare) and my supplemental insurance. 
« Last Edit: June 23, 2014, 07:27:15 PM by Jasper »
ANA 1:160; SS-A+; MSG +; Plaquenil, Rituxan infusions, Restasis, HRT, Curcumin, Calcium, CoQ10, NAC, Resveratrol, Whole Omega, Omega 3, R Lipoic Acid, Acetyl L Carnitine, Krill Oil, Mag. Threonate, Bio-Collagen UC II, NAD+, & Vit A, B, C, D, E, K 1 & 2.

litliwlowa

  • Hero Member
  • *****
  • Posts: 1780
Re: Medicare
« Reply #4 on: June 24, 2014, 06:17:00 AM »
Hi-when I was first diagnosed, 4 years ago, I was still working and my insurance covered everything but the co-pay. Now, I have retired, not on disability and have Medicare and a very good supplement insurance. I am now in a new area and found a doctor who only does Sjogrens. It is a University hospital group. I use this center for oncology and all my other doctors. They always take my insurance cards and I have had no problems. When I got this appt.--for October- they said bring your insurance card too because Medicare doesn't really pay. Has anyone else had this problem? When I searched for all rheumys in the area for Medicare, nothing came up. But, many people over 65 have arthritis conditions.They must have medicare.

Any thoughts on this?
Thank you
Lesley
Lesley,

I have medicare and a very good supplement. This is the first I have heard that Medicare "doesn't really pay". When I get my Medicare statements, it is clear that they DO pay. It is also clear from the statements that what the original charge from the doctor or tests submitted is, that a portion is written off by Medicare pursuant to what the doctors agreed to accept. That difference is not billable to the patient.

My annual deduct for Medicare is low and once met, 80% of the contracted amount (per doctor's contract with Medicare is my understanding) is covered by Medicare (I should mention I have traditional medicare in case it matters) and once deduct is met on supplement, supplement picks up 80% of what is left as balance due fro the Medicare end.

Now, what I AM encountering this year from two of my doctors thus far, is that some tests are limited to once a year. My endo stated the Vit D test is covered only once a year. Well I need it 4xyear. His lab informed me similar restrictions have been placed on other labs, for example affecting their diabetic patients.

So I called Medicare directly and inquired about that. Short answer (and I was on the phone with the woman there over an hour while looked under every nook and cranny) - on some tests the doctors must call the physician line to precertify medical necessity. Once they do that, the respective test is COVERED.

Now I am really trying hard not to ascribe attributes to certain doctors that may or may not be merited. I recently came across with my PCP that he was WILLING to order MRI soft tissue neck W&WO but "they" might not do it out of concern they might not be paid. I haven't talked to Medicare on that yet, as I am waiting to see what ENT decides today. Oh, and PCP did NOT order the test.

But my lesson in all of this is if you're being told Medicare won't pay this or that, VERIFY directly with Medicare. When I called, I gave a brief synopsis of my situation and my concerns and of course Medicare can't give me a specific answer in advance of a test or claim, but she was very helpful in clarifying WHAT THE DOCTOR needs to do to get a certain service or test covered.

I am aware that Medicaid presents a whole new set of challenges in finding doctors who participate in it. Numerous doctors across the country have been reported to have dropped Medicaid patients entirely. I've had the concern running in my mind that it is only a matter of time that we Medicare patients will eventually encounter similar barriers.

Amanda
SJS-Primary; Hashi's, Post surgical hypothyroidism, Hypoparathyroidism, Spondylolithesis, L&C Facet Arthropathy, Fibro, gluten intolerance, TBI, Radiculopathies, Neuralgias, Osteopenia, GERD, Asthma, Allergies. Sphincter Dyssynergia. OSA, Fasciitis, Cervical Spondylosis, Cancer, etc etc etc

Carolina

  • Hero Member
  • *****
  • Posts: 5823
  • —if it ain't one thing, it's another." Roseanne R.
Re: Medicare
« Reply #5 on: June 24, 2014, 06:33:00 AM »
I also have Medicare.

Doctors are not required to accept Medicare.  And if you see a non-medicare doctor you will be responsible for the entire bill.

One reason we chose the Duke Medical Center physicians is that most of them take Medicare. 

People who live in areas with few doctors can be really inconvenienced if the doctors they need do not take Medicare.

And even some of the doctors who DO take Medicare, do NOT contract with my specific  BCBS Medicare Advantage plan.

It is all very challenging and difficult.

Keep searching Lesie and keep us posted, too.

Hugs,  Elaine
Female-Elaine,78-CVID-pSJS-IC-PN-CAD-Osteoarth-SFN-Knee/Shoulder Degeneration-SIBO-Act.Purpura-Tinitus-Meniere's-Hiatal Hernia-Achalasia-Hand Surgeries, UTI's-Braces/Walker-IVIG Gamunex-Medrol-Gabapentin-Atenolol-Pilocarpine-LDN-Nasonex-Lipitor-Estrogel-D-Mannose-NAC-Omega 3-Naltrexone-Esomeprazol

ellieas

  • Full Member
  • ***
  • Posts: 154
Re: Medicare
« Reply #6 on: June 24, 2014, 08:28:59 AM »
Thank you everybody. I will make some phone calls.

Lesley
sjogrens dx'd 2010, non hodgkins Lymphoma(1999), fibromyalgia, age 65, keep trying Plaquenil, Zoloft, Forteo, ibuprofen, love being near my kids

quietdynamics

  • Hero Member
  • *****
  • Posts: 2399
Re: Medicare
« Reply #7 on: June 24, 2014, 09:01:20 AM »

Just curious: was trying to search for a good supplement insurance?
Any suggestions.
Also re: AARP with disability, does anyone have them as supplemental?
Sjogrens ANA 1:640; SS-A/B+; Fibro; IBS; Neuro symptoms,Thyroid Anti-bodies; Ocular Rosacea, Livedo reticularis,

"You can't have a positive life with a  negative mind"

litliwlowa

  • Hero Member
  • *****
  • Posts: 1780
Re: Medicare
« Reply #8 on: June 24, 2014, 09:11:23 AM »
I have United Healthcare, retiree benefit, as Medicare supplement. My rx coverage is via CVS/Caremark
SJS-Primary; Hashi's, Post surgical hypothyroidism, Hypoparathyroidism, Spondylolithesis, L&C Facet Arthropathy, Fibro, gluten intolerance, TBI, Radiculopathies, Neuralgias, Osteopenia, GERD, Asthma, Allergies. Sphincter Dyssynergia. OSA, Fasciitis, Cervical Spondylosis, Cancer, etc etc etc

warmwaters

  • Hero Member
  • *****
  • Posts: 1872
  • Just keep swimming - Dora
Re: Medicare
« Reply #9 on: June 24, 2014, 09:50:47 AM »
Quietdynamics - The "good supplemental" question is tricky, because the same vendor may offer several different plans, and some details vary by state or even region within the state.

When you get ready to enroll in a supplemental the next time around in November(?), you can use the medicare.gov site to get comparison quotes from vendors who offer coverage in your area.   In addition to price, it also has details of what the coverage provides, and previous customer satisfaction on a variety of points (like customer support, doctor access, etc) that you can look at.

I find myself spending a lot of time figuring out what I want, and what my doctors will take.

Primary Sjogrens, dx June 2009, Immunoglobulin deficiency, axial spondylosis arthritis, IBS, autonomic neuropathy
Omeprazone DR 40 mg, mobic 15 mg, Plaquenil, LDN, B1, B6, B12, D, fludrocortisone, gralise, various inhalers

Jasper

  • Hero Member
  • *****
  • Posts: 1009
  • P SJS; SFN; Sensory Polyneuropathy/Ganglionopathy
Re: Medicare
« Reply #10 on: June 24, 2014, 10:28:29 AM »
I have the traditional Medicare coverage (not Medicare Advantage) and I think that can make quite a difference.

My supplemental insurance, which is really quite good, is through United Health Care and it is a retiree benefit through my old employer. United Heath Care has several different plans and the coverage can vary dramatically. It just depends on which plan you are in. My prescription drug coverage is through OptumRx.

I agree that the plans and coverage vary considerably and the plans vary from state to state. One has to really do a lot of research to get the best plan, which may not be, and usually is not, the cheapest plan. The cheaper plans leave a person paying high deductibles and high co-pays and also often do not cover as many procedures and medications as the more expensive plans.

And one has to be sure that one's doctors take the plan one is going to get. Otherwise, one has to get new doctors.
ANA 1:160; SS-A+; MSG +; Plaquenil, Rituxan infusions, Restasis, HRT, Curcumin, Calcium, CoQ10, NAC, Resveratrol, Whole Omega, Omega 3, R Lipoic Acid, Acetyl L Carnitine, Krill Oil, Mag. Threonate, Bio-Collagen UC II, NAD+, & Vit A, B, C, D, E, K 1 & 2.

quietdynamics

  • Hero Member
  • *****
  • Posts: 2399
Re: Medicare
« Reply #11 on: June 24, 2014, 10:54:11 AM »

I was looking to supplement Medicare out of pocket.
So a new learning curve.

I was looking at possibly upgrading to Medicare Advantage (thanks for the heads up Elaine)

And trying to get info on the AARP site.
I was told that if you have medicare due to being disabled you can buy from them.
Possibly not correct information? And on the site of course when I put in DOB it say I am not eligible.

We are going out of town tomorrow.. so when we get back it is something I will have to research.
And get better coverage for DH. This month his insulin is not covered.

ellieas, I hope you make head way with the phone calls.
Once I waited to get in to see a Dr. gave them my insurance information at time of making appt over the phone.
Got to appt and they said we do not take that insurance but you can pay cash?
"I said for what .. you to look at me? Your office just wasted my valuable time and yours."

Ever since I always ask again at the end of the phone/appt. schedule about insurance.. just to double check.
Sjogrens ANA 1:640; SS-A/B+; Fibro; IBS; Neuro symptoms,Thyroid Anti-bodies; Ocular Rosacea, Livedo reticularis,

"You can't have a positive life with a  negative mind"

Breia Lee

  • Guest
Re: Medicare
« Reply #12 on: June 24, 2014, 11:31:22 AM »
As for which plan to choose:

I would start by asking your doctor which Medicare plans/supplements they will accept.  I learned that the hard way, when my doctor of 3 years absolutely refused to accept the plan I had chosen, so I was back to square one.  They told me which plans they do accept.  I'm sure your doctor/clinic will be able to do the same for you.

Breia Lee

  • Guest
Re: Medicare
« Reply #13 on: June 24, 2014, 11:34:05 AM »
Oh, and I supplement Medicare out of pocket.  Since I don't have a lot of tests done or fear being hospitalized, my out of pocket has been smaller than the typical co-pays I used to pay with my husband's employer sponsored HMOs.

Calli66

  • Hero Member
  • *****
  • Posts: 745
Re: Medicare
« Reply #14 on: June 25, 2014, 09:08:42 AM »
Great discussion. I turn 65 this fall, so I'm wondering about supplement plans, and whether I need one.

I had read the Medicare Advantage insurance sometimes does not cover you if you travel and need to find a doctor in another state. Also, I found out my retina and corneal doctors do not accept the advantage plans---but it wasn't really obvious, because the receptionists just told me the names of those plans, and I had to look them up myself.

It's all pretty confusing to me.

Calli