Guest guest Posted February 6, 2008 Report Share Posted February 6, 2008 Hi Barb, you are correct that the commercial group plan is primary. If you send her to a pharmacy that can bill her immunos to the group plan primary and Part B secondary (not all pharms work w/B), as long as she is showing up in the CWF, she is unlikely to have a copay for her immunos. If her entitlement is not yet showing, it doesn't hurt to ask the pharmacy to hold the copay billing. on Financial Counselor Legacy Transplant Services 1040 NW 22nd Ave Ste 480 Portland OR 97210 toll free fax lmorriso@... "Ring out old shapes of foul disease, Ring out the narrowing lust of gold; Ring out the thousand wars of old, Ring in the thousand years of peace." - Alfred Lord Tennyson -----Original Message-----From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ]On Behalf Of Cochrane, Barbara ESent: Wednesday, February 06, 2008 12:07 PMTo: TxFinancialCoordinators Subject: Insurance questions Just when I think I have a reasonable understanding of primary, secondary and COB, a situation presents itself that leaves me at a loss and needing help from my friends. We have a transplant recipient who recently started dialysis, has her application in for Medicare A & B, has primary commercial insurance coverage through her husband’s group, and will be receiving a living donor transplant later this month. The commercial insurance benefits include a combined annual deductible/out-of-pocket max of $5,000 with no co-insurance; and the drug benefits are tied to the medical benefits. Since it is early in the year, she has most of the OOP max to meet unless claims for January dialysis, medications, and other medical expenses reach the insurance payor before she is ready to pick up her first out-patient immunosuppressant meds and Valcyte (which we have already determined she will need for 3-6 months). We have prepared this patient by explaining to her that she will need to have met the $5,000 out-of-pocket before insurance will cover at 100%. The concern is that she may be faced with having to pay by cash/credit in order to get her meds. We have contacted the dialysis center and they have agreed to submit the claim for January dialysis as soon as possible. This should take care of most if not all of the $5,000. We are also working with the retail pharmacy in our facility so that they will work with her on getting immunosuppressants and meds when she is discharged after the transplant. My understanding of this situation is that all medical and pharmacy bills will be sent to the primary commercial policy; and that Medicare, as secondary, will probably not be a factor in even paying for immunosuppressants at 80%. I’m really asking if my thinking about this is correct. Any comments and suggestions will be most appreciated. Thank you, Barbara Barbara Cochrane, MSN, RN Transplant Financial Coordinator Transplant Services Department Mercy Medical Center—Des Moines Fax: bcochranemercydesmoines (DOT) org IMPORTANT NOTICE: This communication, including any attachment, contains information that may be confidential or privileged, and is intended solely for the entity or individual to whom it is addressed. If you are not the intended recipient, you should contact the sender and delete the message. Any unauthorized disclosure, copying, or distribution of this message is strictly prohibited. Nothing in this email, including any attachment, is intended to be a legally binding signature. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 6, 2008 Report Share Posted February 6, 2008 Barb, Do you know what the dialysis unit is billing per treatment? Stoops Program Operations Manager Clarian Transplant From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of on, :LPH Trnsplnt Sent: Wednesday, February 06, 2008 3:19 PM To: TxFinancialCoordinators Subject: RE: Insurance questions Hi Barb, you are correct that the commercial group plan is primary. If you send her to a pharmacy that can bill her immunos to the group plan primary and Part B secondary (not all pharms work w/B), as long as she is showing up in the CWF, she is unlikely to have a copay for her immunos. If her entitlement is not yet showing, it doesn't hurt to ask the pharmacy to hold the copay billing. on Financial Counselor Legacy Transplant Services 1040 NW 22nd Ave Ste 480 Portland OR 97210 toll free fax lmorrisolhs (DOT) org " Ring out old shapes of foul disease, Ring out the narrowing lust of gold; Ring out the thousand wars of old, Ring in the thousand years of peace. " - Alfred Lord Tennyson Insurance questions Just when I think I have a reasonable understanding of primary, secondary and COB, a situation presents itself that leaves me at a loss and needing help from my friends. We have a transplant recipient who recently started dialysis, has her application in for Medicare A & B, has primary commercial insurance coverage through her husband’s group, and will be receiving a living donor transplant later this month. The commercial insurance benefits include a combined annual deductible/out-of-pocket max of $5,000 with no co-insurance; and the drug benefits are tied to the medical benefits. Since it is early in the year, she has most of the OOP max to meet unless claims for January dialysis, medications, and other medical expenses reach the insurance payor before she is ready to pick up her first out-patient immunosuppressant meds and Valcyte (which we have already determined she will need for 3-6 months). We have prepared this patient by explaining to her that she will need to have met the $5,000 out-of-pocket before insurance will cover at 100%. The concern is that she may be faced with having to pay by cash/credit in order to get her meds. We have contacted the dialysis center and they have agreed to submit the claim for January dialysis as soon as possible. This should take care of most if not all of the $5,000. We are also working with the retail pharmacy in our facility so that they will work with her on getting immunosuppressants and meds when she is discharged after the transplant. My understanding of this situation is that all medical and pharmacy bills will be sent to the primary commercial policy; and that Medicare, as secondary, will probably not be a factor in even paying for immunosuppressants at 80%. I’m really asking if my thinking about this is correct. Any comments and suggestions will be most appreciated. Thank you, Barbara Barbara Cochrane, MSN, RN Transplant Financial Coordinator Transplant Services Department Mercy Medical Center—Des Moines Fax: bcochranemercydesmoines (DOT) org IMPORTANT NOTICE: This communication, including any attachment, contains information that may be confidential or privileged, and is intended solely for the entity or individual to whom it is addressed. If you are not the intended recipient, you should contact the sender and delete the message. Any unauthorized disclosure, copying, or distribution of this message is strictly prohibited. Nothing in this email, including any attachment, is intended to be a legally binding signature. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 6, 2008 Report Share Posted February 6, 2008 Barb, Do you know what the dialysis unit is billing per treatment? Stoops Program Operations Manager Clarian Transplant From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of on, :LPH Trnsplnt Sent: Wednesday, February 06, 2008 3:19 PM To: TxFinancialCoordinators Subject: RE: Insurance questions Hi Barb, you are correct that the commercial group plan is primary. If you send her to a pharmacy that can bill her immunos to the group plan primary and Part B secondary (not all pharms work w/B), as long as she is showing up in the CWF, she is unlikely to have a copay for her immunos. If her entitlement is not yet showing, it doesn't hurt to ask the pharmacy to hold the copay billing. on Financial Counselor Legacy Transplant Services 1040 NW 22nd Ave Ste 480 Portland OR 97210 toll free fax lmorrisolhs (DOT) org " Ring out old shapes of foul disease, Ring out the narrowing lust of gold; Ring out the thousand wars of old, Ring in the thousand years of peace. " - Alfred Lord Tennyson Insurance questions Just when I think I have a reasonable understanding of primary, secondary and COB, a situation presents itself that leaves me at a loss and needing help from my friends. We have a transplant recipient who recently started dialysis, has her application in for Medicare A & B, has primary commercial insurance coverage through her husband’s group, and will be receiving a living donor transplant later this month. The commercial insurance benefits include a combined annual deductible/out-of-pocket max of $5,000 with no co-insurance; and the drug benefits are tied to the medical benefits. Since it is early in the year, she has most of the OOP max to meet unless claims for January dialysis, medications, and other medical expenses reach the insurance payor before she is ready to pick up her first out-patient immunosuppressant meds and Valcyte (which we have already determined she will need for 3-6 months). We have prepared this patient by explaining to her that she will need to have met the $5,000 out-of-pocket before insurance will cover at 100%. The concern is that she may be faced with having to pay by cash/credit in order to get her meds. We have contacted the dialysis center and they have agreed to submit the claim for January dialysis as soon as possible. This should take care of most if not all of the $5,000. We are also working with the retail pharmacy in our facility so that they will work with her on getting immunosuppressants and meds when she is discharged after the transplant. My understanding of this situation is that all medical and pharmacy bills will be sent to the primary commercial policy; and that Medicare, as secondary, will probably not be a factor in even paying for immunosuppressants at 80%. I’m really asking if my thinking about this is correct. Any comments and suggestions will be most appreciated. Thank you, Barbara Barbara Cochrane, MSN, RN Transplant Financial Coordinator Transplant Services Department Mercy Medical Center—Des Moines Fax: bcochranemercydesmoines (DOT) org IMPORTANT NOTICE: This communication, including any attachment, contains information that may be confidential or privileged, and is intended solely for the entity or individual to whom it is addressed. If you are not the intended recipient, you should contact the sender and delete the message. Any unauthorized disclosure, copying, or distribution of this message is strictly prohibited. Nothing in this email, including any attachment, is intended to be a legally binding signature. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2008 Report Share Posted February 7, 2008 Hi Barbara, I have a few patients with deductibles like this, and I am wondering if many companies are moving towards this. A few of my patients, have purchased Part D (even tho they have large group coverage)and they use the Part D plan during the large deductible period. This helps them at least cover their meds. In this patient case, we don’t know if she is going to have Medicare after 3 months if she is on hemo, or will have Medicare immediately. My advice to that patient would be if it is 3 months, then wait until Medicare shows to have the transplant, otherwise she will have to pay the out of pocket. However, she will still have to pay the out of pocket to dialysis, so either way she will have this deductible. The only thing that will help her is if she is on PD and getting Medicare from day 1 of dialysis. Pat Kreci Transplant Financial Coordinator Southwest Florida Regional Medical Center Ft Myers, FL From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Cochrane, Barbara E Sent: Wednesday, February 06, 2008 3:07 PM To: TxFinancialCoordinators Subject: Insurance questions Just when I think I have a reasonable understanding of primary, secondary and COB, a situation presents itself that leaves me at a loss and needing help from my friends. We have a transplant recipient who recently started dialysis, has her application in for Medicare A & B, has primary commercial insurance coverage through her husband’s group, and will be receiving a living donor transplant later this month. The commercial insurance benefits include a combined annual deductible/out-of-pocket max of $5,000 with no co-insurance; and the drug benefits are tied to the medical benefits. Since it is early in the year, she has most of the OOP max to meet unless claims for January dialysis, medications, and other medical expenses reach the insurance payor before she is ready to pick up her first out-patient immunosuppressant meds and Valcyte (which we have already determined she will need for 3-6 months). We have prepared this patient by explaining to her that she will need to have met the $5,000 out-of-pocket before insurance will cover at 100%. The concern is that she may be faced with having to pay by cash/credit in order to get her meds. We have contacted the dialysis center and they have agreed to submit the claim for January dialysis as soon as possible. This should take care of most if not all of the $5,000. We are also working with the retail pharmacy in our facility so that they will work with her on getting immunosuppressants and meds when she is discharged after the transplant. My understanding of this situation is that all medical and pharmacy bills will be sent to the primary commercial policy; and that Medicare, as secondary, will probably not be a factor in even paying for immunosuppressants at 80%. I’m really asking if my thinking about this is correct. Any comments and suggestions will be most appreciated. Thank you, Barbara Barbara Cochrane, MSN, RN Transplant Financial Coordinator Transplant Services Department Mercy Medical Center—Des Moines Fax: bcochranemercydesmoines (DOT) org Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2008 Report Share Posted February 7, 2008 Hi Barbara, I have a few patients with deductibles like this, and I am wondering if many companies are moving towards this. A few of my patients, have purchased Part D (even tho they have large group coverage)and they use the Part D plan during the large deductible period. This helps them at least cover their meds. In this patient case, we don’t know if she is going to have Medicare after 3 months if she is on hemo, or will have Medicare immediately. My advice to that patient would be if it is 3 months, then wait until Medicare shows to have the transplant, otherwise she will have to pay the out of pocket. However, she will still have to pay the out of pocket to dialysis, so either way she will have this deductible. The only thing that will help her is if she is on PD and getting Medicare from day 1 of dialysis. Pat Kreci Transplant Financial Coordinator Southwest Florida Regional Medical Center Ft Myers, FL From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Cochrane, Barbara E Sent: Wednesday, February 06, 2008 3:07 PM To: TxFinancialCoordinators Subject: Insurance questions Just when I think I have a reasonable understanding of primary, secondary and COB, a situation presents itself that leaves me at a loss and needing help from my friends. We have a transplant recipient who recently started dialysis, has her application in for Medicare A & B, has primary commercial insurance coverage through her husband’s group, and will be receiving a living donor transplant later this month. The commercial insurance benefits include a combined annual deductible/out-of-pocket max of $5,000 with no co-insurance; and the drug benefits are tied to the medical benefits. Since it is early in the year, she has most of the OOP max to meet unless claims for January dialysis, medications, and other medical expenses reach the insurance payor before she is ready to pick up her first out-patient immunosuppressant meds and Valcyte (which we have already determined she will need for 3-6 months). We have prepared this patient by explaining to her that she will need to have met the $5,000 out-of-pocket before insurance will cover at 100%. The concern is that she may be faced with having to pay by cash/credit in order to get her meds. We have contacted the dialysis center and they have agreed to submit the claim for January dialysis as soon as possible. This should take care of most if not all of the $5,000. We are also working with the retail pharmacy in our facility so that they will work with her on getting immunosuppressants and meds when she is discharged after the transplant. My understanding of this situation is that all medical and pharmacy bills will be sent to the primary commercial policy; and that Medicare, as secondary, will probably not be a factor in even paying for immunosuppressants at 80%. I’m really asking if my thinking about this is correct. Any comments and suggestions will be most appreciated. Thank you, Barbara Barbara Cochrane, MSN, RN Transplant Financial Coordinator Transplant Services Department Mercy Medical Center—Des Moines Fax: bcochranemercydesmoines (DOT) org Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2008 Report Share Posted February 7, 2008 A few of our patients have been kicked off of their GHP script policy once the GHP found out they had a Medicare D policy. The patients had to drop the MC D before the GHP would cover them again. Per that history, I have been told that the patients can not have a Medicare D policy and GHP script coverage at the same time. Has anyone else seen this scenario? Glor Renal Financial Coordinator Akron City Hospital Transplant Dept, OHIO Insurance questions Just when I think I have a reasonable understanding of primary, secondary and COB, a situation presents itself that leaves me at a loss and needing help from my friends. We have a transplant recipient who recently started dialysis, has her application in for Medicare A & B, has primary commercial insurance coverage through her husband’s group, and will be receiving a living donor transplant later this month. The commercial insurance benefits include a combined annual deductible/out-of-pocket max of $5,000 with no co-insurance; and the drug benefits are tied to the medical benefits. Since it is early in the year, she has most of the OOP max to meet unless claims for January dialysis, medications, and other medical expenses reach the insurance payor before she is ready to pick up her first out-patient immunosuppressant meds and Valcyte (which we have already determined she will need for 3-6 months). We have prepared this patient by explaining to her that she will need to have met the $5,000 out-of-pocket before insurance will cover at 100%. The concern is that she may be faced with having to pay by cash/credit in order to get her meds. We have contacted the dialysis center and they have agreed to submit the claim for January dialysis as soon as possible. This should take care of most if not all of the $5,000. We are also working with the retail pharmacy in our facility so that they will work with her on getting immunosuppressants and meds when she is discharged after the transplant. My understanding of this situation is that all medical and pharmacy bills will be sent to the primary commercial policy; and that Medicare, as secondary, will probably not be a factor in even paying for immunosuppressants at 80%. I’m really asking if my thinking about this is correct. Any comments and suggestions will be most appreciated. Thank you, Barbara Barbara Cochrane, MSN, RN Transplant Financial Coordinator Transplant Services Department Mercy Medical Center—Des Moines Fax: bcochranemercydesmoines (DOT) org Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2008 Report Share Posted February 7, 2008 A few of our patients have been kicked off of their GHP script policy once the GHP found out they had a Medicare D policy. The patients had to drop the MC D before the GHP would cover them again. Per that history, I have been told that the patients can not have a Medicare D policy and GHP script coverage at the same time. Has anyone else seen this scenario? Glor Renal Financial Coordinator Akron City Hospital Transplant Dept, OHIO Insurance questions Just when I think I have a reasonable understanding of primary, secondary and COB, a situation presents itself that leaves me at a loss and needing help from my friends. We have a transplant recipient who recently started dialysis, has her application in for Medicare A & B, has primary commercial insurance coverage through her husband’s group, and will be receiving a living donor transplant later this month. The commercial insurance benefits include a combined annual deductible/out-of-pocket max of $5,000 with no co-insurance; and the drug benefits are tied to the medical benefits. Since it is early in the year, she has most of the OOP max to meet unless claims for January dialysis, medications, and other medical expenses reach the insurance payor before she is ready to pick up her first out-patient immunosuppressant meds and Valcyte (which we have already determined she will need for 3-6 months). We have prepared this patient by explaining to her that she will need to have met the $5,000 out-of-pocket before insurance will cover at 100%. The concern is that she may be faced with having to pay by cash/credit in order to get her meds. We have contacted the dialysis center and they have agreed to submit the claim for January dialysis as soon as possible. This should take care of most if not all of the $5,000. We are also working with the retail pharmacy in our facility so that they will work with her on getting immunosuppressants and meds when she is discharged after the transplant. My understanding of this situation is that all medical and pharmacy bills will be sent to the primary commercial policy; and that Medicare, as secondary, will probably not be a factor in even paying for immunosuppressants at 80%. I’m really asking if my thinking about this is correct. Any comments and suggestions will be most appreciated. Thank you, Barbara Barbara Cochrane, MSN, RN Transplant Financial Coordinator Transplant Services Department Mercy Medical Center—Des Moines Fax: bcochranemercydesmoines (DOT) org Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2008 Report Share Posted February 7, 2008 Hi, yes, MY OWN employer has that policy. I queried the Seattle CMS office about it Q: isn't this a case of "taking Medicare into account" and treating the employee differently than other employees who don't have Medicare? A: Part D does not operate under the same rules as Original Medicare. So apparently, sadly, EGHPs can get away with this. on Financial Counselor Legacy Transplant Services 1040 NW 22nd Ave Ste 480 Portland OR 97210 toll free fax lmorriso@... "Ring out old shapes of foul disease, Ring out the narrowing lust of gold; Ring out the thousand wars of old, Ring in the thousand years of peace." - Alfred Lord Tennyson -----Original Message-----From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ]On Behalf Of Glor, L.Sent: Thursday, February 07, 2008 7:35 AMTo: TxFinancialCoordinators Subject: RE: Insurance questions A few of our patients have been kicked off of their GHP script policy once the GHP found out they had a Medicare D policy. The patients had to drop the MC D before the GHP would cover them again. Per that history, I have been told that the patients can not have a Medicare D policy and GHP script coverage at the same time. Has anyone else seen this scenario? Glor Renal Financial Coordinator Akron City Hospital Transplant Dept, OHIO -----Original Message-----From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Kreci, Sent: Thursday, February 07, 2008 9:37 AMTo: TxFinancialCoordinators Subject: RE: Insurance questions Hi Barbara, I have a few patients with deductibles like this, and I am wondering if many companies are moving towards this. A few of my patients, have purchased Part D (even tho they have large group coverage)and they use the Part D plan during the large deductible period. This helps them at least cover their meds. In this patient case, we don’t know if she is going to have Medicare after 3 months if she is on hemo, or will have Medicare immediately. My advice to that patient would be if it is 3 months, then wait until Medicare shows to have the transplant, otherwise she will have to pay the out of pocket. However, she will still have to pay the out of pocket to dialysis, so either way she will have this deductible. The only thing that will help her is if she is on PD and getting Medicare from day 1 of dialysis. Pat Kreci Transplant Financial Coordinator Southwest Florida Regional Medical Center Ft Myers, FL From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Cochrane, Barbara ESent: Wednesday, February 06, 2008 3:07 PMTo: TxFinancialCoordinators Subject: Insurance questions Just when I think I have a reasonable understanding of primary, secondary and COB, a situation presents itself that leaves me at a loss and needing help from my friends. We have a transplant recipient who recently started dialysis, has her application in for Medicare A & B, has primary commercial insurance coverage through her husband’s group, and will be receiving a living donor transplant later this month. The commercial insurance benefits include a combined annual deductible/out-of-pocket max of $5,000 with no co-insurance; and the drug benefits are tied to the medical benefits. Since it is early in the year, she has most of the OOP max to meet unless claims for January dialysis, medications, and other medical expenses reach the insurance payor before she is ready to pick up her first out-patient immunosuppressant meds and Valcyte (which we have already determined she will need for 3-6 months). We have prepared this patient by explaining to her that she will need to have met the $5,000 out-of-pocket before insurance will cover at 100%. The concern is that she may be faced with having to pay by cash/credit in order to get her meds. We have contacted the dialysis center and they have agreed to submit the claim for January dialysis as soon as possible. This should take care of most if not all of the $5,000. We are also working with the retail pharmacy in our facility so that they will work with her on getting immunosuppressants and meds when she is discharged after the transplant. My understanding of this situation is that all medical and pharmacy bills will be sent to the primary commercial policy; and that Medicare, as secondary, will probably not be a factor in even paying for immunosuppressants at 80%. I’m really asking if my thinking about this is correct. Any comments and suggestions will be most appreciated. Thank you, Barbara Barbara Cochrane, MSN, RN Transplant Financial Coordinator Transplant Services Department Mercy Medical Center—Des Moines Fax: bcochranemercydesmoines (DOT) org IMPORTANT NOTICE: This communication, including any attachment, contains information that may be confidential or privileged, and is intended solely for the entity or individual to whom it is addressed. If you are not the intended recipient, you should contact the sender and delete the message. Any unauthorized disclosure, copying, or distribution of this message is strictly prohibited. Nothing in this email, including any attachment, is intended to be a legally binding signature. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2008 Report Share Posted February 7, 2008 That is true you are not allowed to have both Medicare Part D and a GHP Rx policy. The pt has a choice to make depending on if the GHP is as good as or better than what Part D is offering. The GHP should have sent a letter notifying the pt if there policy is either. That way if at some point the pt's GHP ends and they need to get a Part D plan they can get one without being penalized. In some cases GHP will not let a pt get there RX coverage back if they have chose to stick with a Part D plan. Stacey Stout Financial Coordinator O.Strickler Transplant Center University of Virginia Health Systems Phone: Fax: 434924-8774 SAS8W@... -----Original Message-----From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Glor, L.Sent: Thursday, February 07, 2008 10:35 AMTo: TxFinancialCoordinators Subject: RE: Insurance questions A few of our patients have been kicked off of their GHP script policy once the GHP found out they had a Medicare D policy. The patients had to drop the MC D before the GHP would cover them again. Per that history, I have been told that the patients can not have a Medicare D policy and GHP script coverage at the same time. Has anyone else seen this scenario? Glor Renal Financial Coordinator Akron City Hospital Transplant Dept, OHIO -----Original Message-----From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Kreci, Sent: Thursday, February 07, 2008 9:37 AMTo: TxFinancialCoordinators Subject: RE: Insurance questions Hi Barbara, I have a few patients with deductibles like this, and I am wondering if many companies are moving towards this. A few of my patients, have purchased Part D (even tho they have large group coverage)and they use the Part D plan during the large deductible period. This helps them at least cover their meds. In this patient case, we don’t know if she is going to have Medicare after 3 months if she is on hemo, or will have Medicare immediately. My advice to that patient would be if it is 3 months, then wait until Medicare shows to have the transplant, otherwise she will have to pay the out of pocket. However, she will still have to pay the out of pocket to dialysis, so either way she will have this deductible. The only thing that will help her is if she is on PD and getting Medicare from day 1 of dialysis. Pat Kreci Transplant Financial Coordinator Southwest Florida Regional Medical Center Ft Myers, FL From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Cochrane, Barbara ESent: Wednesday, February 06, 2008 3:07 PMTo: TxFinancialCoordinators Subject: Insurance questions Just when I think I have a reasonable understanding of primary, secondary and COB, a situation presents itself that leaves me at a loss and needing help from my friends. We have a transplant recipient who recently started dialysis, has her application in for Medicare A & B, has primary commercial insurance coverage through her husband’s group, and will be receiving a living donor transplant later this month. The commercial insurance benefits include a combined annual deductible/out-of-pocket max of $5,000 with no co-insurance; and the drug benefits are tied to the medical benefits. Since it is early in the year, she has most of the OOP max to meet unless claims for January dialysis, medications, and other medical expenses reach the insurance payor before she is ready to pick up her first out-patient immunosuppressant meds and Valcyte (which we have already determined she will need for 3-6 months). We have prepared this patient by explaining to her that she will need to have met the $5,000 out-of-pocket before insurance will cover at 100%. The concern is that she may be faced with having to pay by cash/credit in order to get her meds. We have contacted the dialysis center and they have agreed to submit the claim for January dialysis as soon as possible. This should take care of most if not all of the $5,000. We are also working with the retail pharmacy in our facility so that they will work with her on getting immunosuppressants and meds when she is discharged after the transplant. My understanding of this situation is that all medical and pharmacy bills will be sent to the primary commercial policy; and that Medicare, as secondary, will probably not be a factor in even paying for immunosuppressants at 80%. I’m really asking if my thinking about this is correct. Any comments and suggestions will be most appreciated. Thank you, Barbara Barbara Cochrane, MSN, RN Transplant Financial Coordinator Transplant Services Department Mercy Medical Center—Des Moines Fax: bcochranemercydesmoines (DOT) org Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2008 Report Share Posted February 7, 2008 We haven’t had that particular scenario, but I do know that if a client has “creditable coverage” with a group health prescription drug plan they do not need to take Medicare Part D. In these cases we have advised the client to try to obtain a letter from their prescription drug plan/group health attesting to the fact that they have “creditable coverage”. If that is not possible, we advised them to keep in their personal files the benefit information and dates of coverage for the group drug plan just in case they are challenged when they do apply for Part D. Barbara. From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Glor, L. Sent: Thursday, February 07, 2008 9:35 AM To: TxFinancialCoordinators Subject: RE: Insurance questions A few of our patients have been kicked off of their GHP script policy once the GHP found out they had a Medicare D policy. The patients had to drop the MC D before the GHP would cover them again. Per that history, I have been told that the patients can not have a Medicare D policy and GHP script coverage at the same time. Has anyone else seen this scenario? Glor Renal Financial Coordinator Akron City Hospital Transplant Dept, OHIO -----Original Message----- From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Kreci, Sent: Thursday, February 07, 2008 9:37 AM To: TxFinancialCoordinators Subject: RE: Insurance questions Hi Barbara, I have a few patients with deductibles like this, and I am wondering if many companies are moving towards this. A few of my patients, have purchased Part D (even tho they have large group coverage)and they use the Part D plan during the large deductible period. This helps them at least cover their meds. In this patient case, we don’t know if she is going to have Medicare after 3 months if she is on hemo, or will have Medicare immediately. My advice to that patient would be if it is 3 months, then wait until Medicare shows to have the transplant, otherwise she will have to pay the out of pocket. However, she will still have to pay the out of pocket to dialysis, so either way she will have this deductible. The only thing that will help her is if she is on PD and getting Medicare from day 1 of dialysis. Pat Kreci Transplant Financial Coordinator Southwest Florida Regional Medical Center Ft Myers, FL From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Cochrane, Barbara E Sent: Wednesday, February 06, 2008 3:07 PM To: TxFinancialCoordinators Subject: Insurance questions Just when I think I have a reasonable understanding of primary, secondary and COB, a situation presents itself that leaves me at a loss and needing help from my friends. We have a transplant recipient who recently started dialysis, has her application in for Medicare A & B, has primary commercial insurance coverage through her husband’s group, and will be receiving a living donor transplant later this month. The commercial insurance benefits include a combined annual deductible/out-of-pocket max of $5,000 with no co-insurance; and the drug benefits are tied to the medical benefits. Since it is early in the year, she has most of the OOP max to meet unless claims for January dialysis, medications, and other medical expenses reach the insurance payor before she is ready to pick up her first out-patient immunosuppressant meds and Valcyte (which we have already determined she will need for 3-6 months). We have prepared this patient by explaining to her that she will need to have met the $5,000 out-of-pocket before insurance will cover at 100%. The concern is that she may be faced with having to pay by cash/credit in order to get her meds. We have contacted the dialysis center and they have agreed to submit the claim for January dialysis as soon as possible. This should take care of most if not all of the $5,000. We are also working with the retail pharmacy in our facility so that they will work with her on getting immunosuppressants and meds when she is discharged after the transplant. My understanding of this situation is that all medical and pharmacy bills will be sent to the primary commercial policy; and that Medicare, as secondary, will probably not be a factor in even paying for immunosuppressants at 80%. I’m really asking if my thinking about this is correct. Any comments and suggestions will be most appreciated. Thank you, Barbara Barbara Cochrane, MSN, RN Transplant Financial Coordinator Transplant Services Department Mercy Medical Center—Des Moines Fax: bcochranemercydesmoines (DOT) org Quote Link to comment Share on other sites More sharing options...
Recommended Posts
Join the conversation
You are posting as a guest. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.