Which is primary?

[Teggie]

What is the name of your state? Texas

My mom recently retired and became Medicare eligible. After much researching due to her limited income we settled on a Medicare replacment plan since it seemed to meet most of her needs for the best price. Her husband is still employed and has her on his Cigna plan but it is a very basic plan, sorta bare bones type.

She is also a Type 2 diabetic in need of a meter & testing supplies. After more research I contacted a medical supply company that advertises they file the claims and ship at no cost.

At first they told me that her medicare replacment plan would cover 80% & she would be responsible for the 20% not covered which averages to 55.00 every 3 monthes. This sounded ok to us and we were going to continue. However, I got a call from them today stating that her husband's insurance would have to be primary and under it her cost would be 45.00 every month. Ack! She doesn't get much, an extra 45.00 a month would be hard for her.

I am debating asking her to get herself dropped from his plan so they can list her medicare replacment plan as primary, but I am afraid it may hurt her down the road?

Anyone have any knowledge of this type of situation? I would appreciate any input at all.

Thanks & I hope everyone has had a good day!

TeggieWhat is the name of your state?

 

[LJ2006]

Hey Teggie,

I hate those so-called "Medicare replacement plans" - IMHO, they do so little for Medicare patients.

Medicare is always the primary payer except under certain circumstances:

"There are certain instances when another insurance will pay before Medicare. These instances are:

When the beneficiary or beneficiary's spouse is actively employed.
Group health plans of 20 employees or more are primary payers and Medicare is the secondary payer if the worker or the worker's spouse is age 65 or older."

Here's the URL for the above (and other circumstances) for Texas Medicare: http://www.trailblazerhealth.com/bene/msp.asp

Unless your father removes your mother from his policy, it may not be possible to have Medicare become the primary payer.

Here's the URL for Texas Medicare beneficiary contact information. http://www.trailblazerhealth.com/bene/index.asp?

My suggestion to you is to contact a representative there who'll tell you ALL the information you want:

1.) long term care costs - what does "straight Medicare pay for?" "what is the beneficiary responsible for in terms of out of pocket expenses?"
2.) long term drug costs - ditto the questions above
3.) long term hospital costs - ditto above
4.) monthly costs & costs per doctor's visit? - ditto
5.) if she makes the switch to "straight medicare" will she be penalized financially?
6.) how long will she have to wait to switch and/or how long will she have to wait for regular coverage if this is what she decides?

Write down your questions & then compare the programs side by side and make a very informed decision.

There are new Medicare policies coming into place now, so your timing may be very good.

In the end, no one can really make this decision but you & your family because no one knows her needs better than you. I wish you good success.

L J

 

[Teggie]

LJ2006,

Thank you so very much for the information! You are the first person to give me a straight answer. I really appreciate you taking the time to answer my questions.

It has been nothing but confusion since she got on the Medicare replacment plan. She has a CIDB card stating a percentage of Indian blood. This has provided her with a means of medical care until now but required traveling 3 hours each way to the nearest facility in another state. Since her back surgery it has become increasingly difficult for her to make the trip & when she retired and became Medicare eligible we thought it would be better to switch her care to a local physician. I was afraid of what would happen if she became seriously ill and needed local treatment.

I see now that we must investigate whether it is worth keeping her on her husband's insurance, he plans to retire prob within the next year. When the medical supply place called me and told me her husbands insurance would be primary and it would cost her 45.00 a month I asked them if her medicare replacment policy would cover any as a secondary insurance. I was told it would not. Is this correct? I looked at the links you gave me but could not find that information. She is on Humana Gold Choice as her replacment policy. It's scary to think that her husbands insurance will be her only coverage if she remains on it.

I reviewed her husband's insurance plan and it does not cover as well as her medicare replacment policy. It is a "bare bones insurance" that he chose because it was cheaper. You know the type, really horrible insurance.

If what the medical supply person told us is true, that the medicare replacment policy won't pick up as secondary, then I am prob going to suggest she be removed from it. Since he will prob retire in the next year and she won't have it anyhow it may be the thing to do.

I feel so sorry for the elderly out there who have no assistance in dealing with all these Medicare related plans, drug programs etc etc. Most don't even have a computer and are unable to educate themselves.

Thank you again and I hope I am not being too much of a nuisance.
Have a great weekend!

Teggie

 

[kNOwtheLAW]

I see now that we must investigate whether it is worth keeping her on her husband's insurance, he plans to retire prob within the next year.

Unless your father removes your mother from his policy, it may not be possible to have Medicare become the primary payer.

Does it really make a difference whether Medicare is primary or secondary? The point is you have two policies covering one individual currently. Why wouldn't the service provider submit the claim to the primary insurer (CIGNA) first and the balance of the claim to the secondary insurer, in this case Medicare? It's called COORDINATION of BENEFITS.

I may be missing something here, but it's generally always better to have two policies in place. Someone, please enlighten me as to the value of taking this woman off her husband's policy? Primary does not infer that only one policy pays claims and the other does not. Primary means that primary policy pays first and the secondary policy pays (generally) the remaining balance not paid by the primary carrier.

Please read all about the Medicare Secondary Payer program, and then Coordination of Benefits and You.

With two insurers in place you really should not have anything to pay after the claim is submitted to both insurers.

KTL

 

[Betty]

KTL - I'm with you - you need to have a "supplemental" policy to go along with Medicare which should, hopefully, take care of the complete claim. I would leave the mother on the father's policy at this time - until he no longer has it. (then look for another supplemental policy)

 

[Teggie]

That was my question in my 2nd post,

I was told by the medical supply place that her husband's CIGNA would be primary.

I then asked if her Humana Gold Choice plan (her Medicare replacment policy) would be considered secondary.

I was told "yes" the Humana choice plan would be considered secondary.

I then asked if the Humana plan would cover anything as the secondary insurance.

I was told "No" that the Humana plan would only cover if it was primary.

So only Cigna would cover a part of her supplies and the Humana plan will cover none.

Was I told wrong? If that was correct it would mean that Humana would not cover anything at all as long as it was secondary to the Cigna plan.

Under that assumption do you see why I am asking?

If what the medical supply person told me was correct then this is how I see it.

With Cigna as primary and Humana secondary she will pay 45.00 a month for her supplies, which is what Cigna covers with no coverage from the Humana plan.

With the Humana plan only she will pay 20.00 a month for her supplies.

And I wonder how the rest of her care will be, will Humana not pay any of her care as long as Cigna is considered primary?

I have to ask, unless I was not told correctly, why pay for 2 insurances when only one will pay?

I stay confused, and I am not insurance savvy.

Teggie

 

[kNOwtheLAW]

I have to ask, unless I was not told correctly, why pay for 2 insurances when only one will pay?

Think about it. . . A company cannot legally expect you to pay premium and then inform you that they would not be responsible for any of the claims incurred.

When a Medicare policy and an employers policy is involved, CMS (the government) takes the position that the employer's policy will be the primary payer, and Medicare will be the secondary payer. Why? It saves Medicare (the government) money!

It would surprise me if the service provider (medical supply place) told you that HUMANA would not be responsible for any charges. Is it possible you misunderstood? They coordinate these benefits daily for hundreds of patients. They know the definition of primary and secondary. They know exactly how this works. It's how they get paid.

I suspected from your second post that you did not understand how benefits are coordinated between carriers when there is more than one policy involved. As I've been reading your posts the underlying theme has been to remove your mother from her husband's policy. Most people would love to have two policies coordinating the benefits.

Contact HUMANA (the Medicare replacement carrier) and inform them of the COB situation. They will communicate with the service provider. The service provider will submit claims to CIGNA first, as primary, and when the EOBs (explanation of benefits) are processed the balance of the claim will be sent to HUMANA, as secondary, for processing. Your mother will be required to assign the benefit payments to the service provider so they may receive payment directly from both insurers.

You should also read the section on 'Coordination of Benefits' in your mother's HUMANA Gold certificate booklet for a more complete understanding of how this works. Did you click on these links and read about the Medicare Secondary Payer program, and then Coordination of Benefits and You. This information is directly from the CMS website.

KTL

 

[Teggie]

Thank you! Thank you!

We contacted another medical supply place that deals in diabetic testing supplies after a diabetic friend of my mother's recommended it.

This represenative was very helpful, got all the neccessary information from us and told us they could work with both insurances, that they had several customers like this, and after a breif time we were informed she could get all her supplies at a cost of about 25.00 a month. We signed up as that was the best news we have gotton! They will even obtain the order from her doctor, whereas the other place said we had to do it.

I will be the first to admit, since I am not insurance savvy that I may have misinterpreted somehow what the first represenative told me. Although I thought I had asked correctly. And I have to wonder how the first place quoted us 45.00 a month whereas the second place stated 25.00 a month. Both places had identical information from us. /boggle

Thank you for the links, it helped me better understand how all this stuff works.

Think about it. . . A company cannot legally expect you to pay premium and then inform you that they would not be responsible for any of the claims incurred

.

Those two sentances helped me more than anything. That was the very thing that had me banging my head against the wall.

I will get my mother's benefit booklet and read up on COB and anything else I'll need to know. With my mom getting older I always want to make the best decisions for her, she relies on me.

I cringe to think of what could have happened if I had not sought help with this issue. We will keep the Cigna insurance until her husband retires, then we will investigate what our other options are.

They say the road to hell is paved with good intentions. Thank you for the detour!

Very appreciative for kindness shown to the insurance illiterate,

my mother thanks you too!

Teggie