Community Chat

[Carmie]

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@itiswhatitis wrote:

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@Carmie wrote:

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@KathyPet wrote:

If you are enrolled in Medicare it is always primary.  Your coverage with your husband's employer becomes secondary and will only pay the portion that Medicare did not cover.

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That is not a true statement.  If you or your spouse are still working and eligible for Medicare and the employer has 20 or more employees, the primary insurance is the employees group plan and Medicare is secondary.

You can look up this information under TEFRA.

It is also possible that Medicare will not pick up a balance left after the primary plan.  There are many things that are not covered by Medicare, but could be covered under the group plan.

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Yes, when I had two coverage amounts it was called "coordination of benefits" and the primary payee was determined by something called the "birthday rule."  In that case, my spouse's insurance was first, then mine.

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If you have health coverage on your own plan and another policy under your spouse's plan, your coverage would be primary for yourself and your spouse's policy would be primary for him/her. If you have children and they are on both policies, the Birthday Rule would probably apply.  This rules states that whoever 's  birthday is first in a calendar year is primary for the children.

At one time, the Gender Rule was popular.  This meant that the father's insurance was always primary for the children.  Business that employed mostly males, complained because they got stuck with high insurance rates because of high use.  

[itiswhatitis]

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@Carmie wrote:

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@itiswhatitis wrote:

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@Carmie wrote:

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@KathyPet wrote:

If you are enrolled in Medicare it is always primary.  Your coverage with your husband's employer becomes secondary and will only pay the portion that Medicare did not cover.

---

That is not a true statement.  If you or your spouse are still working and eligible for Medicare and the employer has 20 or more employees, the primary insurance is the employees group plan and Medicare is secondary.

You can look up this information under TEFRA.

It is also possible that Medicare will not pick up a balance left after the primary plan.  There are many things that are not covered by Medicare, but could be covered under the group plan.

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Yes, when I had two coverage amounts it was called "coordination of benefits" and the primary payee was determined by something called the "birthday rule."  In that case, my spouse's insurance was first, then mine.

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If you have health coverage on your own plan and another policy under your spouse's plan, your coverage would be primary for yourself and your spouse's policy would be primary for him/her. If you have children and they are on both policies, the Birthday Rule would probably apply.  This rules states that whoever 's  birthday is first in a calendar year is primary for the children.

At one time, the Gender Rule was popular.  This meant that the father's insurance was always primary for the children.  Business that employed mostly males, complained because they got stuck with high insurance rates because of high use.  

Yes, this was the case for me some twenty years ago for family.  My husband had minimal coverage and my coverage from work was the one that carried the bulk of the coverage.  In my state "the birthday rule" applied and I had no problem with it.  I recall now, that it applied to my son and not "me though."  The birthday rule is applied for dependent children.  I had to think back a bit and search it.  I knew "birthday something" was at play in my circumstance.

[ErikaShops365]

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@lucieinthesky wrote:

Good advice from everyone. I will not make any more calls to them. I will just take my EOB from Medicare and go demand my reimbursement!   

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I'm not sure which state you live in, but most states require interest to be paid on monies held as "credit on account" aka COA.

Many medical offices mistakenly operate under the customer service premise of automatically treating the monies as COA and do NOT offer a refund unless the patient requests one. 

Some offices actually will use verbage such as "insurance has already taken care of most of the amount you would normally pay for today's services" and it is a MISLEADiNG statement.

Check to see if your state is one that requires interest to be paid to you on the COA.  It will be called interest or escrow.  If you're lucky enough to be in a state that requires it, be sure to find out the APR % and you can calculate the interest amount you've earned thus far.

Some medical offices give discounts if you prepay for services, even if you have insurance.  Same rule holds true for prepaid services and many of the insurance companies have clauses in the provider contract which specifically prohibits prepayment of services (ie: copays/coinsurance/deductibles) for any timeframe longer than 30 calendar days.

Good luck!

[on the bay]

Wow @Carmie@itiswhatitis

and so many of you know so much about the details of this-I applaud you for knowing so much and remembering it! It can all be so mind-boggling, so much so that I have gotten different answers to questions when I have spoken to medicare!

I want to reiterate what @Moonchilde wrote-

that when you stop working and may still have your employers insurance, or don't, still when you turn retirement age

(and I believe there is now a chart for this based on your birthday to make it even more complicated-it is not just 65 for everyone anymore since last year? or before?)I found this on the SS site.

Anyway-you must apply for medicare or you will be penalized every year that you do not and your yearly cost for medicare will go up!

Your employer should notify you of this and also the medicare book which good luck understanding and wading thru the 10,000 or so pages (ok I exagerrate but not much!) but don't depend on either to make sure you know!

It is best to make sure you get questions answered and straight hopefully with both medicare and your other insurance and make sure they are on the same page with your information.

 I always wonder how in the world "they" expect very elderly people to go thru all this and the not so elderly too! and many of the ones manning the phones don't quite have it all down either! Got to keep plugging away and trying to get it straight. Good luck to us all! Amen!

[Carmie]

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@on the bay wrote:

Wow @Carmie@itiswhatitis

and so many of you know so much about the details of this-I applaud you for knowing so much and remembering it! It can all be so mind-boggling, so much so that I have gotten different answers to questions when I have spoken to medicare!

@I want to reiterate what @Moonchilde wrote-

that when you stop working and may still have your employers insurance, or don't, still when you turn retirement age

(and I believe there is now a chart for this based on your birthday to make it even more complicated-it is not just 65 for everyone anymore since last year? or before?)I found this on the SS site.

Anyway-you must apply for medicare or you will be penalized every year that you do not and your yearly cost for medicare will go up!

Your employer should notify you of this and also the medicare book which good luck understanding and wading thru the 10,000 or so pages (ok I exagerrate but not much!) but don't depend on either to make sure you know!

It is best to make sure you get questions answered and straight hopefully with both medicare and your other insurance and make sure they are on the same page with your information.

 I always wonder how in the world "they" expect very elderly people to go thru all this and the not so elderly too! and many of the ones manning the phones don't quite have it all down either! Got to keep plugging away and trying to get it straight. Good luck to us all! Amen!

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Yes, you will be penalized for every year that you do not sign up for Medicare and Medicare RX, unless you already have coverage that is deemed credible.

If you have credible coverage, you should receive a letter of Credible Coverage every year  from your employer/health insurance company.  This letter is just junk mail and can be tossed out unless your insurance ends and you need to pick up Medicare anytime after the first 6 months you are eligible.  WIth this letter in hand, Medicare will waive all penalties.  You won't receive the letter unless you are 65 or retired.

I worked in the CS Dept of a major health insurance company from 1988 until 2015.  I think I have seen every problem that could possibly come up regarding every health insurance plan.  

I too, have had to call Medicare only to have to educate them.  Medicare CS is usually someone who works for a health insurance co.  They have been trained, but it takes many years to really understand health insurance.  The laws keep changing and medical personal have a difficult time keeping up too.

I retired recently, but still help people out with their health insurance/ Medicare issues when I can.  I have three years to go before I am Medicare eligible and I am keeping my fingers crossed that it's still going to be there for me and I still have my wits to understand it.

[KathyPet]

OK so I take back my comments about Medicare always being the primary insurance carrier.  It is possible that your husband's plan that you have coverage under is the primary and Medicare could be the secondary payor.  You do not mention receiving any benefit notices from your husband's insurance indicating what if anything they paid towards this surgery.  Have you received any explanation of benefits from them?  You really need to determine who the primary insuror is.  

The Medicare EOB form will tell you how much Medicare was actually billed by the Doctor.  This amount will tell you if Medicare was considered to be the primary coverage based on how much the Doctor's office billed them for. The EOB will then show you how much the approved Medicare amount for that procedure is and then how much Medicare paid.  You need to put that EOB together with whatever benefit explanation you received from your husband's insurance to determine who was considered to be the primary carrier based on which insurer was billed for the full amount and which was billed for the left over charges.

[Stray]

It all depends on your status.  Our Doctor and when I had foot surgery has the right to demand prepayment, co payment or not accept Medicare at all.  Many have the statement in the office waiting room.  Since you had cataract surgery, the office should be well versed in Medicare

You can submit your claim to Medicare directly as well.

that being said.  @moonchildes scenerio is correct.  If your husband is working and beyond 65 and you are an eligible spouse, Medicare is your secondary insurance and your private insurance primary.  At 65 you must sign up for Part A only, which covers hospitalization, only not physician fees.  So Medicare will not pay anything. 

If if your husband is retired and you are over 65, you must notify Medicare and at that time, you are eligible for Part B which will cover physician fees as well. 

Also, when Medicare is your primary and you or your physician file a claim and you have overpaid, Medicare will send you the refund.  They are good about it and prompt.  My husband was recently very ill and follow up visits to his private MD, who is not fully participating, were paid in full by us.  He filed the claim noting reimbursement was to go to us....his last visit 6/24 has been reimbursed already by Medicare and our secondary (COB).  Be sure you sign up for streamlining or Coordination of benefits with your private insurer so you can track your claims and better understand them.  I would suggest calling your husband's insurer as they will be well versed in your coverage and how it works with Medicare. 

You can open an account online at mymedicare.gov and track your claim to see if it was filed and any action.  If reimbursement, if you are eligible, was to be returned to you, they will follow up because the office will have been paid twice? Or maybe not at all.  I would deal with Medicare, not the doctor's office....believe it or not, I find them efficient. 

I think you might be confused about your coverage and the office confused as well because if you are 65, many times office staff think you are covered by Medicare A&B and maybe you aren't which will cause a delay.  But, I do my own tracking online with Medicare and my private secondary.  Print off all EOBs so you understand it all. 

[LilacTree]

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@lucieinthesky wrote:

I',m hoping someone here can give me some advice because I am at my wit's end. In March I had cataract surgery on both eyes. Upon going in the waiting room on the day of the first surgery, I am told how much I needed to pay up front (basically the amount not covered by insurance). I must say, I was a bit surprised by how much I had to pay because I have very good health insurance through my husband's employer as well as Medicare. Two weeks later, I have the second eye done and pay the same amount that day.

A couple of weeks later, I learn that they were not even aware that I had the Medicare and did not take that into consideration when calculating how much I would have to pay. I had given them the Medicare info last year at my last appointment, so they should have known. Anyway, they file on it. 

Here we are, 4 months later ----I have statements from Medicare showing their payment to the eye clinic, but I have not received a refund from the clinic. (Trying not to make this too long of a story) I have called and spoken to the same lady in the insurance/claims dept. at the eye clinic and she keeps telling me that they have not received payment from Medicare. I tell her that I have talked to medicare and they HAVE made payment to them. So, today I call and ask to speak to her supervisor. I get that person's voicemail and leave a message. Naturally, I get no call back. Not sure what my next step needs to be -- maybe State Board of Insurance to file a complaint.

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@lucieinthesky

I hate to say this, but from personal experience, it will take the state months to even begin to process your complaint.

I would send the doctor a certified letter demanding repayment immediately.  If you get nowhere with that, take it to an attorney.  I guarantee you will receive your repayment after just one letter from the attorney.  If there is anything any doctor is afraid of, it's law suits.

[lucieinthesky]

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@KathyPet wrote:

OK so I take back my comments about Medicare always being the primary insurance carrier.  It is possible that your husband's plan that you have coverage under is the primary and Medicare could be the secondary payor.  You do not mention receiving any benefit notices from your husband's insurance indicating what if anything they paid towards this surgery.  Have you received any explanation of benefits from them?  You really need to determine who the primary insuror is.  

The Medicare EOB form will tell you how much Medicare was actually billed by the Doctor.  This amount will tell you if Medicare was considered to be the primary coverage based on how much the Doctor's office billed them for. The EOB will then show you how much the approved Medicare amount for that procedure is and then how much Medicare paid.  You need to put that EOB together with whatever benefit explanation you received from your husband's insurance to determine who was considered to be the primary carrier based on which insurer was billed for the full amount and which was billed for the left over charges.

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I already know that my primary is my husband's insurance. When I made the eye clinic aware that I also had medicare, they filed it with medicare as the primary and it was denied. So, they then filed it as secondary and medicare paid. Yes, I do have EOB statements from my primary insurance showing what they paid.

[lucieinthesky]

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@Stray wrote:

It all depends on your status.  Our Doctor and when I had foot surgery has the right to demand prepayment, co payment or not accept Medicare at all.  Many have the statement in the office waiting room.  Since you had cataract surgery, the office should be well versed in Medicare

You can submit your claim to Medicare directly as well.

@that being said.  @moonchildes scenerio is correct.  If your husband is working and beyond 65 and you are an eligible spouse, Medicare is your secondary insurance and your private insurance primary.  At 65 you must sign up for Part A only, which covers hospitalization, only not physician fees.  So Medicare will not pay anything. 

If if your husband is retired and you are over 65, you must notify Medicare and at that time, you are eligible for Part B which will cover physician fees as well. 

Also, when Medicare is your primary and you or your physician file a claim and you have overpaid, Medicare will send you the refund.  They are good about it and prompt.  My husband was recently very ill and follow up visits to his private MD, who is not fully participating, were paid in full by us.  He filed the claim noting reimbursement was to go to us....his last visit 6/24 has been reimbursed already by Medicare and our secondary (COB).  Be sure you sign up for streamlining or Coordination of benefits with your private insurer so you can track your claims and better understand them.  I would suggest calling your husband's insurer as they will be well versed in your coverage and how it works with Medicare. 

You can open an account online at mymedicare.gov and track your claim to see if it was filed and any action.  If reimbursement, if you are eligible, was to be returned to you, they will follow up because the office will have been paid twice? Or maybe not at all.  I would deal with Medicare, not the doctor's office....believe it or not, I find them efficient. 

I think you might be confused about your coverage and the office confused as well because if you are 65, many times office staff think you are covered by Medicare A&B and maybe you aren't which will cause a delay.  But, I do my own tracking online with Medicare and my private secondary.  Print off all EOBs so you understand it all. 

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When I first signed up for medicare last year , I  opened an account with mymedicare.gov and I have been tracking the claims. That is how I knew that they had been paid to the clinic and that the clinic should have long ago re-imbursed me. And, yes, I do have part A & B.