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  • Financial Impact After 30 Month COB Period When Medicare Becomes Primary?

    I started HHD, and became eligible for Medicare Parts A & B effective July 1, 2012. I didn't enroll in Medicare Part B until January 1, 2013 because there was little financial benefit to do so, e.g. my employer's health plan deductible and out of pocket max was already past the point of any savings through Medicare as secondary.

    Since 1-1-13, Medicare has been secondary, and in return for my Medicare annual premium outlay of between $1200 and $1300 (round numbers), I have been able to avoid paying a cent towards my employer's deductibles of between $1600 and $2000, and out of pocket max of between $3500 and $4000 - a very nice annual savings and return on my Medicare premiums (and also my employer's health insurance annual premiums of roughly $900 to $1800).

    I suspect the good times are going to come to an abrupt end starting 1-1-15, when Medicare becomes primary and my employer's insurance secondary. If I understand the change in insurance precedence properly, the 20% portion that Medicare does not pay on each claim will drop into my employer's insurance $2000 deductible, and when that is met, will then be subject to my employer's insurance 15% copay, which will continue until I reach the full $4000 annual out of pocket max.

    According to my calculations, even with the reduced reimbursement for each HHD treatment as paid by Medicare, the 20% portion as it drops into my annual deductible and then at a 15% copay, will have me paying out of pocket all through 2015 before I reach the $4000 out of pocket max.

    In 2013 and 2014, the deductible and copay accumulation to out of pocket max was reached by late January of each year owed to the much larger amount reimbursed for each HHD treatment by my employer's insurance. The $3500 (2013) and subsequently $4000 (2014) out of pocket max amounts got picked up by Medicare and/or were never submitted by my provider's to Medicare, perhaps owed to the significantly lower reimbursement rates - roughly 1/3rd of my employer's insurance.

    Unless my calculations are wrong, the new arrangement with Medicare primary and employer's insurance secondary, will produce little if any financial benefit for my Medicare premium investment - I will be stuck paying my employer's insurance $4000 out of pocket max in stark contrast to 2013 and 2014, when my out of pocket max was limited to my annual Medicare premiums of about $1200 to $1300, a difference of $2700 to $2800 per year out of pocket that I saved. Regrettably, this will remain the case until I decide to retire in 6 to 8 years and then become subject to a whole new set of medical insurance circumstances.

  • #2
    That sounds about right. I calculate that I will be Medicare primary on July 1, 2016. However I just signed papers Friday to join the paired exchange list so odds are good I will have a kidney by then. I am like you that I have a $1700 deductible and 3650 out of pocket that needs to be met. And I believe your write up to be accurate.

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    • #3
      Good luck with your paired exchange. The new rules on cadaver kidney transplantion will have me waiting several more years (listed for three years) before a kidney becomes available. It's not an issue for me, as the 2-1/2 year gig on HHD has gone very well, with transplantation representing freedom from hemodialysis but a whole new set of challenges and unknowns.

      The sad reality is that the roughly $5500 that I saved over the span of two years with Medicare as secondary, will be spent in a single year - 2015. After that, I am facing roughly $5300 out of pocket per year - the sum of my employer's insurance out of pocket max plus Medicare premiums compared to the $4000 out of pocket max from my employer's insurance. In effect, I will receive no savings whatsoever from the nearly $1300/year Medicare premium investment outside of being able to deduct the cost of the premiums from my State of Wisconsin income tax return.

      At this point, it would make sense to drop Medicare Part B, but my employer's insurance would never allow that, having waited 24 months for 1-1-15 to come. My employer's insurance out of pocket max does offer limit of financial exposure that Medicare does not - there is no out of pocket max associated with Medicare, that is what Medigap policies are for.

      As a dialysis patient, no companies offering Medigap policies will insure me owed to the known costs of dialysis. There is some type of Medicare gap insurance coverage available for dialyis patients on Medicare, but I have yet to explore the details as my plan is to remain employed and continue my employer's insurance coverage for the next 5-1/2 to 7-1/2 years.

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      • #4
        Do you live in a State that offers a Medicare Advantage plan? Here in Florida the Medicare Advantage plan pays for all my Medicare parts A, B and D. I have not had any out of pocket expense for over 5 years now. I have been on disability for 5 years and want to get my student loans discharged as I have no plans on going back to a job that takes any taxes out of my money. I play Poker Professionally on Sovereign Nation lands so there are no taxes. Which Dr is my best choice to sign my permanent disability papers?

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        • #5
          stumpr, my understanding, as a new Medicare senior myself (but not on dialysis) is that you ARE covered for kidney disease/renal failure in full. I chose Blue Shield Plan K, with a $42.mo. cost ( lower because it is deducted from my bank, otherwise $47,) and the MediGap that covers any of the Plan B 20% left over. MY understanding is the FIRST 6 months .year you are offered Medigap insurance ANY company you choose must accept you..no medical limits.

          BUT if you DON'T begin paying for Medigap when first offered in the first year at age 65/66 then they have NO obligation to cover you.
          CONVERSELY I DID NOT pay for Plan B $104 a month between age 62 and 65 because I HAD VA coverage..so the $3600 I saved went towards paying for future medical needs now.

          SInce I began Plan B last year I need the ER 3 times..at a cost of $10K each time( those are falsely inflated, as no one pays that, even cash patients) ( but my out of pocket was only a couple hundred at most, each time)

          If I choose toy leave BlueShield, or maybe change plans inside BS I may fall under the " drop me" plan problem because I have far too many medical issues , like CKD stage 4, BP meds, post kidney cancer, etc…post car accident/injury..on and on. So I grabbed the Medigap when they were obligated to cover me.

          I could eb wrong on my numbers, but I hope you can find a solution tha doesn't eat up all your savings.or possibly you must pay for a few years until age 65??

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          • #6
            So New and confused about managing my Diabetes w/ every complication, eyes, CKD stage 4. Have been Self employed since 1982 not eligible for Disability. Since I am 61 I am having huge stress mentally about covering my medical costs. Living in AZ I have not been able to really understand how I am going to get the proper medical attention with limited funds and too young for medicare

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            • #7
              If you are on dialysis, you automatically qualify for SSDI, as well as Medicare, regardless of your age. Of course, if you have insurance now, there will be that period between when your current insurance is primary until Medicare becomes primary.

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              • #8
                Here's an update to my rather financially pessimistic 01-07-2015, 12:22 PM post. It turns out that my employer's insurance, which became secondary to Medicare after the 30 month COB period picks up anything not paid by Medicare, e.g. the 20% coinsurance without requiring a deductible or any out of pocket amount to be paid by me as would be the case if employer's insurance was primary and no Medicare coverage.

                During the 30 month COB, Medicare picked up what my employer's insurance did not, and as such, I was not required to pay any deductible or out of pocket for the employer's insurance plan. The reasons for all of this are somewhat cryptic. Here is the explanation I received: the reimbursement rate for employer's insurance is 3X that of Medicare, as a result employer's insurance are obligated to cover up to that amount. After Medicare pays its portion, the rather small amount (20% of an amount that is 1/3 of the amount employer's insurance would pay) remains. This amount is paid by the secondary insurer (employer's insurance) without requiring any payment towards the annual deductible or out of pocket. Both deductible and out of pocket amounts in my employer's insurance increase by the amounts paid, and in with each claim the "Amount You Owe" remains $0.00.

                I am uncertain if all employer or other insurance coverage as primary or secondary with Medicare work in this manner, e.g. no employer's insurance deductible or out of pocket payments required. In my case, having Medicare and employers insurance during the 30 month COB period and beyond has produced and will continue to produce savings of out of pocket max. As an added bonus, I am able to deduct (against income) the cost of Medicare Part B premiums on my State tax return as these premiums are paid with after tax dollars. Overlooking the burdens of HHD, not a bad financial proposition in return for $1449.60 annual investment in Medicare Part B premiums.

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                • #9
                  I'm at stage 3A CKD, I have no insurance. What is my prognosis? Die a slow death, as no money for a doctor?

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                  • #10
                    i have stage 4 and got done work can i get ssdi

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                    • #11
                      Hi shilsea, you may contact the DaVita Guest Services team to speak with an insurance specialist to get your questions answered. They can be reached by calling 1-800-400-8331 or emailing guestservices@davita.com. Thank you!

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                      • #12
                        I was diagnosed back in 2004 with PKD never took it seriously
                        well now I do, my GFR in Oct was 35 and I do not feel good, I have a lot of pain in my kidneys, my job is high stress and high pressure, I am in sales, it is getting very difficult to do my job, I am tired all the time, very concerned about my future, I don't know what to do, my next Dr Appointment is Feb, just hope my GFR has not changed.
                        any suggestions? I have signed up for the 90 minute class tomorrow, but if anyone has good thoughts for me?
                        thanks for listening

                        Comment


                        • #13
                          Originally posted by KLAYSON View Post
                          I was diagnosed back in 2004 with PKD never took it seriously
                          well now I do, my GFR in Oct was 35 and I do not feel good, I have a lot of pain in my kidneys, my job is high stress and high pressure, I am in sales, it is getting very difficult to do my job, I am tired all the time, very concerned about my future, I don't know what to do, my next Dr Appointment is Feb, just hope my GFR has not changed.
                          any suggestions? I have signed up for the 90 minute class tomorrow, but if anyone has good thoughts for me?
                          thanks for listening

                          ​Hi KLAYSON, welcome to myDaVita!

                          I was going to suggest attending a no-cost Kidney Smart class so it's great that you're already planning on that! It's a nice opportunity to get your questions answered by a local kidney disease education expert.

                          You could also speak with a local social worker to discuss working an any lifestyle changes you're experiencing.

                          I hope that helps and that you enjoy the Kidney Smart class. Wishing you the best. Happy New Year!

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                          • #14
                            I did not take the class, I did not understand why Davita wants access to all my medical records?

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