312) Insurance & Medicare Blues

January 6, 2009

Earlier: So, I hate posting about money and insurance and such... but now it has become something to address in this blog... mostly for the considerations of others wrestling with ESRD and dialysis and such. Back in 2006, when I began dialysis, I was on the University of Texas system insurance and it was excellente'. When I came up with the PKD diagnosis, Liz and I transferred me from my TNOYS' small group (8) plan to the big University plan, where I just slipped into the stream of thousands of participants. In those days the University plan covered everything with just low co-pays and reasonable med coverage.

Well, then the state vs university issues related to caps on how much UT and others can charge students was brewing, the university was claiming that they were struggling with all their finances, and needed to find ways to save money, as well as generate new income. They wanted to break the cap on student costs, which they eventually did... causing college costs to raise by 8-29% back in 2004*, and in 2007 the university proposed raising costs an additional 13 to 22%**. So, what this is all about is that the University, in order to save money, also was looking for cheaper insurance packages for the staff and faculty. Our initial insurance thru the university had about four options and we selected one that met our needs; and in hindsight it was a very generous plan. T
hen, last year, the HMO plan we had was axed and the only plan available was a PPO plan with a large (to me) deductible ($250 per person) which we had to pay in the first month... that was a new costly twist for us. After that it seemed that things were okay again. We had adjustments in our outgoing costs which Liz mostly handled through her planning and socking money into her Payflex account.

Meanwhile, Sherry the Social Worker at El Milagro kept bugging me about getting on Medicare, saying that my insurance would hit a time limitation and then I'd have to be covered by Medicare. Liz said, "there is no cap on our insurance" so I just let the whole thing ride.

Now I must admit that I have NO interest and a fairly severe aversion to the insurance side of this whole dialysis medical condition thing. I hate dealing with insurance companies in general and I always feel like an idiot when I try to understand any of their fina
ncial jargon. So, when insurance things progress I usually hope that my best buddy Liz will take care of it all. She is the one who deals with insurance, prescriptions, etc. and God will surely recognize her in his Book of Life for her mitzvahs to me over these years. And, as I write this I know that this is MY own version of the story, and it is twisted by my obnoxiously fetid feelings about insurance.

Anyway, I put off doing anything and finally Sherry Social Worker said "We HAVE
to Do This!" and Lizzie said, "She's right. Do it, dammit." and I filled out and sent in my Medicare application, dated whatever date I sent it in. They explained to me that it would cost me a monthly premium to have Medicare and I thought of that as a little like the flying money cartoon at the right ---> and thinking things like; "I've been paying out for insurance my entire work life for 40 years and never used a dime of it til this damn PKD thing came along... they owe me...".

So, I send it in and then about 30 seconds after it leaves my grubby little fingers, I get in the mail a bill from El Milagro for 987 dollars and 64 cents for September! Well... that must be some sort of mistake I tell myself, Liz, and everyone within earshot. Without another thought I take the bill to Sherry Social Worker and she says, "I'll check into it." and I forget the whole thing. Keeping that bill in my mind would pollute my daily happy as a clam attitude so I file it. I have this uncanny ability to file things in a portion of my brain that I don't even have a map for... they're back there somewhere, in a place similar to where they stored the arc at the end of the first Indiana Jones movie... along with hundreds of other boxed and stored thoughts that only lead to trouble.

In less time than I would have liked, Sherry Social Worker comes back to me and shrugs that the bill is "FOR REAL", my time limit of 30 months of dialysis was reached for my insurance and now El Milagro is billing me for the part the insurance won't pay anymore (20%) ... and this is the bill for September.. and I might have to pay it! My mind automatically flips to it's anarchistic channel and I think... "Sure... I'll pay it at about a dollar a month..." Sherry is very social worky about the whole thing, saying supportive things like she is sorry, she's sure something can be done, we can make an appeal to the rich guys who give money away, etc. etc. And I am vomiting brain curses and anger and bile of the sorts I can't even describe here. (This is only funny now, many weeks and solutions later, BTW)

How ironic! I put in an application starting my Medicare premium at the latest possible date and then get a bill that is nine times that amount that I should have to pay while I am trying to save the measly hunert bucks a month. And there's more to come... another bill for 5 hunert something for October and it's gonna keep going... yikes!

So, Sherry Social Worker says there might be something I can do with the Medicare folks; I should call them and ask to change the date on my application. If they'll let me change the date to September then those bills will be paid by Medicare, not Jack. And paying a hunert bucks premium now seems like a small price to pay for such coverage, doncha' think?

And before I even get a chance to call Medicare I get a letter from them saying; "We did not give you you medical insurance earlier because we did not process it timely. If you want the benefits earlier, you can choose... blah blah blah. And it seems like this whole thing may be settled before the flying dollars get too high to grab back.

But, before it is settled, I must pay my dues: I must contact the Social Security Administration by phone and talk to a bureaucrat! Here in the postmodern world we have this cool new function on our phones. We can punch in a number and then, as long as we don't call any other number, we can hit a little button named "redial" and the phone actually remembers the last number we dialed and dials it again... beep beep beep - beep beep beep beep! This is a very helpful function when one is trying to call Social Security. In fact, I kept count, just for fun... and it takes me 32 tries before getting a line into the place. I get Ms. Blanket and she is very nice and she "Hmmm"'s as I review the letter and tell my story. And she quickly assesses the situation and concludes, "You must appeal... I will send you a form". I protest, saying I don't really need to "appeal" their decision in the letter. I quote from the letter to her: "...we did not process (your application) it timely. If you want these benefits earlier, you can choose... tell us in writing..." and then I add, "all I want is to start the benefits on September 2008, not the date the letter suggests; December 2007".

"Hmmmm. Well, sir, you need to appeal and I will send you a form." I get it, so I say, "Do you have my address?" and Ms. Blanket has it covered... "Yes... we have ALL the information and I will send out your appeal form today." So, there ya go! I am all fixed up. I want to feel confident the whole thing is settled, so I make up a little affirmation to say: "I am serenely happy that my Medicare is completely settled and serving my highest interests" I will memorize this and try to repeat it a hunert times a day til I get my form and complete it and send it back.
Nam Myōhō Renge Kyō***

Morning: Can you believe those Longhorns? What a game... depressing in the first half, good third quarter ending with us ahead and then high fear, loathing, and nail biting in the fourth all the way down to two and half minutes left, when McCoy threw to Cosby for the win with only 16 seconds left. Whew!

El Milagro: I walk in, weigh and poke my head around the corner to Sherry Social Worker's office to show her my Social Security letter and catch her up with my talk with Ms. Blanket. Sherry doesn't seem as enthused about 'appealing' as I was... thinks I should go for the early date and ask the Kidney Foundation to pay the difference. I reply that I think it is better to go thru the appeal process and not use the foundation unless absolutely necessary.

I move on to touch base with Jordi the Dietician, who is standing shortly at the nurses counter and has a new lab report for me. Yes, phosphorous is still high, but only at 5.7, which is more respectable than the last 10.4 phosphorous. She says again that she thinks that one was a mistake. I turn over to her my food chart (from 12/19 til today) to review and mention that it is probably not the best report due to the holidays looking different in my food behavior than more normal times of the year... like the upcoming time in January. So, I say I'll continue reporting it if that is of interest to her. She shrugs, so I'll continue.

Kim the Nurse hooks me up and does my nursing evaluation, while Celeste the Nurse sets up the machine. I settle in to reading my Alex Delaware mystery and half listening to ATC on NPR. Also floating around in the background are various images and sparks of ideas related to a new writing project I just started with my old colleague Leslie. Since I can't get those sparks to lie down, I lie back, put down my book, and concentrate on the radio news... and, of course drift off into la la land. Wake up at 7 and watch NOVA about the Brits who tried unsuccessfully to track the northwest passage over Canada and got frozen into horrible, gap-mouthed, monstrosities that would't be found for hundreds of years or so. Fascinating... and then doze some more and wake to a Frontline Report on the old man and the storm****, which is really worth watching. This absorbs me for the rest of my time and then I get unhooked by Celeste the Nurse, and truck on home.

Notes: In at 78.7 and out at 75.4 kgs
Nazareno, A. (2004) College costs raising faster than incomes. Retrieved online from the College Parents of America website, http://www.collegeparents.org/cpa/about-in_news.html?n=1026
**Hacker, H., Brooks, K., and Rosen, A. (2007) UT, other colleges get third degree for soaring tuition costs.
Dallas Morning News, retreived online from http://www.wiche.edu/news/clips/07Nov18_DallasNews.pdf.
***Daimoku, retrieved online from Wikepedia, http://en.wikipedia.org/wiki/Daimoku
... and in my own translation, from the days of the many morning meditations (circa 1975), "all things according to God's will".
**** The Old Man and The Storm, retrieved online from Frontline, http://www.pbs.org/wgbh/pages/frontline/katrina/


billpeckham.com said...

What are you appealing? The Medicare effective date?

The key is to be sure your provider is submitting Medicare's unpaid 20% to the university and the university insurance now understands they're secondary to Medicare.

Medicare should now be primary - this means they will pay 80% of the their approved rate, then your secondary insurance which is now the university should pick up the 20%.

You'll be responsible for Medicare premiums and any copays or deductibles the university insurance requires. Also note your provider is now getting significantly less income per treatment for providing your care.

Jack Nowicki said...

Bill ~ thanks for the clarification. You are right about the 80/20 thing. The difficulty in my case was that when the social worker and I worked to finally apply, months after I knew I was able to apply, she didn't clearly state that my date would be connected to my being billed by the dialysis center. I naively thought that the whole switchover was up to me and dependent upon when I wanted to start paying the Medicare premiums: I didn't realize that on some date the facility would bill ME for dialysis... so, when I got a 900 bill I was motivated to select a medicare date that would cover that bill. So, then I got my Medicare letter saying I could start 12/07 and pay the premiums for the last year, or start 12/08 and start paying now. I want to start 9/08 and pay their premium instead of the bill from El Milagro. Does this make sense to you?

So, when I talked to the lady at SS she indicated that if I want to do anything different than what they offered in their original letter, I must "appeal". JN