Diana's abdominoplasty/hernia repair insurance journey

[JackieOnLine]

you smoke?

sorry to hear it isn't going to happen but, like Munchkin, I think it will eventually.

 

[hilary1617]

Ultimately, you will prevail, of that I'm sure!

 

[DianaCox]

The saga continues ...

Where I left off in August - could not find a surgeon(s) willing to submit to insurance for abdominoplasty; my plan (with $4000 deductible) restarted on September 1st, and we had my daughter's beach wedding in mid-October, my mother was dying, we were working on getting a mortgage and buying a new-to-us RV, and Xmas, and then a nearly month-long RV trip in January-February. But in February (thanks in part to PT and other procedures for my tailbone pain), I met our new deductible, and starting thinking about surgery again - and keeping in mind that (1) we have a week long trip planned for May 17 and a two month RV trip planned for June-July; (2) my insurance plan ends Aug 31st again, and it will be the last time, since I turn 65 in August, so I have to change to a Medicare plan; and (3) the hernia is not getting better and I've had a twinge here and there.

At the end of the process in August, my PCP's office sent me the name of one in-network surgical practice (headquartered about 40 miles from my home) in which both surgeons are DOs and not MDs. I passed at the time. A couple of weeks ago, when I started thinking about this, I called and made back-to-back appointments with the two surgeons, which appointments were yesterday.

First thoughts - besides the long drive, I arrived on time for my 11am and 12pm appointments. I quickly realized that the office was running WAY behind. I was not brought back to see the first surgeon until well after 12pm. Needless to say, I was not impressed. HOWEVER, when Dr. J finally showed up, it went VERY well.

• He was receptive to my initial spiel about being a scientist and lawyer, and that he could talk to me at a higher level (I tell my doctors to assume I'm a podiatrist - medically knowledgeable, but not about their field), and he was accepting of my giving him three pages of printout of my medical history written to conform with my EoC's description of when reconstructive surgery was covered.
• He said he has submitted for abdominoplasty in the past and usually wins - he has a different approach for how he submits, which I am willing to consider, although I explained how I got Charles' abdominoplasty approved by the same insurance company.
• He suggested that even if I am not interested in further procedures (including butt and thighs), that he should submit for all of them, and he can argue for a staged set of procedures.
• We discussed a couple of more cosmetic procedures (I'm really not interested in a breast reduction/lift, but I would really like it if the underarm splooge that cannot be contained by any bra I've ever found were reduced), as well as fixing the incomplete work that was done on my face (it was supposed to be corrected by the surgeon who did the initial procedure in 2009, which was supposed to be the first of at least 3 procedures, but I chickened out) that could be done at the same time, for a "nominal" amount of out-of-pocket cost (is $1500-2000 nominal for lipo on my side ****age?).
• He determined that he could do everything I wanted done (the incisional hernia repair without mesh, the abdominoplasty and the lipoma excision) by himself, and didn't need the other surgeon to be involved (of all things, the lipoma on my flank was potentially the thing that she would arguably need to do), so I didn't have the second appointment after all.
• He said he's board certified in both specialties - I now have to start researching him.

So they took pix and are submitting. If I got into surgery by the end of the month (probably won't happen), I think I could be recovered enough by mid-May for the trip to LA, and the 2 month trip in the summer. If not, I can delay until we return in August.

I will likely elect a BCBS Medicare supplement plan of some sort to start in September, to make it easier for continuity of care, and in case I get approved for any/further procedures and insanely decide to go forward with them.

 

[Spiky Bugger]

I think you MIGHT need to do a lot of Medicare homework?

For example, I think that all a supplement does is pay some or all of the difference between the percentage paid by Medicare and percentage unpaid by Medicare

If, however, you carry (a not too costly) medical insurance policy through your employer, they are both "payers." The primary, usually Medicare Part B, pays (or doesn't pay) for what it covers and then the secondary insurance is billed, just like when a married couple with insurance cover each other.

The difference being that, again I think, in the first case, if Medicare doesn't cover it, either does the supplement, but the seconary might.

We have the opposite going right now. MrSue has been taking all kinds of medical and injectable meds for psoriasis. Our regular insurance (now his secondary) does not willingly cover the allegedly effective laser treatments for that condition. Medicare does. So he had to wait until he got Medicare.

As far as I can figure out, if Medicare doesn't cover it, the supplement is worthless.

Go S all this, beome an epert and inform the restifus.

Thanks.

 

[DianaCox]

I have forwarded your questions to the Medicare salesperson from BCBS I happened to have spoken to today. More when I get information back.

 

[southernlady]

You will want them done by the time you get to Medicare, not just in the pipeline.
Medicare supplements follow the Medicare rule for "cosmetic surgery": https://www.medicare.gov/coverage/cosmetic-surgery.html

Cosmetic surgery
How often is it covered?
Medicare doesn't cover cosmetic surgery unless it's needed for one of these:

• An accidental injury
• To improve the function of a malformed body part

Medicare covers breast prostheses for breast reconstruction if you had a mastectomy because of breast cancer.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c16.pdf

And unlike insurance companies run by corporations, Medicare can't be sued easily...you can appeal but they are likely to tell you to take a long walk off a short pier. Yes, you can get the hernia repaired but at the least costly option.

Okay. example: My cataract surgeries...considered by Medicare to be medically necessary. BUT just the removal of the cataract with a replacement using a standard BASIC lens. NO way to get the Toric Lens to correct my astigmatisms. Cataracts would leave me blind, astigmatisms come damn close but those can be corrected by glasses. So we paid out of pocket for my Toric Lenses. I had to pay for the lenses and the extra time in the OR on each surgery to implant the toric lens.

Notice that even hearing aids (which many elderly adults require) isn't covered under Medicare. One would think that would be a covered benefit. It isn't.

 

[DianaCox]

Ugh, ugh and UGH! Thanks for warning me - the surgeon said it wouldn't be a problem.

 

[CaitlynR]

Notice that even hearing aids (which many elderly adults require) isn't covered under Medicare. One would think that would be a covered benefit. It isn't.

What the hell. How in the world is that considered ok.

 

[southernlady]

What the hell. How in the world is that considered ok.

I don’t consider it ok. However, the Medicare Advantage plan I have does list it as a covered benefit as long as you use THEIR brand.

 

[Susan in Tennessee]

I think you MIGHT need to do a lot of Medicare homework?

For example, I think that all a supplement does is pay some or all of the difference between the percentage paid by Medicare and percentage unpaid by Medicare

If, however, you carry (a not too costly) medical insurance policy through your employer, they are both "payers." The primary, usually Medicare Part B, pays (or doesn't pay) for what it covers and then the secondary insurance is billed, just like when a married couple with insurance cover each other.

The difference being that, again I think, in the first case, if Medicare doesn't cover it, either does the supplement, but the seconary might.

We have the opposite going right now. MrSue has been taking all kinds of medical and injectable meds for psoriasis. Our regular insurance (now his secondary) does not willingly cover the allegedly effective laser treatments for that condition. Medicare does. So he had to wait until he got Medicare.

As far as I can figure out, if Medicare doesn't cover it, the supplement is worthless.

Go S all this, beome an epert and inform the restifus.

Thanks.

I believe you are correct, at least that's what I was told when I called regarding something on my husband one time. Supplemental policy only pays on something Medicare deems they will pay on. He had plan "f" and it covers yearly Medicare deductibles and the % that Medicare doesn't pay, just like Spiky Bugger said.

 

[DianaCox]

I’m being recommended to take plan G, as plan F is being phased out - any thoughts on that? One $183 deductible/year, about $125/mo.

I can’t keep my current BCBS PPO plan at work as a secondary. Primary or not at all. My plan (including Charles) costs the firm $25K/year, of which I pay $5K; we have a $4K in-network deductible; $9K out-of-network; out of pocket max (after deductibles met) is also high - $4K I think. But I get something over $2K from the firm in an HSA for partially covering the in-network deductible, and I put money in my HSA too, all pre-tax. I’m not seeing how that makes sense, except if the coverage is significantly different - but I’m open to suggestions!

 

[southernlady]

Your ability to do an HSA will disappear on Medicare. You can tuck it away in savings but it is not an HSA or an FSA.
Plan G is the best if Plan F is being phased out but I would take F until it IS phased out.

 

[Spiky Bugger]

....same way my husband's significant, service-connected hearing loss isn't covered by the VA. They'll give him hearing aids and consider him "repaired," because now he can "hear." (They WILL /DO compensate for tinnitus.)

 

[Spiky Bugger]

I’m being recommended to take plan G, as plan F is being phased out - any thoughts on that? One $183 deductible/year, about $125/mo.

I can’t keep my current BCBS PPO plan at work as a secondary. Primary or not at all. My plan (including Charles) costs the firm $25K/year, of which I pay $5K; we have a $4K in-network deductible; $9K out-of-network; out of pocket max (after deductibles met) is also high - $4K I think. But I get something over $2K from the firm in an HSA for partially covering the in-network deductible, and I put money in my HSA too, all pre-tax. I’m not seeing how that makes sense, except if the coverage is significantly different - but I’m open to suggestions!

They save $20k? Can you find a way that they might want to share some of that?

 

[southernlady]

DianaCox and anyone else facing Medicare before 1 January 2020:

Dh got this from his cousin who is a Medicare broker in NC

It is "supposed" to go away for new sales 1/1/20 because it is considered a "cadillac" plan under ACA. That could change of course. But anyone that has Plan F before 1/1 20 can keep it