Hello from Alabama
- Thread starter BellaRose
- Start date
Welcome, @BellaRose
Question, how does your BCBS policy fit in? Is it primary (as in your spouse), is it it secondary as in Medicare is primary, is it a Medicaid plan, or is it a Medicare Advantage option?
Okay, Medicare doesn't approve or disapprove bariatric surgery. You work with a surgeon to make sure you fit the criteria and if you do, you have surgery. IF Medicare agrees they dotted all the I's and crossed all the T's, they pay. There is NO pre-certification as far as Medicare is concerned...no pre-approval letter, etc.
Question, how does your BCBS policy fit in? Is it primary (as in your spouse), is it it secondary as in Medicare is primary, is it a Medicaid plan, or is it a Medicare Advantage option?
Oh and what part of Alabama? My mother in law and the kids/grandkids live between Birmingham and Anniston.
BellaRose
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- Mar 9, 2015
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- 5
I live close to Ft. Payne AL I'm about 1.5 hrs. from Birmingham. ... BCBS is my husband's policy where he works. It's primary my medicare is secondary. I will be losing the BCBS shortly then medicare will be primary and I"m thinking about getting a plan to go with it. Any suggestions here would be forever appreciated. The insurance lady at the doctor's office said if BCBS denied me that medicare would not pick up and pay....She also told me I would have to have required co-morbs. I was diagnosed with GERD and have DDD and bad knees. Any good advice? ....I love this site I'm new to it as of today....
She is so full of horseshit about that, it's hard to not sputter!!
Okay, at the time of my surgery, my husband still had employer insurance, his was primary for me, Medicare was MY secondary. Medicare paid 100% because I did not qualify for bariatric surgery due to not having a 5 year history of being over a 35 BMI that HIS insurance policy required. I kept slipping between 34 and 35 most of those years. All I needed with Medicare was a BMI of 35, a co-morbid (I had type 2 diabetes on an insulin pump), a history of FAILED attempts (I had been obese most of my life)
As to the co-morbids...THAT is where it gets tricky. I am not sure of exactly what Medicare requires...altho diabetes and sleep apnea are the two easiest. The problem lies in that Medicare doesn't exactly have a detailed list of co-morbids...except for type 2 diabetes:
They ADDED the VSG in a memo in July 2011. And deleted the requirement for a COE in Sept 2013. http://bariatricfacts.org/threads/cms-center-for-medicare-medicaid-service-the-coe.315/
IF you are losing his primary, find a Medicare Advantage plan to cover you...it completely depends on your zip code and what you want/willing to pay. I use a Medicare Advantage Regional PPO with drug coverage. Advantage plans cover the 20% that traditional Medicare does not cover.
If you need some help sorting all this out, let me know.
Marie Heaney
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- Mar 9, 2015
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I just wanted to say welcome from a fellow newbee!
BellaRose
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- Mar 9, 2015
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Thank you for your reply.....My BMI is 47.4 so it's a matter of life to get this revision. I'm passionate on fighting. She also told me I'd need to have 2 of these: severe sleep apnea, osteoarthritis, diabetes or Gerd plus taking medicines for them. How would I go about finding out that medicare won't pay if BCBS denies? Dr. Office sent in all my paperwork to BC/BS I got a denial then she said she done an appeal and was denied again....says she can't resubmit it.... If I know that Medicare would pay for sure I'd drop the BC/BS and get the plan you suggested.....I live in zip code 35966 it such a country region that out here we don't get Monday night football until Tues. lol .. I need all the help I can get....I've got all the paperwork that the insurance requires....5 yr. weight from pcp, 6 months completed diet with nutritionists, pcp approval, psy approval, stress test, chest xray, 3 month pcp visits.....I'm diagnosed with IBS, Depression, DDD, Scoliosis. I have appt. in morning for exam on knees and back for osteoarthritis.... What would be your recommendation for me...Thank you so much...
BellaRose
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- Mar 9, 2015
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- 5
Hello to you too. I hope you are well. I'm in the fighting ins. mode with my revision...
Munchkin
Full of Fairy Dust
Welcome! First suggestion, read the policy yourself. The actual policy. Post what it says here.
BellaRose
Member
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- Mar 9, 2015
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- 5
I will be dropping this ins soon and picking up a medicare advantage plan...thank you so much for taking a look at my ins. I don't know which way to turn anymore....
brooklyngirl
Yankee gone south
And good luck on your fight!
Okay, go to https://www.medicare.gov/find-a-plan/questions/home.aspx and plug in your zip code...apparently that zip code covers two counties and you have to chose which one.
Next step is to tell them HOW you get Medicare. I always click "I have original Medicare" and skip the options under it. Second question, I always click, "I don't get help"
Then it will ask you for medications. I usually skip that one NOW as all my options cover the two medications I am still on.
Then it will tell you how many plans are available in your area. The second option is the Medicare Advantage plans WITH drug coverage. (First option is JUST the drug coverage), third option is the advantage plans WITHOUT drug coverage. I always look at the ones WITH drug coverage now...back when I was also on my husband's policy, I did without Medicare's drug coverage cause his employer based one was SO much better.
IF you need more help and want privacy, use the Start a Conversation with me by clicking on my avatar. An overlay will pop up and one option is to "Start a Conversation". That is if you want more privacy. If you don't mind putting your county of residence in this thread, just hit reply.
aaa
Well-Known Member
Welcome.
Hello & welcome to the forum.
I don't know about all this stuff - insurance really confuses me - but there are smart people here (like Liz) who will help.
good luck!!
I don't know about all this stuff - insurance really confuses me - but there are smart people here (like Liz) who will help.
good luck!!
