Navigating the Medicare Insurance Maze!

Hi there – I’d like to share the story of an old colleague of mine, who is herself a nurse advocate. Her situation illustrates the point that everyone, even nurses themselves, needs an advocate at some time. It was hearing stories like this that inspired Patti and I to form Heartwood Health.
(Names and insurance companies involved in this case have been made anonymous.)

“Back in 2001 my partner put me on her health care insurance. This was a benefit provided by her company and was more cost effective than getting my own policy through my employment. The only thing we had to do was provide a notarized statement that we shared a home and had for several years.

Everything worked very well. When my partner’s division was sold to a private company the insurance benefits traveled with her.

In 2005 I became eligible for Medicare, and I spoke at length with a very nice woman with Social Security. She researched my insurance options at length, made many phone calls, and then told me my best option was to keep what I had, enroll in Medicare Part A, and decline Part B. This was based on a Medicare regulation allowing a retired domestic partner to continue on the employed partner's policy. Medicare A would be the secondary payor.

Last year we changed to a different carrier, and when that new carrier was bought out and became what I’ll call Carrier 2, the fun started. All of a sudden I was informed that Medicare was now primary. For example, this meant that lab work would first be billed to Medicare Part A, would be declined as Part A doesn't cover out-patient procedures, then billed to Carrier 2. As a result I was getting bills from the lab, paying them, then getting a refund eventually, sometimes three months later.

It still was working, but it was very unusual. I did call Medicare (not Social Security ... note well, always call Social Security), and the Medicare rep told me that Medicare was indeed primary.

On January 19, 2010, I received a registered letter, return receipt requested, from Carrier 2 stating that since I had refused Medicare B five years ago, Carrier 2 would only pay that part of any outpatient procedure that would not be covered by Part B if I had it. And this was in effect as of January 15, 2010, four days before I received the notification.

This was very concerning. First I called Carrier 2 to see if they could sort out a mistake, perhaps a computer mis-click. Several more calls ensued, and Carrier 2 continued to deny any responsibility for anything that would have been covered by Medicare Part B. This was made worse because I had a rotator cuff repair scheduled for February 5, less than three weeks away, and my physician does these as an out-patient procedure, no exception, save co-morbidities that I didn't have.

I called Medicare, got a very short, rude response from a woman who answered the phone. She told me that I had done this all wrong five years ago, that I had refused part B, and that I could apply for it but would be subjected to a $50/month penalty in addition to the $100/month (or so) premium. She said she would send me the paperwork to fill out, but to this day I haven’t received it.

In the meantime my partner contacted her company liaison with Carrier 2. This person worked and worked and worked on this. But we still kept getting denial of responsibility from Carrier 2. At first they said it was a regulation that I had to have Part B. I proved that wrong. Then they said that they could require it even if it wasn't a regulation. That was more or less wrong, dependant on the contract they had with my partner's company.

An interesting aside: I had a call from a volunteer for the reelection of Gov. David Patterson of New York. In our conversation I told her about my issues with insurance, domestic partner rights and my current problem. It happened that this woman was an attorney with ERISA (Employee Retirement Income Security Act of 1974), and she was enormously helpful, asked me to contact her if I wasn't successful in the battle with Carrier 2.

The next time I spoke with the Carrier 2 rep, I mentioned ERISA, and I left the impression that I had contacted an attorney from that office, not quite true of course. But hey, we do what we need to do.

Per the advice from the ERISA person, I called Social Security, got someone incredibly knowledgeable and helpful who more or less said "hell no" Medicare can't penalize me if I now elect Part B. I came under a category termed special enrollment, a person who is insured by: 1. Self, 2. Spouse, 3. Someone who lives in the household. I qualified under part 3. This means that even though I declined, not refused, (per advice of Social Security rep) Part B back in 2005, I could enroll in Part B at anytime in the future without penalty.

At this point the company liaison brought the company contract with Carrier 2 to the attention of the Carrier 2 rep. Bingo! The contract explicitly included domestic partners.

I made something like 20 phone calls to Carrier 2, Medicare and Social Security between January 20 and February 1, 2010, managed to refute every argument that Carrier 2 came up with, and on Feb 1, 2010, 4 days before my scheduled surgery, I received a call from a rep at Carrier 2 with an apology. My coverage was in effect as before all this began. I asked her for a letter or even an email stating this, and she "declined" to give it to me, said her supervisor wouldn't allow that. She did tell me that all our conversations including this one were recorded, and that recording was part of the permanent record. Yeah, right.

I did keep careful notes, much of which I have written here. I have applied for Medicare Part B as I am certain Carrier 2 will rewrite their contract with my partner's company when renewal time comes. It is to the benefit of these for profit companies to get people like me off the books as soon as they can.

I am an RN, and believe me I have gone to battle for my patients with insurance companies many times. I am fortunate to know that "no" is not always the final answer and that it takes persistence and fortitude to fight these battles.

I am also certain that most retired people of my age do not have the knowledge to pursue a denial. All need help from an advocate. Most do not have money to hire an attorney. Most attorneys will not take a case like this with no realistic hope of a cash settlement. I am lucky to have a couple or three in the family, and they guided me through my long days of calling and calling and calling, and made sure I was documenting everything. But I am not most people.

Today I am wondering how the new health reform will change all this. I am hopeful, but I am realistic. In the meantime, I thank Heartwood health for providing advocacy. Everyone, and I do mean everyone, will need it at one time or another.”