We've met our Medicare deductible for the year. How soon before we stop getting overcharged?

Factual Questions
1

I think this should be pretty simple. We’ve been on Medicare for just over a year. We have an AARP medi-gap policy backed by UHC. We met this year’s out-of-pocket deductible before the tenth of this month, but providers can’t see that in the system, and yesterday I had to pay full price for something that normally has zero co-pay.

So how long does it usually take before the system recognizes that our annual deductible has been met? I know that before I retired, our previous private high-deductible plan through my employer usually took three to four months to catch up, but I don’t remember experiencing anything like that kind of lag last year.

Lucy

2

i don’t think there’s a clear answer. The system will recognize that you’ve met your deductible when the claims are processed. I’ve seen provider claims show up on my UHC statement in a couple of weeks, and some that rattled around for three months before showing up.

3

What do you mean by “met your deductible”?

Your deductible is actually met when the insurance company calculates it is by their accepting and processing claims. They don’t know how much you actually paid to providers, don’t care, don’t have any way of utilizing the information if they did know. The just get a claim, see that they haven’t assigned the full deductible yet, and then assign some of it to that claim.

If you’ve actually paid more than the insurance company says you’ve met in deductible, chances are one of the providers you paid will wind up owing you money back once all the claims process.

4

Well, I guess I’m wrong then. Thought maybe it might be different with Medicare.

On our old high-deductible plan, our out-of-pocket expenses were supposed to be capped at $7,000 but we routinely ended up north of $11,000 with no recourse except hiring an attorney and suing for reimbursement. Just hurts a lot more now that our annual income is under $50K.

What I was hoping would be different is the three infusion medications that are supposed to be covered @ 80% by Medicare after the deductible is met would actually be paid. But we have had to pay 100% out-of-pocket so far this year for a total of more than four times the deductible.

Sigh.

Lucy

5

Do you have a senior care advisor or attorney?

6

No, can’t afford an attorney. We’ll just ride it out like everyone else. Not much else we can do. It’s frustrating, but this is what the rethuglicans want - this is our life now.

Lucy

7

I don’t think this is political.

If your infusion center knows you’re on Medicare and supplemental they can determine you’re covered.
I run into meeting my deductible on private insurance quickly because of dialysis. But my center knows my insurance coverage and waits til it catches up.
Talk to the insurance person at the center. They’ve heard this before. There’s no way I could pay for dialysis out of pocket.
I’m sure infusions are just as expensive.

Won’t hurt to ask.

8

Please understand that I’m frustrated. Let’s refer to it as ‘old white guy syndrome’ for now because it has been ‘a week’.

I guess it won’t hurt to provide a little background here: My wife suffers from Crohn’s Disease. She’s also Diabetic, with Diabetic Neuropathy, which complicates the treatment of her Crohn’s. At one point (about five years ago) her Crohn’s went into complete remission while she was on Humira™, but BCBS took her off of that because it was too expensive. That forced her Gastroenterologist to look for something else and so he started her on Entyvio™ which, at least this far, has not done anywhere near as good in controlling her symptoms. The infusions have proven more effective than the pens, but not by much.

When I signed up for Medicare, I chose an AARP-sponsored supplemental plan that covers everything that Medicare doesn’t, so, effectively, we’re covered at 100% for the vast majority of our needs. We’ve received some bills from providers that were zeroed out by UHC before we had a chance to pay them. Our Part D program could be a little better, but the drugs referred to in this thread, like a surprising number of things we get from pharmacies (like her CGM sensors) don’t fall under Part D.

The infusion center isn’t the issue - they know that we’ve met the deductible and will be billing Medicare and UHC accordingly.

Since the OP, I’ve learned that the problem right now is with the pharmacy that provides the drugs to the infusion center. As I understand it, their computer system is set up in such a way that, even though they are aware that we’ve already paid “them” four times our annual deductible, their system won’t bill Medicare until Medicare shows the deductible as having been met, so until then it’s cash & carry. My wife’s next infusion isn’t scheduled until around the middle of February, so, hopefully, this won’t come up again. This year.

It’s all about timing. My wife’s infusion schedule is on a six to eight-week schedule and varies a little up or down based on her bloodwork and symptomatology. Last year she didn’t have her first infusion until late February so this never came up. This year her first infusion was on January 3 and this has kinda blindsided us. I guess when I posted the OP I was hoping someone could tell me that Medicare is just a little more efficient at getting claims posted than the private insurance companies, but then, “wish in one hand” and all like that … We will work it out, as we have in years past but 'till then:

It Sucks.

Lucy