Big surprise in mail

[ThePlumber1964]

Hugh,

If this is a Medicare Advantage, they MUST cover it; no “but” or “exclusion”, period. If it is another type of complementary insurance, this will be your worst case scenario: Medicare pays for the 80% of all set pre-arranged costs, and you can/will only be held responsible for the 20% of such pre-set costs. That is the law as of today, and they cannot ask you to pay more than such 20%, period. Otherwise, someone is violating the federal law, and usually, as a crime, is prosecuted and paid with jail time, period.

If it is not Medicare, then it is another story.

[Anonymous3]

It not over. The dr is appealing it, then I will appeal it to OPM, the start a Congressional investiagation. It is GeHA thing. I looked at the Blue cross federal plan and they pay

[TomW46]

Medicare and FEP Blue Cross paid every penny for mine. I dumped GEHA years ago over stuff they wouldn't pay. Dealing with them was a nightmare. With both Medicare and Blue Cross, I never pay anything.

[ThePlumber1964]

Agree, that such combo is a great one. I had BSBC Advantage for the original implant and the first revision, and only paid $150, as described in DOB, as an ambulatory procedure, even staying 23 hours.

Now I have a Humana Advantage PPO, which does not even require a pre-authorization since Medicare covers it as long as it is a medical necessity.

[Anonymous3]

We had bcbs till their premiums got so high

[Anonymous3]

Hugh,

If this is a Medicare Advantage, they MUST cover it; no “but” or “exclusion”, period. If it is another type of complementary insurance, this will be your worst case scenario: Medicare pays for the 80% of all set pre-arranged costs, and you can/will only be held responsible for the 20% of such pre-set costs. That is the law as of today, and they cannot ask you to pay more than such 20%, period. Otherwise, someone is violating the federal law, and usually, as a crime, is prosecuted and paid with jail time, period.

If it is not Medicare, then it is another story.

The problem is not Medicare it GeHA. The changed administrator from Coventry to Aetna

[ThePlumber1964]

Hugh,

I understand your situation. Still, if they are initially refusing as a co-insurance to pay, the base price has to be what Medicare has set as usual and customary costs for the procedure, and Medicare will pay the 80% of such amount since is medically needed; otherwise your surgeon would have not done it.

The other 20% has to be based on the amount set by Medicare, not as a private entity would have paid. Your fight for fair payment of whatever is your share of the cost should be using that figure as the baseline.

Now, since the office and the facility went ahead and proceeded with the surgery, you being told that it will be covered, it it in their best interest to get such appeal approved. Specially since you were not requested to pay anything upfront as a condition to perform the procedure. Keep them as part of your team, because they are as vested as you are to have this resolved in your/their favor.

My 2 cents...

[Anonymous3]

I am they think it is stupid also. Told me they had never had GEHA not pay. It not everyday you have to get an implant. The not covered section is about 40 pages deep