Social Security/ Disability/ Medicare

Category Archives: Social Security/ Disability/ Medicare

Medicare: Avoid My Costly Mistake

Posted on May 24, 2010 by Jen 6 comments

I’m becoming accustomed to the ins and outs of Social Security Disability Insurance (or SSDI): I was claimed disabled in January of 2006, I was eligible for benefits starting in July of 2006, and I started receiving compensation in July of 2008 (after a lengthy legal process.) However, I was mid- MS relapse at the time of winning my case and since my husband and I were on shaky financial ground (living pretty much on his moderate income), we decided that I should opt out of my voluntary Medicare coverage that came along with qualifying for SSDI. The monthly cost was small– $110 for Part B medical coverage— and Part A hospitalization coverage was a freebie, but since I couldn’t afford to be on Part D prescription coverage because of my costly injectible MS drug, it seemed like a logical plan to just forego the Medicare Part B coverage and stay with my husband’s company’s extensive group insurance. So this is what we did in 2008, after having to keep the Medicare Part B coverage for a month or two until the lengthy processing could remove me from their list. When I was officially removed, we figured I was in the clear and I’d save $100/month for my Roth IRA contributions. And my husband’s insurance was pricey but very thorough, so there was no need (in our minds) for me to have dual coverage. Case closed? Hardly.

In December of 2009, I had a visit to a satellite emergency room that was a part of our larger local hospital system. When registering I learned that my insurance company knew I was Medicare-eligible. I was asked to submit my Medicare card and even though I no longer carried Part B coverage, I had kept the Part A freebie (why drop free coverage, we thought) so maybe this was considered a “hospitalization” claim. In a few weeks I received this claim, unpaid, from my insurance company with questioning about “coordination of medical coverage.” I wrote back explaining that I had no Part B coverage, only Part A. Soon after I received the bill again from the hospital with no Medicare payment and a partial insurance company payment. I was supposed to pay the remainder— about $600—- out-of-pocket. I already knew my insurance provider was supposed to pay the bill and I would only be left with a $50 ER visit copay. What was going on?? I was beginning to feel that this was no Part A claim, but a misunderstanding over a Part B claim.

I phoned my provider and asked why I was being billed for an out-patient ER visit that didn’t fall under Part A coverage. I reminded them that I had no Part B coverage and that they should resubmit the bill because I had always had just a $50 ER copay in the past. I was told then and there that I would now be responsible for any “Medicare-eligible” portions of Parts A or B claims, since I was eligible for Medicare, and that the insurance company would “carve out” this amount from their payments. Basically my insurance provider wanted me on Medicare so that Medicare would be my primary and then they would not have to pay the entirety of all my claims. I was livid and I told them that nowhere in their coverage material (neither in print nor online) was any of this mentioned. They responded that they would send me a letter with all of this information for my convenience. They could not provide any places where this information was made viewable to consumers. I was even more livid, but I figured my best option was to opt back into both Medicare Parts A and B.

Around the same time I received a bill from a care provider that I believed had been payed by my insurance in the summer of 2008. When I phoned the provider about this, they explained that my insurance company was now renegging on this bill due to what they believed Medicare was responsible for. And since I was technically covered for a brief period by Medicare Part B right after my settlement, the bill was submittable to Medicare. But instead of my insurance company sending a bill to Medicare after the fact, they simply withheld payment to that provider for a similar charge on someone else’s bill. So no proof that the payment was being rescinded, but an angry provider who now was billing me for their own loss. I was fuming. I was able to get the provider to relent with the bill, since they had no proof and I had proof in 2008 that my insurance DID initially pay. A similar bill came to me soon after and this time I had the provider resubmit the old bill to Medicare and have them get payment themselves. But I worried about how many old bills might be overturned in this way as an effort to get Medicare—or more likely ME— to end up paying. UGH.

Present day: I was just reinstated with Medicare Parts A and B, and even though I’m angry that my health insurance is now $110 more/month for the exact same coverage and will likely be complicated by having dual insurance, I suppose I have thwarted thousands of dollars in unnecessary bills that my original insurance company would continue to send me because I am “Medicare-eligible.” I didn’t get out of paying the $600 ER visit, or a separate $225 doctor’s bill, so I’m in the process of getting them off my plate and maybe this insurance fiasco off of my back.

What to Know Before Opting Out of Medicare

If you become eligible for Social Security Disability Insurance (SSDI) or any variation that qualifies you for Medicare, learn first from your insurance provider— if you already have insurance— whether they will “carve out” , “put aside”, or just plain “NOT PAY” a portion of your medical bills that they believe Medicare should pay, whether you are on Medicare Parts A and B or you wish to opt out. Not all companies do this, but when I contacted the billing company for the hospital, the representative seemed to know all about this Medicare-eligible “carve out” situation and further explained it to me.

Of course it’s frustrating to pay for Medicare insurance if you already have perfectly good coverage through private insurance, but when companies do audits to cut costs, they can learn about your Medicare eligibility and refuse to pay for Medicare-eligible services. It happened to me nearly two years after I thought I was in the clear.

Posted in Social Security/ Disability/ Medicare

MS and Affording a Disability Lawyer

Posted on January 21, 2009 by Jen 7 comments

Winning a social security disability insurance (SSDI) case can be very difficult, especially if you’re young and not completely incapacitated. Many disability case processors do not know the harrowing effects that multiple sclerosis can have and how fatigue and weakness alone can keep an otherwise motivated person from maintaining a steady, well-paying job. Sometimes it’s necessary to employ a disability lawyer to secure the case. And it is affordable, because reputable lawyers make it this way.

When I found myself going from a full-time, busy health career to a part-time, low-stress library job, I sensed that my multiple sclerosis would become an obstacle from that point forward. My premonition couldn’t have been more on-target: because of my MS, I began to have problems with fatigue and leg weakness that hindered me even at the library. A few years ago I was let go from the library due to MS-related absences, so I applied for social security (my sketchy employment had been a problem since 2003, so I knew it was time to seek some help.) My first application for disability was rejected about five months later, so I called my local MS Society chapter and inquired about disability lawyers.

I phoned and met with the first lawyer the MS Society recommended. He informed me that about 80% of his clients were through the MS Society, and he won about 95% of his cases. I felt very confident. But what made me feel the most secure was his payment policy: he would represent me and actively gather my evidence and and he would receive payment only AFTER he won my case. It was his gamble, not mine. He would receive payment through my accumulated back-pay, either a flat fee or 20% — the lesser of the two. This completely put my mind at ease and we moved forward. My case went on for 2 and a 1/2 years (from my initial application until my court appearance after my second rejection.) I doubt I could have presented as thorough a case to the judge— my lawyer presented full medical and work files with doctors’ and employers’ notes and surveys that he largely obtained himself— and so I was completely grateful to have employed him to represent me. The case dragged on so long that I ended up paying him the flat fee because it was less: between 15-20% of my back-pay.

I have come to note that this is the standard, ethical procedure for disability lawyers. They should not demand any sorts of fees up front— initial consultation or otherwise. The fee schedule is in place to afford middle- and lower-income clients a fair shot at SSDI. Anything else is unethical.

**To find a reputable disability lawyer, contact your local MS organizational chapter (The National MS Society in the United States.)

Posted in Social Security/ Disability/ Medicare

MS and Medicare Parts A, B, and D

Posted on August 19, 2008 by Jen 3 comments

I just came back from dropping my Medicare parts A and B coverage. I stopped in at my local social security office and opted out. Here’s why:

My husband has us covered under his small (less than 35 employees) company coverage, and even though it socks us with an almost $800 monthly premium (combined), it doesn’t cover dental or vision expenses, and it has a $30 copay for all medical visits, it DOES cover my Betaseron ($2k/month) in full, so there’s no copay.

I investigated Medicare’s coverage. Part A covers hospitalization, and it is similar in coverage to Bill’s company plan (and free with part B), but I have some issues with Part B, Medicare’s medical coverage. There is approximately a $97 premium each month (fine) and a $135 yearly deductible (again, fine.) But after the deductible, Medicare recipients pay 20% copayments on many medical costs. Even on Xrays/ MRIs. So routine MRIs, something that multiple sclerosis patients see as the norm, could end up costing about $4k a year or more, with a patient copayment of $800. Bill’s small company insurance copayment: $30/ per visit x 2 visits = $60. Just the crazy cost for MRIs put up a red flag for me.

Next, I learned about Medicare Part D, which I am not automatically enrolled in and must elect. My father warned me about this prescription plan. He and my mom, who made modest livings as public school teachers, really lucked out in their retirement. They both have solid pensions and my father’s good health coverage (paid for by 25+ years of work as a guidance counselor.) So they have Medicare and also their own good coverage for prescriptions. Part D is a good plan if the recipient is in general good health and doesn’t have many expensive presciptions. Ironically, this is the coverage for seniors, who tend to acquire more and more health problems as they age, causing them to need more and more expensive prescriptions.

For a lot of people with MS, good drug coverage is very essential. But when I asked for the best cost for my Betaseron (there are various drug plans under Part D), the best the Medicare rep could come up with was a $250 yearly deductible (fine) and a monthly copay of about $514 until I reached about $4k (after 8 months), and then the copay would go down to approximately $180/month. In the beginning of the year, the whole deductible and higher monthly copay would start again. UGH. Medicare Rx coverage: at least $514/month for most of the year v. Bill’s plan of a flat rate of about $390/month per person for prescription, medical, and hospitalization. And don’t forget the monthly Part B premium of $97. The choice seemed clear. I picked the lesser of the 2 evils.

Here is the part that makes me a little nervous about my decision: I will be getting the monthly Medicare premium back in my social security check, but because I opted out, if my husband somehow loses his job and we don’t have immediate coverage, to get back into Medicare coverage it will cost me another 10% on top of the Medicare $97 monthly premium for every year after I dropped the coverage. So if I find myself needing Medicare in, say, 14 years, I will then pay a monthly premium of about $240+/month for pretty mediocre to bad coverage. That’s not even counting the yearly increase in the original monthly premium. Or the $514+ monthly copays for the Betaseron!

If my husband worked for a larger company (100 employees or more), then I would incur no penalty for dropping and then reinstating Medicare at a later date. Fortunately I can reinstate it when I’m 65 with no penalty. Hopefully something better will come along in the meantime.

Posted in Social Security/ Disability/ Medicare

Multiple Sclerosis and Disability Benefits

Posted on July 24, 2008 by Jen 5 comments

I’m writing about this topic because I am once again exasperated by another person’s battle with the Social Security Administration. I recently read a post by Blindbeard (a fellow MS blogger) about her third social security disability insurance rejection. Reminds me of my own battle, which after 2 1/2 years, has finally been won.

I first filed for disability in February of 2006. I had just been layed off from my part-time job with a local library, after various attempts at modifying my hourly schedule, taking unpaid time off, and modifying my amount of bending, reaching, walking, and so on. I was there (both as an employee and a volunteer) for almost 2 years. The reason for my termination was clear: the inability to keep a regular work schedule. At the time of dismissal, I was down to about 15 hours a week. My employer (bless her) gave me a written and signed letter about the reason for termination, which I sent in with my disability application.

I was rejected the first time in July of that year. I heard this was standard, unless the claimant was completely incapacitated or had additional complicating medical conditions. So I contacted my local MS Society chapter and asked them if they knew of any reputable disability lawyers. I called the first one on the list.

My lawyer had us send out the first appeal and new supporting medical information. He told me this process was usually pretty quick, because the appeal would most likely be rejected and we’d have to make a second appeal to go to court. Still, I did not receive the second rejection letter until early 2007. The next step was to file another appeal, which would get us a hearing with a judge. That was filed in March of 2007 and in April I received my letter saying to gather as much medical evidence as possible and wait for the court date. My lawyer contacted any relevant doctors I had seen in the past 3 years (neurologists, primaries, and neuro-opthamologists.) I waited for my letter telling us to appear in court.

Finally, a year later— March of 2008—- I received my letter about appearing before a judge. My lawyer had me get a medical questionnaire filled out and signed by my neurologist. Apparently judges respect signed questionnaires, but not medical records. I did just that, and pestered my neurologist, who is very accommodating, until the questionnaire was in my hands. Basically it indicated that I cannot work a regular (even part-time) schedule outside of the home. Dah.

I’m happy to say that we had our day in court this June. 10 minutes of the judge verifying that I have not had gainful, full-time employment in about 5 years, and have ceased to be able to even work part-time regularly since 2006. He loved that stupid questionnaire! That was all it took, after more than 2 years of struggling.

I have to say that I am still waiting for the benefits to start coming. The judge said it could take 60-90 days. My husband and I are hoping for something in early August. I have had sporadic, at-home work and a little outside work in the past 2 years, and we are completely broke. Our out-of-pocket premiums for our health insurance are now $775/month, and we are in a little bit of debt (again, it could be a lot worse.) My husband doesn’t make a ton at his small company, which he has been at for 2 years. It’s awfully hard to live on one income these days, with staggering gas prices, outrageous mortgage payments, and other basic costs of living. Thankfully, our parents have helped us keep our debt from spiraling out of control.

This is the kicker: a person on social security disability insurance (SSDI) can still make some money on top of their payments with part-time employment. So as a person is going through the whole rejection process and feeling guilt and uncertainty because he or she wants to work, doesn’t want to milk the system, or maybe is able to work a little, after winning and receiving benefits, it turns out it’s still okay to do a little work. Weren’t they just telling us we’re capable of work so we don’t qualify for disability?…….

Posted in Social Security/ Disability/ Medicare