Back Surgery, and who pays?

Posted by 1634517678 @1634517678, Aug 17 9:16am

I am 65, epilepsy since 22 yrs old, 95% controlled until 2005. Unable to work after a seizure at work, resulting with Medicare and disability money since 2005.

I had a back injury at 22 (not related to epilepsy) rupturing 3 discs (not known to what extent until 50 yrs old), with no med treatment at the time. Degenerative to the extent of non-existent for those 3. Scoliosis further up as a result of 40+ years. For 1.5 years I've been seeing a surgeon who I can plan on having surgery with during the next 1 to 6 months. Surgery will not be avoidable. My need is how to financially manage Medicare-Medicaid-or any other gang.

The cost I'm sure some of you know can clear 200k pretty easy. I had been putting off surgery since 63 believing Medicaid at 65 was going to pay for 99+%. Medicare was at best going to have a 20% copay. After researching even a small amount on Medicaid for my condition (reading stories like mine before walking through the front door of Medicaid or other) it sounds like I should have a better look at how to plan financial damages with too many variables. My fault or not, I don't know where to get good info, or how to avoid a 60k copay or, what happens when you do.

It's not a new diagnosis or a referral to another surgeon that is needed. I'm looking for direction and "warnings" on how to financially manage my possibilities and how to avoid irreversible decisions.

@1634517678, I'm not sure if you have looked at what is covered by Medicare or Medicare Advantage plans. Here's some information I found that may provide some information and gotchas to watch for.

Is my test, item, or service covered? Surgery: https://www.medicare.gov/coverage/surgery
Medicare – Does Medicare Cover Back Surgery?: https://www.medicare.org/articles/does-medicare-cover-back-surgery/
Medicare Advantage – Does Medicare Cover Back Surgery?: https://www.medicareadvantage.com/coverage/does-medicare-cover-back-surgery
How to Pay For Surgery Costs That Insurance Won't Pay: https://www.verywellhealth.com/how-to-pay-for-surgery-costs-without-insurance-3157020

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@johnbishop

@1634517678, I'm not sure if you have looked at what is covered by Medicare or Medicare Advantage plans. Here's some information I found that may provide some information and gotchas to watch for.

Is my test, item, or service covered? Surgery: https://www.medicare.gov/coverage/surgery
Medicare – Does Medicare Cover Back Surgery?: https://www.medicare.org/articles/does-medicare-cover-back-surgery/
Medicare Advantage – Does Medicare Cover Back Surgery?: https://www.medicareadvantage.com/coverage/does-medicare-cover-back-surgery
How to Pay For Surgery Costs That Insurance Won't Pay: https://www.verywellhealth.com/how-to-pay-for-surgery-costs-without-insurance-3157020

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I would add – if insurance says they cannot/will not pay for certain costs, DO NOT give up! That is exactly what they are hoping you will do! They just hope you say it’s not going to be worth arguing for and go away. Both as a former RN and as a patient, I know this. I literally had to argue for the better part of 9 years for several different procedures and surgeries – all out of “network” because no MD in my network was capable! I seriously thought I might have to remortgage my house. I just kept pointing out their arguments held no water – a jaw joint IS a joint, after all! and said I would appeal to the State Insurance Commissioner if necessary. It was exhausting to do so in the midst of the chronic pain. But I just kept going and each time their review committee would acquiese and finally agree to pay.

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Re your possible surgery – do you have an Advantage plan too, or just “straight” Medicare? I found that straight Medicare just left me open to potential high copays, seems as if you are surmising the same.

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@wisco50

Re your possible surgery – do you have an Advantage plan too, or just “straight” Medicare? I found that straight Medicare just left me open to potential high copays, seems as if you are surmising the same.

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I have A and B. I need to look but I thought Advantage had been presented to me as having A and B.

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@1634517678

I have A and B. I need to look but I thought Advantage had been presented to me as having A and B.

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I don’t think so. Basically with A & B, one covers in-hospital costs, like surgery, nursing care, room rate, meds administered while an inpatient, things like that. The other part pays for office visits, outpatient testing (think bloodwork, XRays, mammograms, colonoscopy, that type of stuff). Medicare D is the medication plan part – some Advantage plans cover it, some you have to buy it separately. Advantage plans basically fill in the gap that Medicare leaves you – that 20% copay type gap. There are many types of Advantage plans. (Kind of confusing if you ask me!)

Liked by lioness

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@johnbishop

@1634517678, I'm not sure if you have looked at what is covered by Medicare or Medicare Advantage plans. Here's some information I found that may provide some information and gotchas to watch for.

Is my test, item, or service covered? Surgery: https://www.medicare.gov/coverage/surgery
Medicare – Does Medicare Cover Back Surgery?: https://www.medicare.org/articles/does-medicare-cover-back-surgery/
Medicare Advantage – Does Medicare Cover Back Surgery?: https://www.medicareadvantage.com/coverage/does-medicare-cover-back-surgery
How to Pay For Surgery Costs That Insurance Won't Pay: https://www.verywellhealth.com/how-to-pay-for-surgery-costs-without-insurance-3157020

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Thank you John. That's great and certainly 99% more than I had to work with yesterday. Medicare and SSD is all that I have other than a place to live. I've read through some of what you sent and know I might have some questions before making contact with someone. If you are the best mentor to answer those questions, should I do that here, the same as today? Would I need to ask for you?

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@wisco50

I don’t think so. Basically with A & B, one covers in-hospital costs, like surgery, nursing care, room rate, meds administered while an inpatient, things like that. The other part pays for office visits, outpatient testing (think bloodwork, XRays, mammograms, colonoscopy, that type of stuff). Medicare D is the medication plan part – some Advantage plans cover it, some you have to buy it separately. Advantage plans basically fill in the gap that Medicare leaves you – that 20% copay type gap. There are many types of Advantage plans. (Kind of confusing if you ask me!)

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Yes confusing. I do have D and not expensive. I'll look at Advantage plans. By plans do you mean various companies offering plans or plans offered by Medicare. I'm pretty green on how woven the crew is to each other. 15 years ago having to get SSD with an attorney was quite a surprise.

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@1634517678

Thank you John. That's great and certainly 99% more than I had to work with yesterday. Medicare and SSD is all that I have other than a place to live. I've read through some of what you sent and know I might have some questions before making contact with someone. If you are the best mentor to answer those questions, should I do that here, the same as today? Would I need to ask for you?

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Hi @1634517678, I'm by no means a Medicare expert. I struggle myself trying to find answers and usually end up calling my Medicare Advantage plan company rep when I have a question about coverage. I think the best be may be to actually give Medicare a call. Here's some info and contact information.

Get Your Medicare Questions Answered – Medicare.gov: https://www.medicare.gov/sites/default/files/2018-07/11386_-medicare-questions-answered.pdf

Liked by lioness

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@johnbishop

Hi @1634517678, I'm by no means a Medicare expert. I struggle myself trying to find answers and usually end up calling my Medicare Advantage plan company rep when I have a question about coverage. I think the best be may be to actually give Medicare a call. Here's some info and contact information.

Get Your Medicare Questions Answered – Medicare.gov: https://www.medicare.gov/sites/default/files/2018-07/11386_-medicare-questions-answered.pdf

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I was an RN and I found it all very confusing!

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@johnbishop

@1634517678, I'm not sure if you have looked at what is covered by Medicare or Medicare Advantage plans. Here's some information I found that may provide some information and gotchas to watch for.

Is my test, item, or service covered? Surgery: https://www.medicare.gov/coverage/surgery
Medicare – Does Medicare Cover Back Surgery?: https://www.medicare.org/articles/does-medicare-cover-back-surgery/
Medicare Advantage – Does Medicare Cover Back Surgery?: https://www.medicareadvantage.com/coverage/does-medicare-cover-back-surgery
How to Pay For Surgery Costs That Insurance Won't Pay: https://www.verywellhealth.com/how-to-pay-for-surgery-costs-without-insurance-3157020

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@migizii I found this information interesting, but it did not include Medicare with supplemental coverage……would you know anything about that?

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@migizii

@migizii I found this information interesting, but it did not include Medicare with supplemental coverage……would you know anything about that?

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@migizii the link for Medicare Advantage is a supplement plan for Medicare.

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@johnbishop

@migizii the link for Medicare Advantage is a supplement plan for Medicare.

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Medicare advantage is a separate plan from straight Medicare….a supplemental plan augments Medicare and there are numerous plans to supplement parts A and B, but does not offer the extra that the advantage plans do like vision, dental, or prescription plans included. Our supplemental plan is United Health Care but I will only start using it next month and our agent did not advocate the advantage plans when a person has health issues and wants to travel to various areas. Idk if this makes sense or will be helpful for my husband and I?

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@migizii

Medicare advantage is a separate plan from straight Medicare….a supplemental plan augments Medicare and there are numerous plans to supplement parts A and B, but does not offer the extra that the advantage plans do like vision, dental, or prescription plans included. Our supplemental plan is United Health Care but I will only start using it next month and our agent did not advocate the advantage plans when a person has health issues and wants to travel to various areas. Idk if this makes sense or will be helpful for my husband and I?

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John Bishop, I'm still going to have to start working with your information, tomorrow. I have spent some time on it before and I know it's going to take a day or more, ha. Confusion was always the reason for not following up 100%. I'd like to come back here when I get some more information just to run past you. I'm assuming you are reading all replies right now.

migizii, By "travel to various areas" did you mean overseas, Canada etc or just US? "has health issues" Meaning, back surgery needed or lesser?

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@1634517678

John Bishop, I'm still going to have to start working with your information, tomorrow. I have spent some time on it before and I know it's going to take a day or more, ha. Confusion was always the reason for not following up 100%. I'd like to come back here when I get some more information just to run past you. I'm assuming you are reading all replies right now.

migizii, By "travel to various areas" did you mean overseas, Canada etc or just US? "has health issues" Meaning, back surgery needed or lesser?

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@1634517678, I may miss a post or two if I'm not specifically tagged by using my member name in the post (@johnbishop). When you use the member name in a post, the member will get an email notification. Otherwise, it's easy to miss a post even if you are following a discussion. Psst…Not sure you want to be running question on Medicare coverage by me 🙂 I have enough trouble trying to figure out my own coverage and I definitely do not know all the ins and outs of coverage. That's kind of why I rely on my insurance coverage Minnesota UCare reps to answer any questions I can't figure out for my coverage with Medicare.

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@1634517678

John Bishop, I'm still going to have to start working with your information, tomorrow. I have spent some time on it before and I know it's going to take a day or more, ha. Confusion was always the reason for not following up 100%. I'd like to come back here when I get some more information just to run past you. I'm assuming you are reading all replies right now.

migizii, By "travel to various areas" did you mean overseas, Canada etc or just US? "has health issues" Meaning, back surgery needed or lesser?

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1634517678, I like to travel to all the areas up you mentioned and I happen to live close to Canada which usually makes it a yearly trip. Also, my health issues center on chronic migraines, bronchiectasis, fibromyalgia, osteoarthritis, and presently recovering from mid foot fusion surgery.

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