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» LymeNet Flash » Questions and Discussion » Medical Questions » Medicare Questions re IV abx

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Author Topic: Medicare Questions re IV abx
Rumigirl
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For anyone who has original Medicare, or who knows about it.

I need to switch soon from private insurance to original Medicare and have a number of questions that are difficult to get answers to. Any answers anyone has, or where else to ask would be welcome.

Are IV antibiotics covered under Part B, say through an infusion company?

Or under Part D, ie, the drug plan?
Including the supplies , like flushes, dressings, IV bags, etc.?

Would insurance limit, or not allow it, unless I met strict guidelines?

Or does it have to be administered at a medical office to be covered under part B?

Thank you very much! It's really hard to get answers. Infuserve doesn't participate with Medicare. And my old infusion company doesn't either.

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Lymetoo
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If infoserve doesn't participate, then that sounds like a bad sign??

I hope someone here will know!!!

--------------------
--Lymetutu--
Opinions, not medical advice!

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Rumigirl
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It's probably because Medicare pays so little. The same goes for my old infusion company.

In any case, with Infuserve you always have to pay out of pocket, and then they bill the insurance company and will reimburse you whatever insurance pays. But not with Medicare.

I am afraid that none of it will be covered, except the vials of ceftriaxone through the drug plan if I mix it myself. But who knows if the supplies are covered?

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Bartenderbonnie
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Rumigirl, you know I love you but I really hate to write my experience on your question because it brings up serious PTSD!!! Here goes...

Navigating Medicare was the WORST!
If you call them, you are on hold for 1 hour.
If you ask 5 Medicare call assistants the same question, you will get 5 different answers!

When you turn 65 or if you become disabled at an earlier age, everyone must sign up for Medicare. Even if you are still working.

If you have private insurance, though your job or your spouse, you can still keep it but you must make Medicare your primary insurance and your private insurance your secondary.

So my question to you is will you still have access to your private insurance?
If not, you will have to sign up for a supplemental insurance plan.
If you do not have access to your private insurance, and you don’t sign up for a supplemental insurance plan, you will be responsible for 20% co-pay on meds, tests, appointments, etc.
Medicare pays 80%. Patient pays 20%.

Medicare part D is your prescription drug coverage.
Medicare pays 80% and you pay 20%.
Medicare will pay for IV supplies and meds minus your co-pay.

My monthly Gamunex IG is between 3,000 to 5,000, always fluctuates. My monthly co-pay is always 600.00 and Medicare always pays 3,000.00 regardless of the suppliers higher costs because of the suppliers contract with Medicare. In other words, the price is locked in.

I’m just throwing numbers out because I get the bills and IVIG is expensive.

It took me 3 months of researching 3 hours of everyday to find a plan that would be affordable. I had 5 different Medicare advocates to my house, for 2 hour appointments, to go over supplemental plans that I could afford. I COULD AFFORD NONE OF THEM!!!!!!

So then I contacted 32 different non-profits, charities, foundations, advocacy groups for immune disorders, hospitals, clinical trials, support groups, etc.

I contacted the company Gamunex for financial help.
They do offer it but not to Medicare or Medicaid patients.
I checked out other suppliers of IG and was told the same thing.

In the meantime, I had 3 monthly infusions and racked up an 1,800.00 co-pay bill that I had to take a payment plan out on.

I applied to my local hospital charity foundation, was approved for 100% IVIG in their out-patient treatment center. (Based on income).

But I found another way to receive in home IVIG through a visiting nurse association, as I’m considered bedbound at this point. This is billed under Medicare part B and pays 100% for your nurse.

Girl, you got some homework to do, so very sorry.

Financial assistance
https://www.gbs-cidp.org/support/resources/financial-assistance-resources/

Gamunex Help
https://www.gbs-cidp.org/support/resources/financial-assistance-resources/

Grants
https://www.medicarerights.org/fliers/Help-With-Drug-Costs/copay_charities.pdf?nrd=1

Co-pay Assistance
https://copays.org/funds/primary-immunodeficiency/

IV Living Patient Support
http://www.igliving.com/resources/connect-patient-support.html

Transitioning to Medicare for IV Living
http://www.igliving.com/life-with-ig/teleconference/transitioning-to-medicare-what-patients-treated-with-immune-globulin-need-to-know.html?zoom_highlight=co-pays

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Rumigirl
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Bartenderbonnie,

OMG, that is unreal what you have gone through to get IVIG (and find answers)!!! I am so sorry to bring you more PTSD triggers. I so understand.

I have been researching all of these issues for IVIG and IV abx, meds that I need, and Medicare on and off for 10 years!!! And I have been dreading having to go on Medicare the whole time due to all of these issues.

I have many documents from all my research. I have read Medicare and You, and highlighted, marked pages, wrote down more questions. Been to the Medicare office, and to the state agency that helps (when those agencies were open pre-Covid).

My husband badly needs to retire from his job. They have been sucking the life out of him with unrelenting pressure and hours for way too many years. I see the toll in him; it's terrible. Plus, he's well past normal retirement age.

Thank you, thank you, thank you for all of this information and all the links---wow!!! You are a trouper. I never heard of igliving.com.

My osteopath says the same thing about Medicare: you call 5 different times asking the same question and get 5 different answers!! Impossible to deal with.

As you found out, I already knew that the coupons/discounts that drug manufacturers offer to make the meds more affordable, we aren't able to use when we go on on Medicare (or Medicaid)---just when you have much less $$!! It makes no sense at all

It penalizes us all so the private insurance companies that offer the drug plans can make more money!! They say it is to encourage patients to choose generics or other cheaper meds. But I have a

number of meds that I need that will be completely unaffordable without these coupons/discounts. And there are NO alternatives.

I cannot thank you enough, dear Bartenderbonnie. And your copay monthly for IVIG, yikes! You need a fairy Godmother! As do many of us. I daily feel like I just don't have the strength to go on. I can only imagine how hard it is for you.

I do have my husband, which is huge. But I can't let his job send him to an early demise!!

Does a Medigap plan pay the copay for the part D med plan? I can't seem to find that answer.

I think I have to meet with several brokers/advocates/agents the way you did.

I ran all my meds, and anticipated meds, through the Medicare links to the part D drug plans and came up with whopping amounts that I'd owe for meds. Amounts that are completely unaffordable for many of them.

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Rumigirl
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So are the Gammunex med and the supplies therefore covered for you under part B or part D? Sorry if I'm dense here. It's confusing.

And I'm still trying to find out if a supplemental plan covers the copays in part D. I would think so, but I can't find the answer to that one.

I hate to ask you more after you've so generously given me lots of information and links.

It's harder to find out, because I've lost two neurologists in a row, and will loose another shortly, so I can't get answers from them. I've tried to find another that would know anything about what I've got and how to treat it. My diagnosis for IVIG was neurological.

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Bartenderbonnie
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Ha Ha Ha
I was waiting for follow-up questions.

IVIG, infused meds and injectable meds are covered under Medicare part B. Medicare pays 80% and you pay 20%.
https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/Downloads/11315-P.pdf

My nurse for in-home infusion is covered under Medicare part A. Medicare pays 100%. You must be home bound. May be other prerequisites.
https://www.medicare.gov/coverage/home-health-services

This lady explains it well although she does not give specifics, such as “Please tell us what supplemental plans are best for IVIG!”
https://www.myositis.org/myositis-library/live-discussions/discussion/navigating-the-health-insurance-maze/

I’m sure you have seem the commercial on Medicare supplemental plans starting Joe Nanmath. He offers you dental, co-pays, transportation to and from medical appointments, no deductibles, breakfast in bed, etc.. What he doesn’t tell you is this plan is the most expensive.

How naive we are to have thought our government would take care of the disabled and elderly population?

Here’s a breakdown of different supplemental plans. So you have to go through each plan, see what benefits it offers, the price, and whether it would work for your medical needs.

Each state is different. Scroll down to where you type in your zip code. Plans that are available in your area will show.
https://www.medicarefaq.com/medicare-supplements/medigap-plans/plan-f-high-deductible/

Next is mathematics.
You have to figure out yearly deductibles, co-pay percentages, whether your meds are offered in their drug formulas ( one plan suggested I switch to sub-q IG, not!), and policy price per month.

So you were right on when you said you want a sit down with a agent. Keep in mind that they tend to talk in circles too.

Insurance companies are the worst!
It’s all about the Benjamin’s. 💰

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Rumigirl
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Wowee, thank you again, Bartenderbonnie!! I am slowly getting a little closer to understanding how to navigate this mess. But I definitely do need to meet with some brokers and/or advocates. Plus, crunch the numbers again on the Medication plans.

Yes, I have been doing battle with insurance companies for decades!! I fight most of the denials, etc. Sometimes I win. But they can wear you down to the point that they outlast my efforts.

Years ago UHC had preauthorized my IVIG for 6 more months. Then, on the late afternoon of New Year's Eve day, they suddenly cut off my IVIG preauthorization, plus disallowed nursing for my port care. Which is life-threatening.

I kept trying to get my Case Manager on the phone, leaving multiple messages that it was life-threatening to cut off my port care. No response. So I made an emergency complaint to the state AG's office. They promptly got it reversed.

My neuro who prescribed my IVIG said that UHC did it to ALL of his patients at once. I was the only one that got it reinstated because I fought it so persistently----and because of my port, so it was life-threatening, so the AG's office responded immediately. We are warriors alright.

[ 05-26-2021, 12:05 AM: Message edited by: Rumigirl ]

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