Medicare Approved Pt B Covered Drug Amount

[Hopes]

I have a follow up appointment with a young, newly paralyzed man - A/B only. One of the procedures he undergoes is a cystoscopy with Botox injection to prevent bladder spasms. He has been receiving temporary financial assistance for the treatments but the assistance will end soon.

I have two procedures codes. One for the actual cystoscopy which I have information for but I'm unable to find the Medicare approved amount for the Botox so the patient will have an idea what his coinsurance will be. I called the billing department but they give me nothing to go by.

The procedure code for the Botox is J0585.

The procedure is billed as:
3 Botox units $6774
Cysto w/chemodenervation $5616
(Misc items) $271

Payments/Adjustments:
Medicare -$1271.51
Medicare Contractual Adjustment -$11009.33
Medicare Contractual Adjustmes M $5.20

The difference doesn't add up to 20% so I don't quite understand.

Also, he caths several times a day and has been buying supplies out of his pocket. But, doesn't Medicare pay for up to 200 straight catheters a month? Is that just for the actual catheter, no gloves, or relevant supplies?

 

[somarco]

I understand the desire to be helpful, but you are skating on thin ice when you offer claim advice.

The closest thing I do is provide a link, usually to Mcare.gov, that addresses their situation. I let them figure it out.

 

[Hopes]

I understand the desire to be helpful, but you are skating on thin ice when you offer claim advice.

The closest thing I do is provide a link, usually to Mcare.gov, that addresses their situation. I let them figure it out.

You are right. I hadn't considered that. I guess I just want to be able to tell this guy what to expect.

The only thing that he can do is stay with OM or go with an MAPD. On one hand, it seems OM may be lowest cost and maybe a drug plan but then I think about the potential oop and I see a big benefit to MAPD. He has had a couple of surgeries already and is looking at another where he would be inpatient 3 days or so.

What do I tell him? How do I advise?

 

[Northeast Agent]

Based on his income/assets, any chance he may be a candidate for a D-SNP if there are any in the area?

 

[Hopes]

Based on his income/assets, any chance he may be a candidate for a D-SNP if there are any in the area?

He doesn't qualify. He makes a decent wage and is married to a working wife. I'm not sure why he qualified for assistance in the first place unless it was because the paralysis was new.

He has a great attitude. He's paying, oop, for stem cell therapy - a limited amount of treatments. He'll know soon if it's working.

He pays, oop, for a type of therapy that involves an "exoskeleton" which allows him to walk with only the assistance of crutches. He showed me a video of him walking and it's amazing!

He does "standing" therapy at home with the assistance of a device (thanks to family for helping pay for) that lifts him up and holds him up to try and strengthen his legs.

Obviously, these aren't Medicare approved. I guess I just want to tell him that he will have help with one thing, you know?

 

[somarco]

How young is young?

Ordinarily I would say MA is his best option assuming he is under 65. If he is in GA he won't find reasonably priced Medigap plans unless you refer him to a direct writer like TA.

OM allows him to use any doc which is nice but the premiums are a killer. Unless he is within 6 months of starting B he isn't eligible for Medigap in Georgia.

 

[Hopes]

How young is young?

Ordinarily I would say MA is his best option assuming he is under 65. If he is in GA he won't find reasonably priced Medigap plans unless you refer him to a direct writer like TA.

OM allows him to use any doc which is nice but the premiums are a killer. Unless he is within 6 months of starting B he isn't eligible for Medigap in Georgia.

He's 40. I looked at a few medigaps, just in case there was a reasonably priced option (considering everything he is still looking at facing), but quickly learned if it wasn't the rates it was U/W.

I don't recall the numbers but he told me his portion of one surgery was below the 20%. That's why I question the OM option. Deep in heart I believe the MAPD is a safe option.

As always, I want to make sure I'm not missing anything - that there isn't something I should be warning him about.


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[Northeast Agent]

I know others with a spouse with a good job but still collect Social Security Disability and get Medicare. Sometimes, just A and skip B so they can stay on the spouse's group plan at work.

What about the QDWI Program?
The QDWI Program: How Disabled Workers Can Keep Medicare When They Start Working

 

[Hopes]

I know others with a spouse with a good job but still collect Social Security Disability and get Medicare. Sometimes, just A and skip B so they can stay on the spouse's group plan at work.

What about the QDWI Program?
The QDWI Program: How Disabled Workers Can Keep Medicare When They Start Working

Oh wow! I hadn't even considered that he could lose his Medicare and I don't think he has either. I think he's been working for around a year or so. I wonder how quick Medicare is to pick up on a person's change in financial status?

His wife has a good job but no group health or other benefits. Last year they went through the marketplace and they had no rebate so the place was pretty expensive. They both work for small employers.

Thanks for the link.