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Author Topic: medicare payed for implant?  (Read 329 times)

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2Oldfords

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medicare payed for implant?
« on: November 16, 2019, 10:03:51 AM »

   After my excision/grafting surgery failed and left me with hour-glassing severe enough to prevent sex. My Dr. said my only recourse now was to get an implant. My BCBS denied my prior authorization several times as the policy just doesn't cover an implant. My Dr's admin person said if I had medicare it would pay no problem. I contacted Medicare and was told as long as I was under my employeer's policy (BCBS) they pay as secondary ins. OK, I asked if my primary ins would not cover this procedure would Medicare step up and pay as primary? Answer NO. So my option would be to quit (BCBS) and just have Medicare. The Medicare rep kept telling me they only pay for necessary medical needs. So here is my question. Did Medicare pay for your implant? Did Medicare deny your claim?
   I will go on Medicare in 9 months but need to make decisions about private health ins now (end of year).
   Waiting sucks, My wife and I miss being together and it has been way to long already
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Age - 63
Peyronies of unknown length of time
70 Deg curve 10-11 o'clock
first 2 uro's offer for xiaflex and referral
incision/grafting 12/18/18

tomas1

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Re: medicare payed for implant?
« Reply #1 on: November 16, 2019, 02:01:00 PM »

I think I have this right:
If you have a Medicare supplement (it ain't free),
Medicare will pay.

If you have a Medicare advantage, it's up to the advantage company to decide what to do.

One caveat is when you schedule surgery, make sure all members of the operating team are covered under Medicare,
That cost me $500 and I was pissed. I'm glad it wasn't the anesthesiologist.
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81 years old.
Implanted 01/22/19 by Dr Avila.
18cm AMS 700 CX, 3.5cm RTE 100cc reservoir
Diagnosed with Gleason  prostate cancer.
Monitoring it for now.

Hawk

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Re: medicare payed for implant?
« Reply #2 on: November 16, 2019, 08:46:03 PM »

Any Medicare will pay.  You do not need Medicare Advantage.  I have basic Medicare as my primary and BCBS as a secondary.  The secondary will not pick up any expenses if the primary does not pay.  That is how secondary insurance always works.

Medicare paid the vast majority and BCBS paid every other penny.  I paid nothing.
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Prostatectomy 2004, radiation 2009, currently 68 yrs old
After pills, injections, VED - Dr Eid, Titan 22cm implant 8/7/18
Hawk - Updated 10/27/18 - Peyronies Society Forums

tomas1

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Re: medicare payed for implant?
« Reply #3 on: November 17, 2019, 08:56:07 AM »

I really don't have first hand knowledge of exactly how Medicare Advantage plans work since I've never had one,
I found this article informative:

https://finance.yahoo.com/news/apos-difference-between-original-medicare-183200814.html
Logged
81 years old.
Implanted 01/22/19 by Dr Avila.
18cm AMS 700 CX, 3.5cm RTE 100cc reservoir
Diagnosed with Gleason  prostate cancer.
Monitoring it for now.

2Oldfords

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Re: medicare payed for implant?
« Reply #4 on: November 17, 2019, 11:56:42 AM »

    Thanks guys for the great info. I guess I will have to come off my employer ins when the time comes and check out all the different advantage plans out there to see which is best for my wife and I. She can get Ins were she works I just don't know how good it is.
   I don't mind paying for Insurance, It is a fact of life you need some type of coverage. I wish I could get on a plan sooner that would cover my implant, 9 months wait for medicare plus about 18 months since Peyronies made normal sex impossible is brutal...........
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Age - 63
Peyronies of unknown length of time
70 Deg curve 10-11 o'clock
first 2 uro's offer for xiaflex and referral
incision/grafting 12/18/18

TonySa

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Re: medicare payed for implant?
« Reply #5 on: November 17, 2019, 01:40:42 PM »

2old, when your Medicare kicks in be sure to keep your insurance as secondary-rather than primary-it will be cheaper that way and if Medicare covers it the secondary is required to pay the copays, etc
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PxD 2 yrs, failed all tx. 9/18: excision, grafting & implant Dr Karpman MtnView Ca, AMS CX 18cm + 3rte

Stepone

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Re: medicare payed for implant?
« Reply #6 on: November 17, 2019, 05:29:10 PM »

I have united healthcare advantage plan. They charged me about $1400 up front, but later reimbursed me $800. I was in the hospital overnight.
I was very pleased with the care and everything is going well.
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Nesbit surgery 2015, 66 years young, Titan Implant 4/25/19, 22cm, Dr. Lentz, Duke University NC

Hawk

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Re: medicare payed for implant?
« Reply #7 on: November 17, 2019, 09:27:37 PM »

He can NOT keep his insurance as a secondary.  My understanding is that IF you have insurance through your own employer then it IS ALWAYS the primary.  If he has insurance thought a sposes' employer and has Medicare then Medicare is the primary and his spouse's insurance is the secondary.  In the last case, he probably would not also want Medicare Advantage since it likely is a higher premium with no extra benefit over the other two.

He will want to check whether being added to his wife's insurance has a cost/benefit advantage over getting a good Medicare Advantage.  If I knew I was having an expensive surgery I would drop my employer insurance, get Medicare, get added to my spouse's insurance.  Your surgery will likely not cost you a cent.

The only thing to confirm is that Medicare will be primary IF you work and your employer provides insurance but you opt-out.  I think Stabler will know the answer to this since she works with insurance claims.

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Prostatectomy 2004, radiation 2009, currently 68 yrs old
After pills, injections, VED - Dr Eid, Titan 22cm implant 8/7/18
Hawk - Updated 10/27/18 - Peyronies Society Forums

TonySa

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Re: medicare payed for implant?
« Reply #8 on: November 17, 2019, 09:38:26 PM »

Sorry Hawk, that’s not always true.  In fact when I have Medicare my previous employer requires that I switch to a secondary insurance plan.  Be sure to check w your employer or prior employer if retired, it’s not always the same.
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PxD 2 yrs, failed all tx. 9/18: excision, grafting & implant Dr Karpman MtnView Ca, AMS CX 18cm + 3rte

Hawk

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Re: medicare payed for implant?
« Reply #9 on: November 18, 2019, 09:21:36 AM »

Tony,

I am certain that with companies with 20+ Employees. Medicare is secondary if you age 65 or older and your employer has more than 20 employees and you are still ACTIVELY working (not a retiree or on COBRA). This is called Medicare Secondary Payer.  I think a call to Medicare will confirm this.

If retired with insurance through your old employer (as I am) then Medicare is Primary and retirement insurance through your old employer is secondary.  When in doubt call Medicare.  They are surprisingly helpful.
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Prostatectomy 2004, radiation 2009, currently 68 yrs old
After pills, injections, VED - Dr Eid, Titan 22cm implant 8/7/18
Hawk - Updated 10/27/18 - Peyronies Society Forums

Stabler

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Re: medicare payed for implant?
« Reply #10 on: November 18, 2019, 11:02:17 AM »

Okay guys I'm at work so I'm making this quick.

Medicare will not automatically be primary if you are employed and are carrying an plan through an employer. Even though you are of age to qualify for Medicare if an employer is carrying you on their plan they will remain primary. This can be said also if you are on a spouses ins and the spouse is employed. If you are retied but still carrying medical insurance through your employer you need to call the plan and ask them once you go on Medicare, will they then become secondary. I suggest calling several times asking this same question to see what you are told because insurance companies are not the best at giving information, sadly. always write done the name and time of who you spoke with and ask for a ref#.

Medicare Advantage plans ARE NOT the same as Medicare. They are Medicare replacement plans and do not have the same coverage as Medicare. Many use these plans because of co pays and patients feel they got "more coverage" with prescriptions etc..., they are good plans but they are not Medicare, they usually have higher deductibles and the plans do not pay the same as Medicare. They generally need a referral from a primary care Dr (not all but generally) which means if your PCP doesnt refer you or wont give you the referral then you can go and have coverage from the plan, and yes there are Pcp's that refuse to give referrals. Advantage plans also have fewer providers that take their plans as where Medicare is accepted everywhere. Medicare also doe not require a precertification or authorization to have testing done. (this is a perk)

As Hawk said, If you have Medicare and a MEDICARE supplement plan then your costs are minimal and likely Zero for testing and procedures. You always want to make sure that ALL of your providers are in network no matter what ins you are carrying.

Stabler
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Moderator since 2015- Missouri- I work in the medical field and have strong knowledge of insurance and how to obtain coverage for medication and other treatments. Being a woman I do not have Peyronies but you can ask me anything. I am happy to help.

TonySa

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Re: medicare payed for implant?
« Reply #11 on: November 18, 2019, 02:20:39 PM »

Thxs Stabler, you rock.  You’re a great resource for the forum as treatment often comes down to making the insurance we pay for to cover us!  And that’s often not only complicated but stacked against the patient-such as needing a PCP referral for a specialist.  We really need a sticky on this topic, or maybe there is one?
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PxD 2 yrs, failed all tx. 9/18: excision, grafting & implant Dr Karpman MtnView Ca, AMS CX 18cm + 3rte

2Oldfords

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Re: medicare payed for implant?
« Reply #12 on: November 18, 2019, 03:48:53 PM »

   Again thank you all for sharing info. Yes this stuff is complicated and full of holes to trip up on.
I have called Medicare and since I'm not on Medicare yet they really weren't that interested in answering my questions. What I did glean from the phone call was as long as I'm actively employed by a Co. with 20+ people employer Ins would all-ways be primary with Medicare secondary. I did not know that If we get our ins thru my wife same applies. The difference then would be my BCBS Ins thru work will not cover penile implants. Possibly my wife's Ins would.
    On a side note if I was a woman who had breasts removed due to cancer they would cover implants. But I'm a man who has Peyronies and can't function like a normal man so that doesn't count. We need to stage all kind of walk-a-thons and sell blue shirts that say penises matter....
Maybe then we can get fair treatment for our issues. LOL
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Age - 63
Peyronies of unknown length of time
70 Deg curve 10-11 o'clock
first 2 uro's offer for xiaflex and referral
incision/grafting 12/18/18

Stepone

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Re: medicare payed for implant?
« Reply #13 on: November 18, 2019, 04:19:52 PM »

I have United Healthcare Advantage Plan through my old employer. I pay a monthly fee, but I also receive prescription care too. My United Healthcare is a PPO, which means I don't need referrals and I can go to doctors in and out of plan. I had no problems finding an excellent implant surgeon.
...and yes I thought the same thing about "penises matter". When I first started my search about Peyronies Disease, the first two urologists were clueless and as I had mentioned in my blog, one urologist prescribed like 16 Potaba capsules a day. It was crazy and that was only 4 years ago.
I think many men that have Peyronies Disease suffer, give up sex, and become depressed. There are still a lot of men out there that were diagnosed years ago and continue to suffer not knowing about implants.
I met a guy that wanted to talk about the problem. He was not computer literate, so a friend of a friend connected us up. He was married, 55, HVAC guy, but had broke his penis while having sex. He said it took everything he had to bring it up to his family doctor. He told me the doctor looked at it and said there was nothing he could do, maybe it would heal after a while, he should soak it in warm water and not have sex! OMG!!!!!! To look at this handsome guy, you would think he should be having a great life, but he was not. It was so sad, so I told him what I had been through and so many questions, but most importantly I gave him my urologist's name and telephone number. I know he got help, because he texted me, and I think he had surgery later that year, but as we all know, no news is good news. Maybe someday, some news station will bring it up and then all of America will know and it will no longer be a big secret.

StepOne

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Nesbit surgery 2015, 66 years young, Titan Implant 4/25/19, 22cm, Dr. Lentz, Duke University NC

Stabler

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Re: medicare payed for implant?
« Reply #14 on: November 18, 2019, 06:00:15 PM »

@Oldfords:
"I did not know that If we get our ins thru my wife same applies. The difference then would be my BCBS Ins thru work will not cover penile implants. Possibly my wife's Ins would"

Be careful and check before acting on this because if YOUR employer offers you health ins, Your wifes may not allow her to put you on her plan BECAUSE health ins is offered to you where you work OR if they do allow her to add you it may come at a higher cost.

@TonySa
No problem I am always happy to help. We do have a sticky in the forum about how to get ins to pay for Xiaflex using codes and such but I am not sure we have one with this particular information.

@Stepone
You are correct, there are Medicare replacement plans such as yours that are PPO based and you can choose your own doctors with no referral needed but again they do not pay the same as Medicare does and if you choose to use providers that are not IN network with your plan the plan may not cover the services unless you have OUT of network benefit, which means you can see them but the coverage is less and at more cost to you..

Keep in mind, You can choose any plan you like but just because you can see any doctor you want to does not mean the doctor accepts your insurance plan. Whatever plans you look at (other than straight Medicare) make sure that the doctors that you want to see take the plan. Call the doctors office and ask them if they accept the plans you are looking at. you dont want to end up with a plan no one takes.

Stabler
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Moderator since 2015- Missouri- I work in the medical field and have strong knowledge of insurance and how to obtain coverage for medication and other treatments. Being a woman I do not have Peyronies but you can ask me anything. I am happy to help.

Hawk

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Re: medicare payed for implant?
« Reply #15 on: November 19, 2019, 02:42:19 PM »

As a final clarification, IF YOU HAVE MEDICARE AS PRIMARY insurance.  It will pay for an implant.  The only requirement is that there is a 48 hour waiting period between your presurgical exam and surgery.  I guess they hope some will chicken out and save them some money.

Even most great surgeons like Dr. Eid and Kramer take Medicare.

Remember that your secondary insurance will never kick in and pay unless your primary accepts the initial claim.
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Prostatectomy 2004, radiation 2009, currently 68 yrs old
After pills, injections, VED - Dr Eid, Titan 22cm implant 8/7/18
Hawk - Updated 10/27/18 - Peyronies Society Forums

2Oldfords

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Re: medicare payed for implant?
« Reply #16 on: November 20, 2019, 12:24:45 PM »

   Again thanks to all of you that contribute to this great forum. I have been talking to a lot of people about the whole Medicare business. From my research I find straight Medicare to be the most usable. I found it is probably the best If you have supplemental Ins.  Medigap covers everything Medicare doesn't. I'm talking medical needs only. you probably should still have something else to cover Vision, Dental and prescriptions. What a racket. It is definitely a buyer beware situation.
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Age - 63
Peyronies of unknown length of time
70 Deg curve 10-11 o'clock
first 2 uro's offer for xiaflex and referral
incision/grafting 12/18/18

tomas1

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Re: medicare payed for implant?
« Reply #17 on: November 20, 2019, 05:18:52 PM »

Medicap isn't cheap.
At my wife's and my age it's around $474 a month.
It was less expensive when I first got Medicare.

Bear in mind that once you are on a Medicap plan you may have to stay with that company if you have serious health issues.
I had a hard time switching when a plan got too expensive and I only had Treatable HBP and controlled High Cholesterol.
I was able to switch though.

The way I rationalized the cost was when my wife and I were on our own before Medicare, we were paying close to 9K a year.
I promised we could go the Medicap route when we reached 65.

Our health has been great since turning 65 except for the damn Erectile Dysfunction, and my cutting myself and falling off roofs
Logged
81 years old.
Implanted 01/22/19 by Dr Avila.
18cm AMS 700 CX, 3.5cm RTE 100cc reservoir
Diagnosed with Gleason  prostate cancer.
Monitoring it for now.
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