BS: US Medicare / GM medical cover query

Subject: BS: US Medicare / GM medical cover query
From: John J
Date: 29 Nov 09 - 02:55 PM

I wonder if any of our American Mudcatters can help me:

My rather aged father lives in Florida for half of the year - he's a Snowbird, travelling over from UK every November for 6 months of sunshine.

He gets a pension from GM as well as some medical cover, this is down to him marrying a GM retiree who has since died: he's a surviving spouse.

I'm with Dad for the next week or so before I have to return to UK but before I leave I could do with finding out how the Medicare system works here, and if it integrates with addition private medical cover, ie: GM.

It's the real nuts and bolts I'm trying to find out about:

If he goes for medical attention does he pay the provider and claim his costs back?

Would the GM cover need to be accessed separately or would Medicare deal with the claim 'in one'?

I've seen that Dad receives a payment from US Social Security, is this likely to be a government pension only or would it be a payment involving the GM pension scheme - ie do GM make their pension payments separate to any (any?) state pension?

I'm going to phone the GM pension people tomorrow morning with a couple more specific queries, but in the meantime if anyone can help me clarify things for Dad I would be eternally grateful!

Thanks,

John
(who is eternally grateful for the UK NHS!)

Subject: RE: BS: US Medicare / GM medical cover query
From: Ebbie
Date: 29 Nov 09 - 05:25 PM

I don't have many answers - even though I use Medicare but I can perhaps ancwer one little bit. If your dad is receiving US Social Security he may be getting it on the basis of his late wife's earnings. When a spouse dies, the survivor can switch to the dead spouse's level, if s/he wishes. Usually because that amount is greater than the one the survivor qualified for.

Subject: RE: BS: US Medicare / GM medical cover query
From: artbrooks
Date: 29 Nov 09 - 05:45 PM

Social Security is a separate pension system, and anything he is entitled to from GM won't be included. Medicare is a deduction from Social Security; Part A covers hospitalization and is free, Part B covers doctors' bill (etc) and generally costs about $95 per month. This is not mandatory and, if he has been living outside the US, he may not have signed up for it. Generally, a doctor (assuming he accepts Medicare at all, which isn't universal) will either bill Medicare for the whole thing and then bill him for the deductible (20%) or they may want the deductible paid at the time of service. He may have supplemental insurance through GM - what we call Medigap insurance - that will pay the 20%.

Check here for general Medicare information and call 1-800-633-4227 for more specific stuff. Be prepared to get a very hard time if you try to get specific information on his account yourself - the privacy watchdogs are pretty powerful. It would be best to write down the specific information needed (i.e., "am I covered by Medicare"), wade through the morass of computer-generated questions and answers until you get to a real person, and then put him on the phone. Have his social security number, date and place of birth, and mother's maiden name available when you call.

Good luck.

Subject: RE: BS: US Medicare / GM medical cover query
From: JohnInKansas
Date: 29 Nov 09 - 06:06 PM

To receive Social Security payments one must have worked and earned income from employment in the US (or for a US based company) and must have paid the "Social Security" taxes on that income. A surviving spouse can continue to receive a benefit, and it's likely that's the reason your dad is receiving SS payments. The "surviving spouse" benefit is based on the benefit received by the original SS recipient, but you would need to contact SS (see artbrooks post above) for details.

A person may be insured under Medicare because of a disability, but the more normal situation is that Medicare "insurance" is provided to persons receiving SS payments after the person reaches a particular age.

Technically, anyone receiving Social Security retirement benefits, after reaching "full retirment age," is required to have and pay for Medicare coverage, unless they prove that they have "comparable other insurance." (Some get by with ignoring this requiremnt.)

So far as I've heard, medical/health insurance provided by most companies insist that any payments from/by Medicare "have primacy" and must be paid first, before the corporate/retirement insurance picks up any portion of the remaining costs.

In the US, few medical practitioners/services will fail to ask a person to show identification of their medical insurance coverage(s) prior to treatment; and your dad needs to have a "Medicare Card" and also a GM Insurance card that can be presented when services are requested. Most medical providers will bill any and all insurers identified by the patient.

In the typical way it works in practice, Medicare will send an "Explanation of Benefits" that will show that they have paid a certain amount, and that a remaining balance is owed. Medicare (or the provider of the billed service) will then notify other insurers.

The GM insurance should then pay whatever benefit is applicable to the remaining balance, and will send the patient a separate Explanation of Benefits, showing the amount the GM insurance has paid directly to the provider, and showing the amount remaining to be paid by the patient.

Once Medicare and the GM insurance have paid "their shares" the provider usually will bill the patient directly for any remainder. The provider may bill, showing "claims pending," prior to the settlement by the insurers, but most (not all) will wait until insurance claims have completed processing before demanding that the patient make the final payment.

This process typically takes at least a month, and in some cases two or three months before the patient gets the final bill. It can become difficult to keep track when a provider bills quarterly, Medicare then takes two months or more to make their payment, the "private insurer" then takes another month before the original provider can invoice the patient.

Medicare must be informed that other insurance exists, so that they will automatically refer the balance after Medicare payment to the other insurer. Under new rules, Federal regulations require that most SS/Medicare recipients show proof of other private insurance (the so-called "gap insurance"). "Dad" should already have received (or will soon) the mandatory statement that the GM policy meets the requirements for the required "gap" insurance.

The other insurer (GM) must be informed that the person is covered under Medicare, as it is illegal to receive payments for the same "loss" or expense from more than one insurer.

Problems may arise from the fact that not all medical providers accept patients using Medicare insurance, and/or will refuse to file claims with Medicare. Some may refuse to file with any insurer. The patient then is "expected" to pay the bill, and file his/her own claim with Medicare and/or others. This gets messy, but can be done.

I would expect that any insurance provided by GM would offer an option to use "preferred providers" at reduced cost to the patient. Most companies require an "annual re-enrollment" at which time the insured person can choose one of several "plans" to best suit personal conditions. It likely would be of value to check out whether "dad" is enrolled in the GM plan best suited to his needs.

A "typical" invoicing may help clarify:

1. One of my services bills $460 per month for "services."

2. Medicare informs the provider that they allow only $269 for this service.

3. Medicare pays $143 to the provider, and informs me that since I am covered by Medicare the provider cannot bill me for the $191 disallowed by Medicare¹. But I do remain "responsible" for the $269 - $143 = $126.

4. My retiree insurance (like dad's GM) pays 80% of what Medicare doesn't take care of (80% of $269 - #143 = $101); but since I get this service from a "Preferred Provider," the provider has agreed to accept the amount the insurer allows them to charge for the specific service for which they billed. The insurance pays $22,² indicating that the limit imposed (they say "negotiated") by the insurer is even less than what Medicare allows(?).

5. Eventually, the service sends me a bill for $7.00.

The provider billed $460, but receives $269+$22+$7 = $298.

I pay $7, but without insurance would have paid $460.

¹ It should be obvious why not all providers will accept "Medicare clients."

² It should also be obvious why it is to my advantage to use the "Preferred Providers" who are associated with my insurance - when I can get the treatments/services needed from them. The costs of going "out of service" are generally not too bad, but do add up over a time³.

³ A certain person covered under "spousal benefits" from my retiree/corporate policy refuses to use a "Preferred Provider" just because she objects to "being told what to do." It generally costs about $15 extra per office visit, but other costs - with my exceptionably good policy - are fairly small. The situation might be different for other insurers.


I've tried to avoid being technical while giving a sample of what dad might encounter. The Medicare coverage should be similar for most, although Medicare is administered under rules which may vary from one state to another. You can get most information from the fed site; but the day-to-day handling of medical claims may vary with what state dad is in. My retiree insurance is, to be quite honest, exceptionally good (so far); but I would expect that even with their recent troubles GM coverage for retirees (and their surviving spouses) should be similar.

John

Subject: RE: BS: US Medicare / GM medical cover query
From: GUEST,John J
Date: 01 Dec 09 - 08:25 AM

Thank you all for this information, especially John who has the uncanny knack of providing full and comprehensive answers to my odd questions.

Yesterday I spoke to his GM insurers - today I might just write to Medicare. The mud is beginning to clear!

John