Medicare and Humana

After a tremendous effort to understand what our insurance options are and subsequently decipher which was the best, we’ve decided to accept Medicare Part A and Part B and ask Humana to become our secondary insurance.  We still have a number complicated worries so until we see it in action, we won’t really know if we made a good choice or not.  But we have worked hard to be well-informed and believe it to be the best choice for our specific situation.

Medicare is divided into parts to allow people to pick and choose the most appropriate parts for their situation.  Part A is for covering hospitalization.  If you are walking down the street one day and your head falls off, then you would use Medicare Part A to cover your stay in the hospital while they reattach your head.  Part B is for general doctor’s visits.  When you need to visit your doctor because that pesky rash isn’t going away, that doctor’s visit would be covered under Part B.  And Part D is what would cover the ointment that you’d get from the pharmacy after you get your prescription from the doctor.  Make sense?

Each part can be loosely described like this.  Part A – major medical.  Part B – outpatient only.  Part D – pharmacy drug plan.  At least this is how I understand it all right now.

We, of course, have private insurance through Humana called Humana One.  Although Humana has made some pretty sketchy moves in are what I believe attempts to get me to screw up so they can drop us, they have paid hundreds of thousands of dollars since January 07.  They continue to pay exactly as our policy states and have basically been trouble-free.  Now why mess with what works?  Here’s why.

Medicare Part A is your mandated right as a citizen of the United States.  If you participate in the social security system, meaning, if you draw back the retirement benefits that you have paid in or file for disability, then you are required by the US Government to take Medicare Part A as your primary insurance.  Yup.  Required.  No choice.  This seems very whacky to me but apparently it’s true.  Here in America we have freedom of speech, religion, assembly and (coming soon!) sexual preference but not freedom of choice for insurance.  How bizarre.

So, as of November 1, Maggie now has Medicare Part A as her primary hospitalization insurance.

Medicare Part B (outpatient care) is optional, unlike Part A and most of what we deal with falls under this umbrella.  We had debated opting-out of Part B but have had an enormously difficult time finding supportive evidence of why we should lean either way.  No one seems to fully understand how it works.  Worse, no one is motivated to learn since there’s no money in selling Medicare.  And because of our age we are in a dead-zone of government support.  There just ain’t that many early-30-year olds looking at Medicare coverage.

This is where things get pretty scary.  Outpatient care is where we spend most of our time and accumulate most of our bills.  Humana, despite all the trickery, is covering most of the bills.  But two things have changed in the last two or so weeks that are threatening to upset the apple cart.  First, we are being forced to, *cough* I mean, are eligible to have Medicare Part A.  Second, we are switching to non-standard treatments, specifically, clinical trials.

Humana doesn’t cover clinical trials.  It will cover anything related to standard care, meaning any procedure that would normally fall under the umbrella of typical patient care.  However, if a charge is tied to a clinical trial Humana will deny the claim.  Now there’s this fuzzy gray area that exists right at this juncture where non-standard and standard care meet.  If a nurse pokes an IV line into Maggie they will bill Humana the cost of the tubing, the needle, the alcohol swabs, the labor, etc.  However, if through that line they drip a non-standard drug (read “clinical trial drug”), the clinic won’t bill Humana for that drug (more on who pays for the drug later.)  So, from Humana’s perspective, they see a bill for:

  • IV and arm preparation,
  • Inserting an IV, and
  • Removing an IV.

It’s not hard to see that, from Humana’s perspective, the nurse forgot to put the good stuff in!  But, as long as the bill doesn’t mention “clinic trial” then Humana will probably pay the bill.  I say “probably” because apparently Humana is in the process of installing more smarts into their system and can sometimes detect and flag the oddness I’ve just described.  It’s all pretty shady.

Who pays for the clinical trial drugs?  The company who is trying to bring the new drug to market pays for all costs specifically associated with doing so, including the cost of the drug, any non-standard tests required, scans, etc.  All of those costs are free to us for volunteering to be a lab rat.  At least that part is clear.

Humana may drop us completely now that we have Medicare.  Yes, I know that lots of people think that Humana can’t do that but despite a tremendous amount of effort we’ve yet to find any definitive evidence either way.  In fact, when pushed to give us an answer, Humana sent us a “Sample Document” that detailed what they “might” do if this situation were to occur.  What a crock.  What will likely happen (fingers crossed) is that Humana will slide quietly into a secondary insurance position and pick up the costs that Medicare doesn’t cover.  But, until I get paperwork saying it’s so, I’m keeping my guard up.  Humana isn’t our friend and certainly doesn’t want to keep us as customers.

Now, for the good news.  It’s a two-parter.  Good news #1:  Medicare covers clinical trials.  Back in June of 2000 the President issued an executive memorandum directing the Secretary of blabity-blah explicitly authorizing Medicare coverage for clinical trials.  Good news #2:  The secondary insurance coverage company is required to act in lock-step with the primary which means Humana has to cover clinical trials.

So, as of November 1, Maggie now has Medicare Part B as her primary outpatient insurance.  We have opted-in.  Humana can suck it.  But we are NOT participating in Medicare Part D.

<Begin Rant>
It’s shameful that Humana won’t cover clinical trials.  This is where the new drugs come from.  For a new drug to become available to you and me, it must be tested through the FDA clinical trial process. But, by Humana refusing to support the system by refusing to pay claims that might be somehow associated with clinical trials, I have to again question Humana’s ultimate goal.  It’s certainly not for the benefit of their customers.  All we have to do is follow the money.  They won’t pay claims associated with the new drug creation process thus they clearly don’t want any new drugs to come out, drugs that might be better at saving or extending lives.  Since they don’t want any new drugs to come out, it seems to me that saving or extending lives is not part of Humana’s goals.

I figure the Humana is more likely in the “gym membership” business than the “help people pay medical bills” business.  You know, that membership to Gold’s Gym that you are paying $19.95 a month for while the membership card is gathering dust on your dresser?  Gyms would much rather have 1,000 members that never exercise (like me!) than 100 members that show up 7 days a week.  Humana wants everyone to pay in but heck, if someone actually needs their insurance that’s just not part of the plan.  They definitely don’t want those type of folks sticking around very long.  Therefore, they definitely don’t want any new drugs to come out else they just might have to pay out longer.  And that’s bad for their business.
<End Rant>

The good news is that we think we are in a favorable insurance position headed into our clinical trials part of The Great Cancer Adventure.  I hope that our painfully-acquired learning will one day be helpful to someone who has stumbled upon this blog.  This stuff is confusing, convoluted, and scary.  If you are reading this right now and are going through the process of figuring out what you need to do, don’t give up.  And, even though it seems like it, you aren’t alone.  Just keep calling people and asking questions.  If you get overwhelmed, ask for help.

Becky at VersaClaim has been enormously helpful to us during this process.  I can’t recommend her enough.  If not VersaClaim, search for “patient advocacy” to find someone to help.  Help is out there.

8 thoughts on “Medicare and Humana

  1. Yes, insurance make their money by denying people. It’s really messed up and there will be a nice place in hell for them all. I saw “Sicko” and man our insurance companies are crooked. It’s good the prez mandated that law if Humana tries any monkey business.
    BTW it was wonderful to see you both Friday, it wouldn’t have been a party without both of you there.

  2. Oh, my goodness, son … I’m so glad you have some knowlegeable advisors to keep you from sinking in Federal (or Humana)quicksand. This is a tangled and slippery mess of red tape!

    Love, love, love and prayers continue with renewed vigor!

  3. Have you spoken to the Texas Dept of insurance? They can explain this to you free of charge.The Consumer Protection phone number at TDI is 800-252-3439.

    My thoughts and prayers are with you always!

  4. First off thank you for sharing the insight, the gym membership analogy helps.

    Clinical trials might be a kind of Pandora’s Box for insurance companies. There is no clear measure on which to base premiums for supporting the noble cause of pioneering medicine. It is nice to know that Medicare recognizes the importance of clinical trials and required the secondary providers to follow their lead.

    A carrier can bring up their right to drop a subscriber but in our internet age such a provocative action is something they “might” not want to rush into. All those passive gym members “might” get really pissed off.

    A representative of my insurance company comes to my work about once a month. They’ve got a couple hundred thousand invested in me… so I make an appointment and constructively present a helpful hint of the month. “It is contractual …. And we can’t change” is pretty much the answer I get every time.

    Hold Fast

    Don MacLeod

  5. A non profit organization, recommended by many other legitimate non profits, the Patient Advocate Foundation is a place one may want to also try for help in dealing with the ever-so-lovely issues, especially cancer related, Chris is referring to…
    Their website is http://www.patientadvocate.org and their phone number is 1-800-532-5274.
    If you want to find out about ANY non profit and their legitimacy, fund raising practices or missions, you can go to the Better Business Bureau’s Wise Giving Alliance website at http://www.bbb.org.
    Keep the Faith, Chris and Maggie. You guys and your puppies are ALWAYS in my thoughts and prayers.

  6. Hi Guys, I’m just getting here to read the blogs from the past several days. I’m so sorry about Niko. I’ll make her puppy PJs extra special this year.
    I know a little about Medicare since I work with the state agency involved in licensing home health and hospice agencies and certifying them for Medicare covered services. I am a Medeicare-certified surveyor for nursing homes, and home health and hospice agencies in Texas.
    Chris, you are correct about outpatient coverage. Medicare Part B pays for all services delivered by a certified clinic, doctor’s office, or home health agency. (Make sure you ask, when you get an appointment at a new location, to ensure they can bill Medicare for services.)
    What I’m wondering is whether Humana will continue to pay for other medications…nausea, pain, etc., or if you’ll need to consider Part D to ensure coverage of FDA approved meds. May be Humana could be the other co-pay on expensive medications for the portion that Part D does not cover?
    All my Love,

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