Medicare Hybrid

azsenior · July 16, 2011

I think I have read all the Medicare posts on this forum and others, but I have not seen my particular situation so I would like to see if there are others like me.

I have had an Aetna plan for quite some time as part of my pension benefit from the state of NJ. When I turned 65, I was required to also pick up Medicare. It is my primary and Aetna is my secondary.

When I first started at the Banner Gateway Bariatric Center, the insurance clerk told me that I would not be able to get the sleeve since Medicare did not cover it. Even when I told her that I also had Aetna, she was very firm in her answer. I called Aetna four different times and was told by their agents that I would be covered. They had my card number that says I am Aetna Medicare.

The original insurance agent is currently on leave and her replacement says they are requesting approval for the sleeve. Guess I will find out the answer sooner or later, but I would love to know if anyone else has this type of Medicare policy. I do not want the lapband and I am not a candidate for bypass. I have a "belt-line" which would make movement of the lap instruments difficult and open is just not an option given my age and previous surgical scar tissue.

Would love to hear from other seniors in my position. Thanks!

RSREED53 · July 16, 2011

They are being petty--I think your glitch is that Medicare was Primary. I don't think you would have had any problem had your Aetna plan been your primary carrier. However, your doctor could push for coverage and auth for the sleeve had he or she done a peer to peer conf call; I would ask for that. My surgeon did this for me, as I am on state Medicaid. I had surgery May 31st and am doing very well. I can give you name and no of my surgeon here in No. Phoenix, if you would be interested. He is the guru of bariatric treatment and very gifted in insurance negotiations. I wish you the very best in seeking treatment. :DRonda

I think I have read all the Medicare posts on this forum and others, but I have not seen my particular tesituation so I would like to see if there are others like me.

I have had an Aetna plan for quite some time as part of my pension benefit from the state of NJ. When I turned 65, I was required to also pick up Medicare. It is my primary and Aetna is my secondary.

When I first started at the Banner Gateway Bariatric Center, the insurance clerk told me that I would not be able to get the sleeve since Medicare did not cover it. Even when I told her that I also had Aetna, she was very firm in her answer. I called Aetna four different times and was told by their agents that I would be covered. They had my card number that says I am Aetna Medicare.

The original insurance agent is currently on leave and her replacement says they are requesting approval for the sleeve. Guess I will find out the answer sooner or later, but I would love to know if anyone else has this type of Medicare policy. I do not want the lapband and I am not a candidate for bypass. I have a "belt-line" which would make movement of the lap instruments difficult and open is just not an option given my age and previous surgical scar tissue.

Would love to hear from other seniors in my position. Thanks!

azsenior · July 16, 2011

Rhonda, thanks so much for that info. I think I need to wait until I get a denial. Assuming that happens, I would definitely go for the peer to peer strategy. Would like to get the name of your surgeon, though. My sister is on ACCHS and is interested in WLS. ]

RSREED53 · July 18, 2011

Rhonda, thanks so much for that info. I think I need to wait until I get a denial. Assuming that happens, I would definitely go for the peer to peer strategy. Would like to get the name of your surgeon, though. My sister is on ACCHS and is interested in WLS. ]

Hi, AZ! My surgeon is Dr. Steven C. Simon, MD at Arizona Weight Loss Solutions. His no. is 480-419-2280. His office is located on Tatum Blvd, on the SW corner of the Desert Ridge Mall Entrance. He does his surgeries at Paradise Valley Hospital. Either way, I wish you and your sister the very best with getting your WLS needs met. I know Dr. Simon would be excellent at negotiating any needed support for treatment.

Ronda

marksmith · July 23, 2011

Reducing inpatient hospitalizations as a way to control senior members' costs causes outpatient utilization to rise. The answer may lie in creating a hybrid Medicare plan that combines managed care with medical savings accounts.A medical levy exemption is a feature of Australia’s universal healthcare program which frees certain taxpayers from the requirement to pay the tax that supports the program. In addition to low-income taxpayers, those who are not eligible for medicine also may be exempted from paying the levy. Considering the overall participation of Australians in Medicare, the population of exempted taxpayers is relatively small.

Australia’s universal health care system was introduced in 1975 under the name Medibank. Its name was changed to Medicare in 1984, and it currently operates as a hybrid of private and public health care. Totally subsidized care is available to participants in public hospitals, and partially subsidized care is provided by doctors in their offices and clinics, as well as by private hospitals. Funding for the original Medibank program initially was provided from Australia’s General Fund, but in 1976 a 2.5% tax – or “levy” – was enacted to support the program. An exemption for low-income taxpayers was included in the legislation.

Thanks

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RSREED53 · July 23, 2011

Obamacare is supposed to operate similarly, but the argument is the cost of supporting such a healthcare plan. I am drawing welfare due to decline in employment nationwide. Politically, the Republican Party is fighting the Congress over any new taxes. Our people face terrible economic conditions and no work! :unsure:

azsenior · July 30, 2011

Received a phone message yesterday that even though Medicare declined, my secondary, Aetna, had approved!!!! I have completed all the prerequisites except the lab work. Am hoping for an August surgery date or September at the latest.

RSREED53 · July 30, 2011

Wonderful news! Thank you for keeping me posted. How is your sister doing? :DRonda

Received a phone message yesterday that even though Medicare declined, my secondary, Aetna, had approved!!!! I have completed all the prerequisites except the lab work. Am hoping for an August surgery date or September at the latest.

azsenior · July 31, 2011

My sister is not quite ready to pursue WLS. She had part of one foot amputated in April (diabetes) so she is still recuperating. She had a bypass about 30 years ago that had to be reversed. I think it was practically experimental. She ended up with such severe malabsorption issues she had to have it reversed and she gained back all the weight and more Not sure she would be candidate, but if she can get this wound healed she may be giving your doctor a call.

RSREED53 · July 31, 2011

:rolleyes:I hope she can get herself healed so that she can get treated for her weight--that would nip diabetes in the bud!! If you take the Protein and Vitamin supplement as the doctor directs, you won't have any trouble with malnutrition after surgery. Dr. Simon is really the best!

My sister is not quite ready to pursue WLS. She had part of one foot amputated in April (diabetes) so she is still recuperating. She had a bypass about 30 years ago that had to be reversed. I think it was practically experimental. She ended up with such severe malabsorption issues she had to have it reversed and she gained back all the weight and more Not sure she would be candidate, but if she can get this wound healed she may be giving your doctor a call.