Hi please bare with me I’ll try to explain my best! so I have Medicare as my primary insurance and state medicaid as my secondary insurance. Typically I don’t get a bill bc the state insurance picks up what Medicare doesn’t pay.

Well my surgery is approved by Medicare but the Medicaid is saying they won’t approve it bc they require 1 year free from alcohol/ drugs as I use marijuana for pain management that violates there rules.

Typically I follow Medicares rules as they are the primary n the medicaid They would cover the part A Deductible and the leftover copayment 20% etc. I feel like the medicaid denial is based on if they were they primary which they are not. So I basically have no idea of I’ll have a huge bill or not. has anyone been through something similar?

The Medicaid denial is based on your state Medicaid guidelines, not whether Medicare is primary. Since it is a Medicare covered service, you will be liable for the 20% Medicare coinsurance, and it can be pursued all the way to collections even though you are a Medicaid patient, specifically because it is considered non-covered by your Medicaid plan.

I mean obviously I'm a stranger on the Internet so take this info with a grain of salt. But my career is in Medical Billing, specifically Medicare and Medicaid.

Best of luck to you!

Because it's government money being used, they can dictate the rules, so you would be responsible for the 20% if you didn't wait the year without drugs.

The use of medical marijuana to treat chronic pain conditions isn’t what I call drugs but yea throw a bit more rude n judgmental smh

Unfortunately I don’t think it matters whether you classify them as “drugs” or not. Only matters what your insurance classifies them.

Would it help if you submitted a prescription issued for the medical marijuana by your PCP? I would assume that the rules would only apply to recreational use...which yours is not.

But as the other poster said above, I’m just a stranger in the internet...

Good Luck!

Edited November 22, 20205 yr by ms.sss

I believe that medicare is a good platform. One of the most unpleasant things that could happen when you don't have medical insurance is getting sick. In this case, all the expenses fall on you, as a patient, because you will be treated regardless of whether you have medical insurance or not, but the expenses will add up in your account and at some point, you still have to pay. I would suggest taking a look at the best Medicare supplement plans 2022 because they are already available and it is better to have a clear idea about them in advance.

Edited November 30, 20214 yr by Perfect1on

I can’t imagine that medical marijuana would be used against you. I would call again and talk to someone else and make sure and consider appealing it if it is true. On another note, if the marijuana makes you eat a lot (I know some people it does not) I would want to be off of it and have an alternative pain management plan in place before the surgery because that will stop your progress before you even get started post surgery.

Edited November 30, 20214 yr by ShoppGirl

You pay 20% of the medicare allowed amount which is WAY lower than the price the hospital bills for.

No, it is your responsibility to follow the rules. It is government money that is used, so they dictate the rules. This means that you are responsible for the 20% if you didn't wait the year without drugs. For such cases, it is better to use better options which are medicare advantage plans good. You have to plan such things to know the rules in advance. Plus, it will get you free from risks and tell you exactly what you have to do to protect your health. I personally plan everything to know what I can't consume, like alcohol or drugs.

I know that Medicare can be primary insurance especially if you haven't been working and have shared insurance with your spouse. But if you have to choose between insurances, you better consider some nuances especially if the meds are banned by the insurance and are prescribed to the doctor. And if you wait until a year has passed (since not using marijuana), the insurance will expire. I read the Plan G Vs Plan N summaries and so I clarified such questions right away before getting such insurance. And I was prepared for that. But if your Medicare plan isn't ready to pay most of the costs, you can change it while you can