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Those with Medicare as primary and state ins as secondary



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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?

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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!

Sent from my SM-G950U using BariatricPal mobile app

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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.

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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 by ms.sss

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