Jump to content
×
Are you looking for the BariatricPal Store? Go now!

Those with Medicare as primary and state ins as secondary



Recommended Posts

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?

Share this post


Link to post
Share on other sites

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

Share this post


Link to post
Share on other sites

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.

Share this post


Link to post
Share on other sites

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

Share this post


Link to post
Share on other sites

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 by Perfect1on

Share this post


Link to post
Share on other sites

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 by ShoppGirl

Share this post


Link to post
Share on other sites

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.

Share this post


Link to post
Share on other sites

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

Share this post


Link to post
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now

  • Trending Products

  • Trending Topics

  • Recent Status Updates

    • LeighaTR

      Four days post surgery. I am sipping as fast as I can and getting NO WHERE near the goal of 60 - 80 grams of protein or the 64 oz of liquids. I just feel FULL. I don't know if it can still be the gas build up (I would think by now that would be gone) but it is a struggle to drink. And so far I have not had the nausea or spasms and don't want to wander into that territory by pushing too hard with liquids. I about passed out today as it was my most "strenuous" day. Went from second story to basement for shower and I was sure I was going to pass out. Looking back on my last few days I have had a total of less than 1000 calories. Am I just not getting enough nourishment in me? Once again a friday where I can't get ahold of the doc until Monday rolls back around so I am hoping maybe someone here has some experience on how to keep energy going. I do have fibromyalgia too and that may be where some added fatigue comes into play. How did you all fair with the goals the week after surgery?
      · 0 replies
      1. This update has no replies.
    • Doughgurl

      2 days until I fly out to San Diego to have my Bypass Surg. in Tiajuana Mexico. Not gonna lie, the nerves are starting to surface. I don't fear the surgery itself, or the fact that I'm traveling alone, but its the aftermath that I'm stressing about the most, after this 8 week wait. I'm excited to finally be here, but I am really dreading the post surgical chapter. I know its going to be tough, real tough and I think I'm just in my head to much now that the day i here. Wish me luck, Hopefully I'm one of the lucky ones, and everything goes smoothly. Cant wait to give an exciting update,. If there is anyone else have a June bypass or even a recent one, Id love to have someone to compare war stories with. Also, anyone near San Antonio Tx? See ya soon with the future me. 💜
      · 3 replies
      1. Phil Penn

        Good Luck this procedure is well worth it I am down to 249.6 lb please continue with the process..

      2. Selina333

        I'm in Houston so kind of near you and had the sleeve in Dec. Down 61 lbs. Feeling better. Was definitely worth it. I hope the everything is going well for you. Update us when you can!

      3. Doughgurl

        I am back home after my bypass surgery in Tiajuana. I'm post op day 4. Everything went great! I guess I'm one of the lucky ones who have not encountered much pain at all, no nausea thus far and I'm having no problem keeping down broths and water. Thank you for your well wishes. I cant wait to keep up this journey and have a chance at better health and simply better quality of life. I know there will be bumps in the road ahead, and everything won't be peaches and cream, but at least I have a great start so far. 😍

    • LeighaTR

      I am new here today... and only two weeks out from my sleeve surgery on the 23rd. I am amazed I have kept my calories down to 467 today so far... that leaves me almost 750 left for dinner and maybe a snack. This is going to be tough for two weeks... but I have to believe I can do it!
      · 0 replies
      1. This update has no replies.
    • Doughgurl

      Hey everyone. I'm new here so I thought I should introduce myself. I am 53y/o and am scheduled for Gastric Bypass on June 25th, 2025. I'm located in San Antonio, Texas. I will be having my surgery in Tiajuana Mexico. I've wanted this for years, but I always had insurance where bariatric procedures were excluded. Finally I am able to afford to pay out of pocket.  I can't wait to get started, and I hope I'm prepared for the initial period of "hell". I know what I have signed up for, but I'm sure the good to come will out way the temporary period of discomfort and feelings of regret. I'd love to find people to talk to who have been through the same procedure or experience before. So I look forward to meeting you all. Hope you have a great week!
      · 2 replies
      1. Selina333

        I'm so happy for you! You are about to change your life. I was so glad to get the sleeve done in Dec. I didn't have feelings of regret overall. And I'm down almost 60 lbs. I do feel a little sad at restaurants. I can barely eat half a kid's meal. I get adults meals often because kid ones don't have the same offerings at times. Then I feel obligated to eat on that until it's gone and that can be days. So the restaurant thing isn't great for me. All the rest is fine by me! I love feeling full with very little. I do wish I could drink when eating. And will sip at the end. Just a strong habit to stop. But I'm working on it! You will do fine! Just keep focused on your desire to be different. Not better or worse. But different. I am happy both ways but my low back doesn't like me that heavy. So I listened (also my feet!). LOL! Update us on your journey! I'm not far from you. I'm in Houston. Good luck and I hope it all goes smoothly! Would love to see pics of the town you go to for this. I've never been there. Neat you will be traveling for this! Enjoy the journey. Take it one day at a time. Sometimes a few hours at a time. Follow all recommendations as best you can. 💗

      2. Doughgurl

        Thank you so much for your well wishes. I am hoping that everything goes easy for me as well. We don't eat out much as it is, so it wont be too bad in that department. Thankfully. Also, I hear you regarding your back and feet!! I'd like to add knees to the list. Killing me as we speak! I'm only 5' so the weight has to go. Too short to carry all this weight. Menopause really did a doosey on me. (😶lol) My daughter also lives in Houston. with her Husband and my 5 grand-littles. I grew up in Beaumont, so I know Houston well, I will be sure to keep in touch and update you on my journey. I may need some advice in the future, or just motivation. Thank You so much for reaching out, I was hoping to connect with someone in the community. I really appreciate it. 💜

    • Alisa_S

      On day 4 of the 2 week liquid pre-op diet. Surgery scheduled for June 11th.
      Soooo I am coming to a realization
      of something and I'm not sure what to do about it. For years the only thing I've enjoyed is eating. We rarely do anything or go anywhere and if we do it always includes food. Family comes over? Big family dinner! Go camping? Food! Take a short ride or trip? Food! Holiday? Food! Go out of town for a Dr appointment? Food! When we go to a new town we don't look for any attractions, we look for restaurants we haven't been to. Heck, I look forward to getting off work because that means it's almost supper time. Now that I'm drinking these pre-op shakes for breakfast, lunch, and supper I have nothing to look forward to.  And once I have surgery on June 11th it'll be more of the same shakes. Even after pureed stage, soft food stage, and finally regular food stage, it's going to be a drastic change for the rest of my life. I'm giving up the one thing that really brings me joy. Eating. How do you cope with that? What do you do to fill that void? Wow. Now I'm sad.
      · 1 reply
      1. LeighaTR

        I hope your surgery on Wednesday goes well. You will be able to do all sorts of new things as you find your new normal after surgery. I don't know this from experience yet, but I am seeing a lot of positive things from people who have had it done. Best of luck!

  • Recent Topics

  • Hot Products

  • Sign Up For
    Our Newsletter

    Follow us for the latest news
    and special product offers!
  • Together, we have lost...
      lbs

    PatchAid Vitamin Patches

    ×