Medicare Benefits Call

I called Medicare today with questions regarding coordination of benefits when I still have my work insurance. The person on the phone was really nice but the call took awhile since she had to look up a lot of info. I guess it’s not a common topic.

She confirmed that as long as I have my work insurance, Medicare will pay as secondary insurance, except for dialysis after 30 months, and the kidney transplant. I asked about previous claims where I paid a co-pay and was told that I can file a claim. However, if the provider charged more than the Medicare rate, and most do for private insurance, Medicare will calculate their responsibility with the lower rate. I’m still unclear what that means. If my doctors bills my insurance $200 and they paid $160 since my co-pay was $40, how much will Medicare reimburse me? If the Medicare rate is $100, will they pay up to $80 (80% of the initial claim at the lower rate), or pro-rate my co-pay and only reimburse me $20? We decided over the phone that I should just file the claim for $40 and see what happens. I also didn’t get any statements from my doctors so I’ll need to go back to all of them for more info in order to file the claims. Medicare does pay for cardiac rehab so that’s a lot of co-pay to get back for the entire program.

I also got the first statement from my dialysis clinic. The insurance amount was close to $30k. My work insurance only pays 85% but since I also have an out-of-pocket maximum each year, my portion comes out to ~$3,000. I’m thinking Medicare should pay that but their dialysis reimbursement rate is much lower, probably like $3,600. So will Medicare pay only 80% of that or $2,880? Also, if Medicare pays some of the bill, will my insurance count that when calculating my out-of-pocket maximum? Otherwise I’ve hit my max and my work insurance will pay 100% from now on. Super confusing.