Insurance is asking for reimbursement because I have Medicare part A and not part B

[Mimi K]

Please, please help!!! When I received social security disability in 2011 I was happy the process was over. Although, I was receiving long term disability and paid insurance through the company I had worked for 23 years.
I have part A. Now the nightmare...my insurance company is saying I should have gotten part B at the time and didn't and I now owe them everything they have paid for me to doctors and hospitals since 2011.
I am devastated and confused.
I don't know how the system works but I must learn very quickly.
mimi

[Kimba22]

Hi Mimi,

Welcome to MSWorld. Glad you joined us, just wish it was under a different scenario. I truly hope what you've been told isn't the case!!

I think the answer all depends on how many employees a company has. Here is a link for you: www.medicare.gov/Pubs/pdf/02179.pdf

I hope Rich has some encouraging words/ suggestions for you when he checks in.

Good luck.

[Mimi K]

Group insurance 100 people or less...who should ask this question

Thank you for responding. Even though my insurance card says group....it is a company of 12. I was never told it wouldn't be my primary because it wasn't over 100 people. Never!!! For an insurance company to be able to do this is beyond my comprehension.

A heavy price to pay for someone who didn't get the rule book. It is hard for us with cognitive issues to begin with and now are asking me to remember a conversation in 2011
(Did they offer part B?). I feel like I failed my family and am going to have to pay dearly for this.
Very sad

[Kimba22]

Hi Mimi,

I can't even tell you how very sorry I am. Maybe Rich will have some suggestions about how to navigate through this mess? I also think it would be well worth it to find an attorney to advise you on the next steps you should take.

I can remember bits and pieces of the conversation I had about Medicare A and B coverage, but unless it was recorded, how can you prove any of it? Things can easily be misinterpreted if you don't understand the verbage. I know I knew absolutely nothing about medicare when I became eligible! (And I'm still learning ... ) But, at least I was fortunate to have another set of ears listening when they called. From what I remember, the guy I talked with also was pretty informative. So, I guess I was also lucky there.

Here's some explanation about "group" coverage:

"Group health insurance coverage is a policy that is purchased by an employer and is offered to eligible employees of the company (and often to the employees' family members) as a benefit of working for that company."

"At this time, small employers are not required to offer health insurance to employees. Many do so because they believe that health insurance coverage is a valued employee benefit that helps employers attract top employees and retain them. State and federal laws apply to varying degrees – again based on factors including the number of employees, the type of business and whether an insurance company is providing the coverage."

" ... states require companies to have at least two employees to qualify for group coverage. Insurance companies and the individual states often have specific and strict requirements for very small employer groups to document that they actually are legitimate businesses and have the appropriate number of eligible employees to prevent fraud. Employers generally have to provide payroll tax documentation validating who is an employee." http://www.nahu.org/consumer/GroupInsurance.cfm#

It's so unfortunate this wasn't all explained to you in a way you could understand. So very sad. I guess its another case of " buyer beware," regardless of our disabilities. It would be helpful if we'd also receive written information instead of just phone calls before making such an important decision. I know I don't always comprehend things (spoken or written) right away.

Best of luck to you. I only hope your post will help others avoid making the same mistake.

Hugs ,

[MSW1963]

It seems to me that the medical insurer would have followed up with you about your financial obligation for medical costs if you turned down Medicare Part B coverage. They had to know you were on SSDI?

check with the department of insurance in your state to verify if there was some disclosure the insurer was required to provided to you, probably the kind of informed consent form letter that you would be required to sign and return, indemnifying the insurance co from liability by declining Medicare Part B. Hard to believe the insurer just willy-nilly paid your policy benefits for such a long period of time, to come back to you now, doesn't make sense to me.

I'm clueless about Medicare B beyond that they are the primary payer, and the group policy is considered secondary payer.

Hopefully, Rich Feingold will be along soon.

[Mimi K]

Thank you for your responses.
I think it came to their attention in November because I was hospitalized for a few days and Medicare part A came into play for the first time.
I really wonder if the broker that provided the information to the insurance company left out the part that I was on disability. I would think he would have told my company that they needed to tell me to take Part B. They have been paying for primary insurance for me.

[MSW1963]

It seems someone dropped the ball that resulted in you not receiving the initial 'informed consent' letter that's required by either state or federal insurance law, or both.

You were entitled/obligate to receive info about the consequences of declining Medicare part B from your insurer.

My guess is you'll need an attorney to request records to determine who's responsible. (I can't remember how to spell the word for a court order for your records from your insurer, and agent.)

The NMMS may be able to help you with a referral to an attorney.

Also your state department of insurance should be a great resource particularly if there was a violation of the required informed consent law.

[Mimi K]

Reimbursement follow up

My daughter went with me to the social security office to discuss my options. The only option available was to submit a letter to social security. In the letter I was to detail my original conversation with the representative of social security.
Basically I wrote what I recalled in the phone conversation:
I was not informed that my group insurance through my company would not cover me because it was too small. When the woman asked if I had other insurance I said "yes, I have group coverage until I'm 65 with the company I had worked for before going on long term disability."
She said okay.

That is it folks....it was a short conversation that had dire consequences years later.
They said they would submit the letter with the file. It will take 30 to 45 days. Wish me luck.

[MSW1963]

My impression is this is the insurer/agents failure to notify you in a timely manner, that you were no longer eligible for group benefits because employee populations under 50? are exempt from offering continuing coverage under COBRA for disability.

I'd encourage you to contact your state insurance dept., for info about legal requirements of the agent and the insurance co. when you became disabled, yet insurer continued to pay your claims for years.

Were you paying monthly insurance premiums to the group insurer?

I hope this resolve quickly and favorably for you.

[Mimi K]

The only reason I found out was because I called the insurance company about claims that hadn't been paid. I was put on hold and when she returned she stated her supervisor said they would be paid as if I had Part B. I was never notified by mail and still have not received anything by mail from insurance company. Broker is the one who said he had tried everything and they said no.
No written notification from anyone.
I have been given a case number from state insurance commissioners office.
Fingers crossed!!

[MSW1963]

Good move to get the insurance commissioner involved.

Accepting your monthly insurance premium payments, refusing to pay your claim since November when Medicare A brought things to their attention, not sending you written denial of that November claim, is sounding more like the initial Medicare part B notification = 'informed consent' when insured refuses part B coverage was overlooked.

This may also involve your employer who processed lots of paperwork when you separated from service/retired on SSDI, and should have resulted in you being removed from their monthly medical insurance premium list bill.

Keep us updated and fingers crossed for good news coming your way soon.

[MSW1963]

BTW

BTW, if you continued to be covered under the company plan while on LTD, it sort-a make sense, in the back handed, nonsensical way the entire situation was handled, that you didn't receive the required 'informed consent' letter of the consequences of declining Medicare Part B.

Not to mention that an organization of 12 employees is exempt from offering Federally Protected continuation of coverage, yet you were covered, with primary coverage by the insurer under the company plan.

I guess any company can voluntarily offer continuation of coverage despite being exempt from doing so, but it would have to be offered in a non-discriminatory manner too all employees with x number of years of service, with a written plan document, and with consent of the insurer, who is ultimately responsible for administering the plan.

Nothing about this is making much sense, at every turn there is contradiction.

Hope you are making some progress.

[Mimi K]

Insurance commissioners office called and said, "insurance company is not doing anything wrong. This happens all the time. Company or insurance representative should have informed me.
It is very sad and I feel foolish for not knowing and angry. I am getting calls everyday for payment or explanation. Costs of tysabri alone is going to be horrible.
Very sad and I hope this saves so done from the mistakes I made.
Mimi

[MSW1963]

I can't believe you were covered by the company plan while on LTD for 3-4 years, filed past claims that were paid and no one in authority or with any responsibility. Now years later decide you needed Medicare part B.

Have you contacted an attorney? Most local chapters of the NMMS have referral list for attorneys who specialize in various types of insurance law.

I worked in a state where the insurer, a huge 'association' that was the largest employer in the state, and it mattered a lot when it came to how conflicts were settled with the insurance commissioner.

I hope you talk with an attorney soon.

[Kimba22]

Insurance commissioners office called and said, "insurance company is not doing anything wrong. This happens all the time. Company or insurance representative should have informed me.
It is very sad and I feel foolish for not knowing and angry. I am getting calls everyday for payment or explanation. Costs of tysabri alone is going to be horrible.
Very sad and I hope this saves so done from the mistakes I made.
Mimi

"This happens all the time?" How very scary!

I'm so sorry you didn't receive more positive news , it certainly doesn't seem right, especially since you were on LTD.

But, you shouldn't feel foolish. I think the same thing would've happened to most people, when totally unaware there's a problem. I knew nothing in the beginning (and still learning things, like with what has happened to you). But, since my husband works for a very large company, every year we've been reminded about their policy in regards to continuing someone's health coverage. At least in my case, it's the same thing the guy from Medicare told me years ago. (Grateful I talked with someone who gave me the correct information.)

Please consult a lawyer, who will guide you through your next steps. Good luck with everything, and please let us know what happens.