How do we get Dad the care he needs if his Medicare supplement won't cover it?

1 answer | Last updated: Jun 22, 2010
Lunchlady2 asked...

My dad has Parkinson's disease. When he lived in California, he had a DBS (Deep Brain Stimulation) device put in. It has really helped him. We have recently moved him to Oregon, and had to sign him up for a new supplemental insurance plan, in addition to his Medicare. The device needs to be checked. We only have a few doctors here in Oregon that are qualified for that, and the new insurance company is refusing to pay. I'm not sure if it doesn't like the doctor that is available, or if it considers his Parkinson's or the DBS as "pre-existing". What, if any, are his options?

Expert Answers

First, you need to find out exactly why your father's Medigap insurance company is denying coverage for the check-up, and whether they are denying any coverage at all or just part of the doctor's bill. There are several possibilities. The first is that Medicare itself is not covering this DBS check-up. If Medicare doesn't cover a medical procedure, the Medigap policy won't cover it, either. So, you or your father need to check with the doctor he's chosen to determine whether the doctor participates in Medicare (almost all doctors do) and if so, whether Medicare will cover the check-up for your father. If for any reason Medicare won't cover it, the Medigap policy won't cover it, either. (By the way, as long as the doctor participates in Medicare and Medicare approves that doctor performing the procedure, the Medigap insurance company doesn't have the right to approve or disapprove of the particular doctor.)

If the doctor participates in Medicare and Medicare will cover the check-up of the device, then there are several other possible reasons why the Medigap insurance company might fully or partially deny coverage. One is a pre-existing illness exclusion. Many Medigap insurance policies include a pre-existing illness exclusion for a period of time -- usually no longer than six months -- immediately following purchase of the policy. Because your father just bought this new policy, you need to check in the policy itself to see whether there's a pre-existing illness exclusion and if so, for how long. If there is such an exclusion, your father may have to wait until the exclusion period is over before the Medigap policy will cover the procedure.

There's also the possibility that the doctors who do this procedure do not accept "assignment" for it, meaning they charge far more for the procedure than Medicare approves for payment. Unless your father has a Medigap policy that covers these excess charges above what Medicare approves, the Medigap policy will only cover 20 percent of the Medicare-approved amount, leaving perhaps a big chunk of the bill uncovered. Again, you have to look at the policy to see what the extent of coverage is, and then speak to the doctor's office about whether they accept assignment of the Medicare-approved amount.

You should be able to get all the information you need by speaking with the doctor's office, looking carefully at the Medigap policy and, if necessary, calling the Medigap insurance company. If you have trouble getting information from any of these sources, you can get help from the Oregon State Department of Insurance at 888-877-4894.