50% out of network...Primary vs Secondary

[LostDollar]

3. I specifically asked them both if Medicare/Supp, as 2nd and 3rd payers, would pick up the $12,000 deductible that would be incurred by the EGHP for the visit to MDAnderson. They both said it would NOT!

I have been unable to read this concept into CFR 411.33. (Code of Federal Regulations about Medicare secondary payments.)

It is possible your advisors may have confused the proper application of the term "deductible" for Medicare secondary payment computation- Confusing the EGHP deductible with the Medicare Part A deductible.

I see CFR 411.33 talking about Primary Payer payment amounts, but not how those amounts are computed.

 

[LostDollar]

Is you Medigap plan one that pays excess charges?

 

[LostDollar]

Caveat, I am NOT an agent. The following are just comments of another Medicare beneficiary and I accept no liability or responsibility for any use you choose to make of them.

WPS Government Health Administrators Portal

There is a link for an MSP estimate calculator provided by one of Medicare's MAC's. I don't know if it has any use for you, just passing it on in case it does.

Vocabulary is a KEY item when you are talking about Medicare issues.

Deductible does not relate to your EGHP. It relates to the Medicare Part A deductible of $1408 and the Part B deductible of $198 (both for 2020). Non-participating relates to a provider's status in regard to Medicare, not their status in relation to an EGHP.

The questions I would ask are things like: the MD Anderson total cost; whether or not you are liable to them for that total cost; what the Primary (EGHP) will pay; the allowed amount by Medicare and what Medicare will pay; and then what of the remainder will be paid by the Supplement. (Also you should learn if MD Anderson is likely to make any charges that are NOT covered by Medicare (which means the supplement will not cover them either).)

MD Anderson's website says they accept Medicare Parts A and B, but I don't know exactly what that means in relation to the questions above, particularly for Part A charges which I have no experience with.

You have probably already seen this, but here are MD Anderson's general comments about their pricing:
Price Transparency

 

[LostDollar]

Caveat, I am NOT an agent.

PPS-Exempt Cancer Hospitals (PCHs) | CMS

MD Anderson appears to have a statutory exemption from what are apparently more "normal" billing computations for hospitals.

Again, I don't know what ramifications that has for your specific situation.

 

[StephanieCJ]

I am in Northwest Louisiana and know several central and south LA agents who are reputable if you want to sit down and talk with someone in the area who can steer you in the right direction. If she is 65 and leaves her group, she has guarantee issue, so that is good, but one of the things she does not have to contend with is the coverage gap/donut hole for drugs. That would be a huge deciding factor for me if I were working with her. That being said $12K for out of network is a ton of money too. The coverage gap is the reason I keep my mom on my dad’s group plan, even though the medical out of pocket is higher, because in her case the meds would eat our lunch on a Part D. I’m sorry ya’ll are having to deal with this, but at least she has you as an advocate.