The HHS Office of the Inspector General (OIG) recently found that Medicare Advantage plans deny care—inappropriately—at relatively high rates. It may be that prior authorization rules are a reason that sicker Medicare Advantage patients are more likely to dis-enroll in their plans than healthier people.
Four in 5 Medicare Advantage enrollees are in plans that require prior authorization for some services, including for Part B drugs, hospital and skilled nursing facility stays, lab tests, home health and medical equipment.
Step therapy requirements can mean that patients are denied access to new and better medications until they have tried a less expensive drug. For cancer patients, this can mean delays in using the best treatments to treat their cancer, side effects and treatments.
If you plan to travel, you will need to contact your Advantage plan to find out if/which benefits are available out-of-state. Does your plan offer out-of-state coverage, or you may need to find a similar plan offered by another firm in your area. If you decide to switch to a different plan, however, you will need to wait until the annual Medicare Open Enrollment period (October 15 to December 7). You can also use the annual Medicare Advantage Open Enrollment period (January 1 to March 31) to switch to a different Medicare Advantage plan or switch to traditional Medicare.
Cancer Treatment Centers
In 2019 most Advantage plans issued in Georgia limit your out of pocket to $6700. The limit only applied to approved in network health care charges.
More than half of 1.4 million new cancer diagnoses occur in people age 65 and older. This according to the American Cancer Society. Roughly 20% of retiree deaths are a result of cancer. Medicare pays for almost half of the $74 billion spent on cancer treatment. The elderly account for 70% of cancer deaths each year.
Medicare Advantage and Cancer Treatment
Did you know some cancer centers may not participate in certain Medicare Advantage plans. This includes Mayo Clinic, Sloan Kettering and MD Anderson
Many cancers respond to chemotherapy. Approximately 80% of cancers are treated with chemo. Those treatments occur in an outpatient setting and are covered under Medicare Part B.
Chemotherapy drugs administered in a doctor’s office or clinic normally fall under Part B. Medication from a retail pharmacy or by mail fall under your PDP.
You have questions? We have answers. GA Medicare expert Bob Vineyard reviews cancer and Medicare Advantage.