Hospitals dropping Medicare Advantage agreements leaves patients in lurch

[Northeast Agent]

Hospitals dropping Medicare Advantage agreements leaves patients in lurch

"The underlying issue is that health providers, whether doctors or hospitals, are demanding more payment for their services rendered to those on Medicare, and the Medicare Advantage plans are refusing to pay more," said Mississippi Insurance Commissioner Mike Chaney.

Hospitals nationwide complain that Medicare Advantage providers routinely deny payment for services, driving up administrative costs for appealing the denials. Insurance providers say doctors and hospitals try to charge too much or prescribe unwarranted expensive medications and procedures.

North Mississippi Health Services CEO Shane Spees recently told the Northeast Mississippi Daily Journal that only 4 percent of his company's patients use Humana Medicare Advantage, but they account for 85 percent of payment denials for all payers.

 

[StephanieCJ]

It’s a touchy subject. Original Medicare and a supplement don’t require PA, Original Medicare has no out of pocket max (exposing people to a greater risk), MA has PA for certain procedures but also has an out of pocket max and allows for predictable expenses for those living on a fixed income who are not able to afford a supplement. Unless the hospital is willing to pay the bill for these people, MA really is the best option for some people based on budget.

 

[somarco]

Access to care is always a concern with a managed care plan. Deciding between managed care and original Medicare is more than just budget.


The American Cancer Society tells us that more than half the 1.4 million new cancer diagnoses occur in people age 65 and older. 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.


Some cancer centers, such as Mayo Clinic, Sloan Kettering and MD Anderson may not participate in certain Medicare Advantage plans.


Not all cancer responds to chemotherapy, but 80% of cancers are treated with chemo. Those treatments occur in an outpatient setting and are covered under Medicare Part B

 

[rousemark]

It’s a touchy subject. Original Medicare and a supplement don’t require PA, Original Medicare has no out of pocket max (exposing people to a greater risk), MA has PA for certain procedures but also has an out of pocket max and allows for predictable expenses for those living on a fixed income who are not able to afford a supplement. Unless the hospital is willing to pay the bill for these people, MA really is the best option for some people based on budget.

Not if they can't get treatment..

 

[rousemark]

Access to care is always a concern with a managed care plan. Deciding between managed care and original Medicare is more than just budget.


The American Cancer Society tells us that more than half the 1.4 million new cancer diagnoses occur in people age 65 and older. 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.


Some cancer centers, such as Mayo Clinic, Sloan Kettering and MD Anderson may not participate in certain Medicare Advantage plans.


Not all cancer responds to chemotherapy, but 80% of cancers are treated with chemo. Those treatments occur in an outpatient setting and are covered under Medicare Part B

And, the newest and, in many case, most effective treatment, immunotherapy is often not covered by supplemental plans.. I don't about Medicare and MAs but it would be interesting to know.

 

[somarco]

And, the newest and, in many case, most effective treatment, immunotherapy is often not covered by supplemental plans.. I don't about Medicare and MAs but it would be interesting to know.

If not covered by Medicare would not be covered by Medigap either.

Is there a specific drug you can reference or is this just a general observation?

 

[rousemark]

If not covered by Medicare would not be covered by Medigap either.

Is there a specific drug you can reference or is this just a general observation?

general observation about ancillary plan coverage and curious about medicare coverage. Keytruda, Opivoid are a couple that come to mind.

 

[somarco]

Appears Medicare might cover Keytruda with prior authorization
https://www.priorityhealth.com/~/~/media/documents/drug-auth-forms/i-n/keytruda-pa-medicare.pdf

Same for Opdivo
https://www.priorityhealth.com/~/~/media/documents/drug-auth-forms/o-s/opdivo-pa-medicare.pdf

 

[StephanieCJ]

Not if they can't get treatment..

You make a great point if the whole picture is not taken into account. Example (common one in my area): Senior who makes 1300/mo. SS. Qualifies for partial extra help (which I help them apply for). Doesn’t qualify for Medicaid. Pays $650/month in rent, no retirement income except for SS. Signed up for a supplement when they were first going on Medicare and have had it since. They are now in their mid-seventies and supplement has gone up to $225/month with another $30 for a drug plan. Tried to underwrite them with another plan, but they won’t pass. That’s $905/month for rent and health plan premiums...leaves 395/month for utilities, gas, food, co-pays for meds, etc. You’re totally right, they should forego eating and electricity to pay those premiums even though they only see their primary care doctor once a year and one specialist twice. We have three major hospitals in my area and 6 companies for MAPD. Not all of the hospitals work with all of the MAPD plans, but there are options out there which can provide people with quality care and help them get into a position where they don’t have to chose between groceries or their cardiologist.

 

[somarco]

supplement has gone up to $225/month

Can this same person afford to pay $225/mo for health care?