MAPD Secondary?

[somarco]

I have a friend in another state, on Medicare, recent prostate cancer DX. After exploring and discussing various treatment regimens he has opted to go with proton therapy.

He has a BX MAPD. A few days ago he met with the finance people at the PT center and was told since he has cancer he will be placed in a special program where Medicare is primary, his MAPD is secondary and his only OOP is a $40 copay.

Something isn't adding up, or is it?

 

[bluediamond]

I knew there was a fight a year or so ago about proton therapy even being covered under Medicare because of the cost. Since he met with finance people sounds like they are working payments out, but doesn't sound like they are working it out with Medicare. I'd have him call Medicare, I am still thinking they don't cover it.

----------

Proton Therapy Questions and Answers

Guess I may have been wrong.

 

[somarco]

Medicare (and some insurers) will cover proton therapy for specific cancers. Using it for prostate cancer is relatively new on the approved list. The question is, does the extra cost (vs traditional radiation) justify the treatment.

Is proton beam therapy for prostate cancer worth the cost?

According to a link on the center's site, proton therapy is approved by Medicare.

What I don't get is Medicare as the primary payer and MAPD as secondary. Either he misunderstood or someone is confusing the issue at the center. The "Who Pays First" booklet from CMS never mentions MAPD as a secondary payer.

 

[yogooglethis]

I have a friend in another state, on Medicare, recent prostate cancer DX. After exploring and discussing various treatment regimens he has opted to go with proton therapy.

He has a BX MAPD. A few days ago he met with the finance people at the PT center and was told since he has cancer he will be placed in a special program where Medicare is primary, his MAPD is secondary and his only OOP is a $40 copay.

Something isn't adding up, or is it?

My guess would be that that something got lost in translation and what is really happening is his MAPD is still primary and the cancer center hooked him up with a charity type of program that helps defray the cost of the treatment. This is common with consumers on MAPD who often can get the 20% for chemo and dialysis paid for by these types of programs. People applying for these programs don't have to be poverty level and from my experience most if not all of my MAPD clients who told me they needed chemo or dialysis were able to get it entirely paid for by one of these programs.

 

[midwestbroker]

The only thing I can think of is your client may be part of a research study of some kind that is receiving funding elsewhere.

I know MA plans will cover proton therapy for certain types of cancers, but not all.

 

[somarco]

Thanks.

He's not poverty level. Does live a modest lifestyle, collecting SS and a very small pension. Net worth around $1M, mostly liquid, no debt.

I initially wondered if this were some kind of experimental deal but from what I have read proton therapy is now approved by Medicare for prostate cancer.