Need information on how a Pt B covered expense may be paid

[Hopes]

Hello Gurus.

I have a client I'm quoting for a UHC MAPD In Georgia. He is already on A/B and has group coverage through BCBS but wants to leave plan. I've called Broker Support and read the EOC.

Client has arthritis and receives a Remicade infusion every 8 Weeks at a hospital clinic. He does not see a doctor during this time and it is a fairly quick procedure. He pays $0 for the treatment on his current plan.

I have scoured the EOC for UHC H8748-008. Under Section 4 Page 32, it says he would pay 20% of the Pt B drug cost in addition to the appropriate copay for PCP, Spec, Outpatient - in this case Outpatient.

Is there something I'm missing? Something I'm not factoring in?

 

[Hopes]

Also, see Pg 4-39

 

[sman]

You're not missing anything. He would be responsible for 20% if on a MAPD until he reaches the out of pocket maximum. Back when I was on Remicade, the bill to my insurance company was in the $5,000 range. Of course, it was reduced based on the contractual pricing between my insurance company and the provider. But let's say the contractual price between UHC and this doctors office is $3,000. Your client would owe $600 for each treatment (usually treatments are given every 8 weeks). So your client needs to decide if he's willing to pay that high amount every 8 weeks.

If your client can get a Medicare Supplement, he would be much better off as it would cover the 20%. And assuming he's not having to pay the 20% on his group plan, I think you'd be doing him a disservice by changing him to a Medicare Advantage plan.

 

[somarco]

Prescription drugs (outpatient) | Medicare.gov

FAQ | Rheumatoid Arthritis

https://www.medicareinteractive.org/pdf/B-vs-D-chart.pdf

 

[Hopes]

You're not missing anything. He would be responsible for 20% if on a MAPD until he reaches the out of pocket maximum. Back when I was on Remicade, the bill to my insurance company was in the $5,000 range. Of course, it was reduced based on the contractual pricing between my insurance company and the provider. But let's say the contractual price between UHC and this doctors office is $3,000. Your client would owe $600 for each treatment (usually treatments are given every 8 weeks). So your client needs to decide if he's willing to pay that high amount every 8 weeks.

If your client can get a Medicare Supplement, he would be much better off as it would cover the 20%. And assuming he's not having to pay the 20% on his group plan, I think you'd be doing him a disservice by changing him to a Medicare Advantage plan.

Wow! I really kept thinking I was missing something.

I agree about the med supp but he is 73, in bad health, has had cancer, etc. He's not losing the group plan. It's his wife's - he just thought an MAPD sounded good.

Perhaps when the wife retires he will have another chance to get a med supp?

 

[Hopes]

Prescription drugs (outpatient) | Medicare.gov

FAQ | Rheumatoid Arthritis

https://www.medicareinteractive.org/pdf/B-vs-D-chart.pdf

Thanks for the links! I am heading towards the FAQs on RA now for the first read and bookmarking!

 

[sman]

Wow! I really kept thinking I was missing something.

I agree about the med supp but he is 73, in bad health, has had cancer, etc. He's not losing the group plan. It's his wife's - he just thought an MAPD sounded good.

Perhaps when the wife retires he will have another chance to get a med supp?

Yep, involuntarily losing group coverage would give him a GI to a Med Supp. However, he's not necessarily an automatic decline with the AARP branded Med Supp. Most likely level 2 rates though.

Plan F - $332.25
Plan N - $220.87

Maybe find out how much they are having to pay for the group insurance and if it's remotely close to one of the numbers above, write him the Med Supp and a PDP. But if the wife is planning on quitting work within the next couple of years, they should probably just stay put until then.

 

[kgmom219]

If he is doing it himself, you've got a problem.

If he is going to an infusion center, its covered under B and the Supp.

MAPD and Remicaid is not a good idea. Of course, I NEVER think MAPD is a good idea, so I might be a little biased....

 

[Hopes]

Yep, involuntarily losing group coverage would give him a GI to a Med Supp. However, he's not necessarily an automatic decline with the AARP branded Med Supp. Most likely level 2 rates though.

Plan F - $332.25
Plan N - $220.87

Maybe find out how much they are having to pay for the group insurance and if it's remotely close to one of the numbers above, write him the Med Supp and a PDP. But if the wife is planning on quitting work within the next couple of years, they should probably just stay put until then.

I'm waiting for a call back, he's on the road now. I think she may be getting close to retirement but will have to ask.

I just looked and see that a GI even a couple of years from now would be a big savings if the rates stay stable. He's been on disability for years because he had a brain tumor which caused strokes so I know his healthcare expenses have been quite high at different times. I'm all for saving him some money.

I'm defi

Yep, involuntarily losing group coverage would give him a GI to a Med Supp. However, he's not necessarily an automatic decline with the AARP branded Med Supp. Most likely level 2 rates though.

Plan F - $332.25
Plan N - $220.87

Maybe find out how much they are having to pay for the group insurance and if it's remotely close to one of the numbers above, write him the Med Supp and a PDP. But if the wife is planning on quitting work within the next couple of years, they should probably just stay put until then.

I'm waiting for a call back, he's on the road now. I think she may be getting close to retirement but will have to ask.

I just looked and see that a GI even a couple of years from now would be a big savings if the rates stay stable. He's been on disability for years because he had a brain tumor which caused strokes so I know his healthcare expenses have been quite high at different times. I'm all for saving him some money.

 

[Hopes]

If he is doing it himself, you've got a problem.

If he is going to an infusion center, its covered under B and the Supp.

MAPD and Remicaid is not a good idea. Of course, I NEVER think MAPD is a good idea, so I might be a little biased....

kgmom219, yes the above situation is a great example of how quickly an MAPD can add up to the OOP. But, I've met people who can barely afford inexpensive meds so an MAPD is better than nothing. I've also met people who can easily afford the premium, have health problems but love the ring of $0.