What to look for in a MAPD plan with cancer?

[jack3454]

I have a client on a MAPD now, who just got diagnosed with leukemia. What should I be looking for in a plan to best suit him for next year's coverage? Obviously the network and making sure the cancer docs are all in network is top priority. His current plan is good, but knowing he has cancer there are better options.

I was thinking of finding the lowest MOOP plan would help even if that means going to an HMO plan. He's not planning to go to Johns Hopkins or other top hospital, he will stay local. He's most likely going to have quite a large expense, so figuring a low MOOP would also be a priority.

Anything else? Not sure what to expect with this. Thanks!

 

[Fisher]

Doctors and MOOP. Chemo will max the MOOP in a flash. You're on the right track, Jack.

 

[Special Agent]

I have a client on a MAPD now, who just got diagnosed with leukemia. What should I be looking for in a plan to best suit him for next year's coverage? Obviously the network and making sure the cancer docs are all in network is top priority. His current plan is good, but knowing he has cancer there are better options.

I was thinking of finding the lowest MOOP plan would help even if that means going to an HMO plan. He's not planning to go to Johns Hopkins or other top hospital, he will stay local. He's most likely going to have quite a large expense, so figuring a low MOOP would also be a priority.

Anything else? Not sure what to expect with this. Thanks!

Biggest solid you can do for them is educate them on the fact that very often the 20% part B charges can be paid by foundations etc or written off by provider if they apply/ask for help.

 

[steveadlman]

If the patient is low-income, that may happen. If not, many doctors will set up a payment plan to cover the 20% coinsurance. Some may even refuse to treat them if they cannot afford the 20%.

 

[annon123]

Biggest solid you can do for them is educate them on the fact that very often the 20% part B charges can be paid by foundations etc or written off by provider if they apply/ask for help.

Leukemia and Lymphoma Society (LLS) has copay programs (that also pay for chemo meds, anti nausea meds, insurance premiums). He needs to check it frequently as they don't do notifications when it opens. Only one "kind" of leukemia is open right now.

Copay | We Can Help You Cover Your Treatment Costs | LLS

At LLS, we can cover treatment-related costs for you, such as copays, prescription medication, insurance premiums, and more. Find out how we can help you.

www.lls.org

If he checks the left of the webpages he will find some other one time awards of $100 and $500 that is open to pretty much any blood cancer.

The Pan Foundation has several "kinds" of leukemia funds (what is paid depends on the fund)

Find a disease fund - PAN Foundation

Patient Access Network Foundation is helping underinsured patients get the medication they need.

www.panfoundation.org

He can sign up for alerts when these open up BUT they close quickly so when the text or email comes through he needs to drop everything to sign up now.

Both organizations have family size income limits typically 400-600% of the poverty line.

There are some programs open just to people in their state, If he googles adult leukemia financial aid he will see some. For example the first one that came up after LLS was for people who lived in IL or within 100 miles of Chicago.

Incidently 400% or the poverty line (swipe from on grant site so presuming it is up to date:
Family of 1 $60,240
Family of 2 $81,760

Also make sure the formulary includes the anti nausea drugs usually used. And while IV and injection chemo is usually under B, there are some pill treatments. Often the pharma that makes the pills has financial aid as they are under D and often not on a formulary. Neulasta (for low white count) is an in office injection so that would be under B).

Tell him to talk to the social work office at the hospital he is using (if he isn't going to a separate oncology office where the oncologist isn't a hospital employee) about what financial aid they know about.

If he is really financially stretched he needs to find out which hospital system that is in network doesn't cut off care or sue you if you end up in collection and use that one unless medical care there sucks). Setting up a payment plan often forestalls that (as long as the payments are made).

 

[axeman462]

On a side note, that 20% coinsurance and MOOP convo is great for cross-selling cancer plans

 

[Special Agent]

If the patient is low-income, that may happen. If not, many doctors will set up a payment plan to cover the 20% coinsurance. Some may even refuse to treat them if they cannot afford the 20%.

Happens often i was just with a couple last night who are certainly not poor she is on a ppo and went through chemo this year and had it all paid.sometimes it does take some initiative on the patient part but very often the patient is not paying all or even most of the 20% and they get the bonus of reaching their moop on a third parties dime..Oh and news flash she was extremely happy with the care she received on her MA plan as just about every MA client cancer patient i have talked was.

 

[annon123]

Oh and news flash she was extremely happy with the care she received on her MA plan as just about every MA client cancer patient i have talked was.

Whether or not she was happy with her MA plan would depend on who was in network for her cancer and whether or not they were decent at what they did. In some cities there are plenty of good choices. In other cities and several states there are no good choices. If you live, for example, in MS, you'd better hope you can get an out of state second opinion as they are last in the nation for health care and some counties have no health care. On the other hand if you lived in a large metro area likely you have more then one choice, some of which are top ranked in the nation. I am sure the later folks would be happy, the former not so much so.

 

[Packerland]

I would approach it the following manner if they had an MA plan.

t’s important to ensure that the doctors they need are within the plan’s network and that the plan has the lowest possible maximum out-of-pocket costs. Additionally, verify that the plan covers all of their current medications to avoid unexpected expenses.

Beyond these essentials, there are a few additional items I would consider to help provide comprehensive coverage. First, check if the plan allows access to necessary specialists and if referrals are required, as this can impact the client’s ability to receive timely cancer care. Some plans also offer specific cancer-related benefits, such as coverage for radiation therapy, chemotherapy, or other support services, which can be valuable during treatment. For Instance a Humana plan that I am framilair with charges 10% for Part B RX and 15 for DME. Lastly, given that healthcare needs may evolve, you might consider plans that offer flexibility, such as a passive PPO plans with out-of-network coverage, to allow for access to specialists beyond the immediate area if needed.

By addressing these aspects, you can help your client select a plan that best meets both their immediate treatment needs and potential future healthcare requirements.

 

[annon123]

For Instance a Humana plan that I am framilair with charges 10% for Part B RX and 15 for DME.

Adding on - when you looking up chemo costs (eg B ones) be aware that 10% of chemo can still be astronomical so they are likely going to max out their out of pocket likely in the first chemo visit.

Check what ER coverage it as well (eg do they limit the number of times you can go and how hard is it to get an exception after the fact). People undergoing chemo often have multiple ER visits.