MAPD/pre-auth denied cancer treatment

[CMS]

Diagnosis: squamous cell carcinoma
Treatment: keytruda
MAPD carrier denied pre-auth..said it not medically necessary..any other options besides going back to original Medicare

 

[MichFlor]

Find another MAPD and switch them while still on OEP?

 

[DonP]

Just looked it up . Only 31.9% survival rate in 5 yrs . Seems like an outliar treatment so I’m willing to bet many CO’s won’t pay for it .

 

[policywunk]

Diagnosis: squamous cell carcinoma
Treatment: keytruda
MAPD carrier denied pre-auth..said it not medically necessary..any other options besides going back to original Medicare

If its covered by medicare part b it has to be covered by mapd so they can appeal that but first i would find out why it denied to make sure it wasn't a coding issue by provider

 

[somarco]

If its covered by medicare part b it has to be covered by mapd so they can appeal that but first i would find out why it denied to make sure it wasn't a coding issue by provider

Whoa there.

Just because keytruda immunotherapy is a covered by Medicare does not mean it is automatically covered by a managed care plan. The carrier has a right to authorize lower cost treatment plans before going to the most expensive treatment.

That is how managed care works. Go cheap, if that doesn't work we will consider something else.

When an MA carrier says no it doesn't mean they will never cover it, just try the stuff on the $1 menu first.

It you don't want pre-authorization go with original Medicare not an MA plan.

 

[DonP]

I think there’s a misunderstanding here .Most people would much rather have a plan G than a mapd . But in retirement many people make $25 to $50 k and can’t afford $200 plus a month plus $20 plus for part d . Just like many self employed agents would love to have a $1 k deductible family plan but they can’t afford $3 k a month for it thus must gamble with a $5 -$8 k plan . A husband wife on plan G and a pdp is near $5 k a yr

 

[vic120]

I think there’s a misunderstanding here .Most people would much rather have a plan G than a mapd . But in retirement many people make $25 to $50 k and can’t afford $200 plus a month plus $20 plus for part d . Just like many self employed agents would love to have a $1 k deductible family plan but they can’t afford $3 k a month for it thus must gamble with a $5 -$8 k plan . A husband wife on plan G and a pdp is near $5 k a yr

My mother in law now lives with me we got her GI on med supp 2 years ago 4 years after her husb died on MA plan they felt they could not afford a supp, However, he had cancer died in hospice and she is stil paying off his bills

However, she has Med Supp now had cancer now has kidney desires she can travel go to doc in NY FL here wherever she wants and goes S

She is amazed at how something that cast most actually cost less

The point is most of us including myself at times feel I cannot afford something that Actually can't afford not to pay

 

[DonP]

So again tell that to the 50 yr old husband wife with 3 kids . Aca costs $3200 a month for a $1 k deductible . A $8 k deductible is $1500 a month . What do you say to him ? He doesn’t have $38 k a yr for health ins . I know 3 people right now that have been paying $2 k plus a yr for Med sups for 10-15 and hardly ever used . So theoretically they’d have been much better off with mapd . We keep bringing up networks and how they suck . Every single American under age 65 has been subject to the grasp of networks all their life you and me included with employer or self employed ins and we survived .

 

[vic120]

So again tell that to the 50 yr old husband wife with 3 kids . Aca costs $3200 a month for a $1 k deductible . A $8 k deductible is $1500 a month . What do you say to him ? He doesn’t have $38 k a yr for health ins . I know 3 people right now that have been paying $2 k plus a yr for Med sups for 10-15 and hardly ever used . So theoretically they’d have been much better off with mapd . We keep bringing up networks and how they suck . Every single American under age 65 has been subject to the grasp of networks all their life you and me included with employer or self employed ins and we survived .

I have no idea what you are saying how does ACA factor I pay $1400 pre month with 14 K out of pocket what does that Have to do with medicare

The point I was making is the out of pocket on the MA was more than the total cost of med supp when there are major issues

Its a gamble when you go MA you are gambling that the lower premium will help you more then the cost of the out of pocket and you wont be too effected by network issues

 

[DonP]

Obviously Ma penetration is up to 37-38% so many people believe in it . I only sell Ma to people who already have MA or to duals . I run into many people who say their plan F premium is killing them but their usually in bad health and I refuse to move them to a mapd even though they might want to .