New rules from the US CMS [Center for Medicare Services] for those who use Medicare Advantage Plans (part C). Here are some selected quotes:
"Specifically, CMS clarifies rules related to acceptable coverage criteria for basic benefits by requiring that MA [Medicare Advantage] plans must comply with national coverage determinations (NCD), local coverage determinations (LCD), and general coverage and benefit conditions included in Traditional Medicare regulations. "
translation: Medicare Advantage plans must follow CMS guidelines for basic benefits
"CMS is also finalizing that when coverage criteria are not fully established, MA organizations may create internal coverage criteria based on current evidence in widely used treatment guidelines or clinical literature made publicly available to CMS, enrollees, and providers. In the final rule, CMS more clearly defines when applicable Medicare coverage criteria are not fully established by explicitly stating the circumstances under which MA plans may apply internal coverage criteria when making medical necessity decisions. CMS believes that permitting the use of publicly accessible internal coverage criteria in limited circumstances is necessary to promote transparent, and evidence-based clinical decisions by MA plans that are consistent with Traditional Medicare."
translation: For new therapies (not yet covered by CMS guidelines), Medicare Advantage plans may develop their own coverage criteria, but those criteria must be explicit, publicly declared, and consistent with best practice.
"The final rule also streamlines prior authorization requirements, including adding continuity of care requirements and reducing disruptions for beneficiaries. CMS’ final rule requires that coordinated care plan prior authorization policies may only be used to confirm the presence of diagnoses or other medical criteria and/or ensure that an item or service is medically necessary"
translation: a Medicare Advantage plan may only require prior authorization to confirm medical necessity
"the final rule requires that approval of a prior authorization request for a course of treatment must be valid for as long as medically reasonable and necessary to avoid disruptions in care in accordance with applicable coverage criteria, the patient’s medical history, and the treating provider’s recommendation."
translation: The Medicare Advantage Plan may not end treatment before the doctor says so.
I have been told that Medicare coverage decisions are made on a regional basis... not for basic stuff, but for new things where differences in professional opinion exists.
This seems like a generally good step though.
The real problem with the advantage plans is you have very diminished control over who your doc is. And in the end, they are the ones in real control of your treatment decisions.
You cannot accurately paint all Medicare Advantage plans with a broad brush. You said:
The real problem with the advantage plans is you have very diminished control over who your doc is.
That is just not true. My Advantage plan through United Health is a PPO plan and I can go to any Doctor who accepts Medicare. Furthermore, I do not need any referrals, I just make my appointment with the Doc of my choice and go. I would be very hesitant to enroll in an HMO plan.
My Advantage plan is through Humana Choice PPO. I haven’t had any problems with Humana. Like you I don’t need any referrals and can see any doctor. I made a self referral to a medical oncologist at MUSC a year ago. My plan doesn’t cost me any thing. This year I have no co-pay too see any for my doctors.
I never said anything about any panel. I have no idea what you're talking about. My United Healthcare PPO pIan is not by definition an HMO plan. I can visit any Doctor who accepts Medicare and it makes no difference if that Dr. is in the UHC network or not. I am treated exactly the same whether or not the Dr. I visit is in their HMO network. The United Health HMO and PPO Advantage plans have significant differences and you can read about them on their website. I have had the same Medicare Advantage PPO plan through UHC for over five years and so far, it's been excellent.
TA, thank you for posting this information and thank you for your valued translations.
would it be correct then that the HMO option comes with a lower premium? otherwise, why select an HMO when PPO is available? You don'have higher out-of-pocket if you visit a Doc not in the PPO network???????????
Wrong. The difference between an HMO and PPO is that with a PPO one may choose a physician OUTSIDE the network and pay extra; with a HMO, there's usually no such choice. However, if the HMO doesn't offer the specialty you need, you may petition but good luck with that.
There's an enrollment period every year during which I may shop for the best plan that suits my family. I have remained with my current provider for most of my adult life because it has been flexible enough to meet my family's needs. I do not feel "captured."
Basic question for someone who will soon need to decide Medicare plan...let;s say the patient is considering initial treatment, surgery or RT, different otions for RT, etc. Does Medicare traditional and or Advantage plans allow for multiple consults with different ROs and surgeons......thinking there must be some limitations? With non-Medicare Kaiser plan, I haven't really tested this, but have the feeling they discourage more than opinion from their RO clinic physicians...and probably are all on the same page anyway, supporting each other and discouraged from disagreeing with a fellow Kaiser practtioner? so, 2nd opinions of limited value in that environment?
I think the issue was the perceived arbitrariness, the lack of transparency, and the delays in getting pre-authorization. I have seen cases where for two patients in the same situation and the same plan, one got timely authorization while the other was refused and only got it after a time consuming appeal. I think the new rules address that.
I think CMS is pretty good about approving all FDA-approved medications on a timely basis.
This does not refute the fact that advantage plans are private insurance policies. They can and do change the policies at will and can cancel policies at a whim.
These companies fleece the Medicare fund and just received a pass by government to continue the practice.
thanks TA. Lots of people do not understand their advantage plan. But Joe Namath said it was a good deal on TV. Lol
Imho most of us that use this site will need expensive treatments now or later. I can confirm that standard medicare plus a supplement plan F or G pays the bills for whatever normal treatments or tests/scans the Dr needs
The "Advantage" plans have no advantage over the "Supplemental" plans. Advantage plans have many restriction, ie. foreign coverage, large co pays, etc. Read the limitations. I have had the J supplement with part D drug plan with United Health for 14 years. Never a copay or out of pocket expense. All my PC care is covered at 100%. I have the premiums deducted from my bank to avoid any missed payments. If you miss a payment, you lose your plan. J is no longer available. That's my experience. Helmet
it sounds like my non advantage plan is the same as the advantage plan. Qualifying issue is if Medicare approves blue cross will pay. If medicare doesn’t pay blue cross won’t.. sounds like I’m paying a lot more for nothing.
If you have an Advantage PPO, the out-of-network providers often cost more and have to agree to accept only Medicare. With a Supplemental PPO Plan, all providers are covered equally and can charge the Plan whatever they want, so they will all accept you as a patient. I am able to get all of my drugs between low cost generics (I use Mark Cuban's Cost Plus Drug) and most other drugs available from India. But if you have other drugs, Advantage may be preferable -- you have to do a spreadsheet.
My 71 year old husband is on the Aetna Advantage PPO Plan here in CT. He tried to switch to regular medicare with a supplemental during the re-enrollment period but because he was never on regular Medicare there would be a 3 month waiting period for prescriptions and we couldn't afford to pay for all his meds for 3 months. So he upgraded his Advantage plan with Aetna. Even though it was a PPO plan, it didn't cover his visits to Sloan Kettering or Yale. I'm choosing the regular Medicare plan with a United Healthcare/AARP supplemental for my upcoming 65th birthday. Those advantage plans without a premium and all the other perks are tempting but I am not starting out with one like my husband did.
My husband has Advantage HMO and was with Hoag/Keck but as of this month he can no longer see his doctor at Keck because they not longer see Advantage HMO. Was told he could switch to regular Medicare but if he did there was no way he could get a medi-gap insurance with stage 4 PC. So what ever regular medicare didn't cover would be out of pocket. So three days prior appointment with MO (Keck) we were told his appointment canceled and would have to get all new referrals for Xgeva and any other infusions and a new MO. The MO would have to be a Hoag MO and we basically could not choose any Doctor. So we are stuck! Keck referred us to another MO but he was on vacation that week and when he returned he wouldn't see him and pawned him off to another MO. I would never sign up for advantage HMO you do not have a choice. When learning of this I quickly changed my medicare plan which was advantage HMO to regular medicare and plan G with UHC.
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