About Medicare Advantage plans, frustrated doctors, and an old gal who has changed her mind
Full disclosure: I've always had a MA plan and I never had a single issue regarding coverage or denial of service or medications. I've gone through cataract surgery and two brain stents for for a brain aneurysm that costs thousands of dollars. Then in 2024 I ran into this:
I developed Geographic Atrophy, better known as 'Wet' Age Related Macular Degeneration (AMD), which is characterized by the growth of unnecessary , damaged, blood vessels that leak blood and fluid into the eye, causing central vision loss. The most common treatment is ongoing eye injections (yup, a shot into the eyeball) that temporarily stop the proliferation of these rogue blood vessels.
There are three or four different medications (most of these medications are anti-cancer drugs (It gets complicated) that are injected into the eye at a cost of $50 to $2000 per injection. The $50 shot works sometimes. The higher priced medications work all the time.
So, this is what my Retina Specialist (who is DISGUSTED) with MA plans told me today after I had my 4th shot in four months. Because one of the previous three shots was not the lowest cost drug, but a sample he used, it did not meet their 'requirement' that three shots of the lowest cost drug be used AND is shown not to be working before they will approve the higher priced drugs.
So, there you have it. The physician cannot provide the best, most appropriate medication for a disease that could well cost me my central vision. So, after ten years of coverage with an MA plan, I am going to enroll in original Medicare as soon as I meet a qualifying event.
I don't know what the moral of this story is. All I know is the decisions these health insurers are making are not based on sound medical advise, but on saving a few hundred dollars at the risk of human lives and the loss of payments directly from Medicare, because you can't get blood from a stone or dollars from a dead old gal.
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gab13by13
(26,001 posts)are planning to make everyone use a MA plan and do away with Medicare.
Joinfortmill
(16,989 posts)Attilatheblond
(4,969 posts)if they didn't stand to make a LOT of profit on these policies. And the way they make the profits is by denying coverage.
SheltieLover
(61,291 posts)![](/emoticons/grr.gif)
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EYESORE 9001
(27,737 posts)I havent had occasion to butt heads with my MA provider yet. I havent switched over to regular Medicare totally, as it would require paying a monthly premium, and Im a cheap bastage. Still, I prefer not negotiating with a death panel composed of hospital administrators and corporate bean-counters.
Joinfortmill
(16,989 posts)Which may well happen. It's happened often to me in the past, I'll switch.
djtexas
(36 posts)You may not be eligible for original Medicare.
I think it is an unfortunate restriction (in the fine print) that if you enroll in a Medicare Advantage plan that you can never get original Medicare.
Please report back what you find out.
Joinfortmill
(16,989 posts)dpibel
(3,487 posts)The problem is that you may not be able to get a supplemental plan, or may have to pay through the nose for one.
Without a supplement (which is, for all the wailing about Advantage, private insurance), you're on the hook for 20%.
Joinfortmill
(16,989 posts)have a 3 to 6 month waiting period.
JT45242
(3,074 posts)Regular medicare D it is between $50-60 a month.
Medicare advantage put it on name brand formulary and you must show other generic blood thinners didn't work.
His best option is to try to quit his advantage and go back on regular medicare part D or just suck it up and pay $400 a month until his prescription total for the year hits $2000 thanks to Biden.
It is so hard for me to not say..you voted for the felon three times. Reap what you sow.
gab13by13
(26,001 posts)but it is worth a phone call. I was paying 400 dollars for a 90 day supply of Eliquis and now I am paying 10 dollars a month. It has nothing to do with income, it is a program done through Bristol Myers Squibb.
Call this number to find out about eligibility
1-855-ELIQUIS - 1-855-354-7847.
JT45242
(3,074 posts)Got two months cheap and is no longer eligible.
Big cluster f....
Wife called me last night. Asked me try to find a solution.
I do appreciate the helpful link...
Silent Type
(7,880 posts)work well the vast majority of time.
Medicare -- what we consider the model for universal healthcare -- has coverage requirements for treating macular degeneration too.
I'm at high risk of macular degeneration. If it gets to that point, I'll try the cheaper med that is like $100 to see how it works just because it makes sense. Other folks will rush to the expensive, heavily advertised meds.
Joinfortmill
(16,989 posts)In my case, my condition is worsening and They're denying medication that would be effective.
Silent Type
(7,880 posts)some doctor -- who probably is invested in companies that make the more expensive drugs -- recommends it.
I hope your treatment is successful, the little blurry spots get annoying after awhile especially when they get bigger.
Joinfortmill
(16,989 posts)JT45242
(3,074 posts)All the cheaper drugs that my FIL should have to step up through to get the new name brand have potential major problems with one of the many other cancer or other meds he is on.
Joinfortmill
(16,989 posts)IbogaProject
(3,978 posts)We were doing every 6 weeks and once when delayed to 8 weeks the condition improved. Not sure if her's was wet or dry. But yes, MA plans have profit seeking and those delays in care are often dangerous.
XanaDUer2
(14,961 posts)And said choose traditional M. I can't afford a supplement. I may look into that. I'm hoping to get a small pension in 8 mos.
I'm sorry. Id b pissed. My thought s are Republicans want to end TM move everyone to MA and start cutting benefits. So i don't want it.
I hope your ok
Zombie2090
(1 post)I recommend that we start making fireside chats like FDR. We are now, just like Germany in the 1930s, in a country that voted away its rights. I recommend that we have fireside chats like the one I created on AI for free. But done much more professionally for each day of the occupation.
Joinfortmill
(16,989 posts)B.See
(4,210 posts)B.See
(4,210 posts)turned to shit, including my own Aetna PPO where maximum out of pocket expense has tripled.
Don't quite know what u mean by qualifying event, but I THINK you can switch from a MA plan to a regular Medicare plan (or to another MA) ANYTIME before the end of March.
Joinfortmill
(16,989 posts)had a qualifying event
SheltieLover
(61,291 posts)I'm so sorry you are going through this!
Joinfortmill
(16,989 posts)SheltieLover
(61,291 posts)Was the chespest for me by hundreds of dollars per month.
Is there a manufacturer discount program you could use?
Call your local Council on Aging & ask if there is an organization who can help to defray costs.
I hate that you are going through this & would gladly cover the cost for you if I could. Vision is nothing to play around with.
I hope you find a solution soon!
Joinfortmill
(16,989 posts)I make the transition to traditional medicare.
SheltieLover
(61,291 posts)👀
Voltaire2
(15,082 posts)But a lot of people are happy with their shitty dental plans and their shitty vision plans and the gym memberships they never use, and they haven't been denied coverage yet, so they stay on MA.
Getting off MA is difficult as you can be discriminated against by medigap plans for pre-existing conditions.
The whole system needs to be reformed, ACA, Medicare and Medicaid all need to be combined in a single universal comprehensive public health insurance system.
Perhaps after the fascists finish wrecking everything we can put it back together the right way.
B.See
(4,210 posts)what each person's particular needs are. As with all plans, one size doesnt fit all.
Lonestarblue
(12,162 posts)Because they now hold over 50% of the Medicare market, the insurance companies are more blatant about maximizing their profits and minimizing medical care through denials of coverage.