How to get the treatments you need on Medicare: change Advantage/Medigap carriers

[WillowJ]

it's open enrollment at Medicare (Oct 15 - Dec 7).

I was just told by my state volunteer organization that decisions about what to cover on Medicare Advantage plans (at least as far as drugs/Part D go, not sure about tests and procedures) are made by the carriers; there is no central Medicare authority which tells what is and isn't covered.

So if you are getting "not covered for CFS" denials (I have heard complaints about this), consider changing plans. There are carriers that do cover, for example, famciclovir for CFS. (I'm saying CFS because that's what the provider has to code and bill it under.)

Some of the Medicare Advantage plans are relatively low cost. They reduce the patient share of costs. Some even remove the "doughnut hole", but those have a higher monthly rate.

You can use the tools at medicare.gov or look at your state insurance commissioner's page for a volunteer organization which will provide you with information.

 

[Vincent]

I had coinsurance at one point but it was 200 dollars per month and I eventually dropped it. About a year and a half later I tried to sign up for a coinsurance plan but was denied. My understanding was that you couldn't be denied during the open enrollment period, but that you would have to pay a percentage per month penalty for each month you did not have coinsurance.

I tried to find more information online and have tried to find a case manager to help me but they never return my phone call.

 

[WillowJ]

sorry to hear that

mine is only $32/month and that includes Part D

There does seem to be a penalty for not enrolling in any Part D. It is waived if one qualifies for Extra Help.
http://healthinsurance.about.com/od/medicarepartd/a/Medicare-Part-D-Late-Enrollment-Penalty.htm

 

[Shoesies]

My flipping medicare denies everything and so does my primary provider PHCS. It sucks.

 

[Sushi]

Yeah, for treatments, I think "Medicare Central" has policies about what it will and won't pay for (including labs), but each Part D (meds) has its own choice of (inexpensive) meds. They routinely deny the more specific (expensive meds) I am prescribed, but I did find one that covered a pretty expensive one I take routinely, so I used open enrollment to switch to that company, just for that one med!

Sushi