The Affordable Care Act (ACA) forbids Medicare Advantage plans from charging patients more for some benefits that are covered by traditional Medicare, including chemotherapy drugs. However, due to changes among some Medicare Advantage plans, beginning January 1, 2011, patients began incurring higher out-of-pocket expenses.
As a result, some patients may not be able to afford higher-cost drugs and treatment, and some physicians find themselves in a difficult position. On the one hand they recognize that they cannot absorb patients’ out-of-pocket expenses. On the other hand, they do not want to add an additional burden to their patients.
Medicare designates certain drugs, when provided in an office setting, to be covered under Part B (rather than Part D). Chemotherapy drugs are one example. Under traditional Medicare coverage, Medicare pays the provider 80 percent of the determined payment allowance and the beneficiary is responsible for the remaining 20 percent, commonly referred to as coinsurance. If the patient purchases additional coverage with a Medigap or Medicare supplemental insurance plan, the plan would then pay the coinsurance.
In contrast, Medicare Advantage plans had generally charged patients an out-of-pocket copayment for chemotherapy, which generally was a lesser amount then the 20 percent coinsurance.
As of January 2011, the maximum out-of-pocket expense (MOOP) permitted under the law for both Medicare and Medicare Advantage plans is $6,700. Some Medicare Advantage plans have a MOOP lower than $6,700.
Once the patient has met the MOOP, the Medicare Advantage plan is responsible for the entire balance. Yet, physicians report incidents of some seniors on Medicare finding it difficult to pay even the MOOP.
Medicare has provided a venue for physicians to register complaints on behalf of specific patients who have issues with their Medicare Advantage Plan or Prescription Drug Plan. Send a separate email for each beneficiary with as much detail as possible, including the beneficiary’s full name and Medicare number, to
PartDComplaints_RO3@CMS.HHS.gov.