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Navigating Medicare & Medicare Advantage Plans With Bladder Cancer

Last updated: September 2020

I read a distressing story about a bladder cancer patient that got me curious about Medicare and the unintended consequences of choosing a certain plan.

In February, the New York Times ran a story about a 72-year-old bladder cancer patient. He sought out the best specialist in his area for the treatment of his aggressive disease. But he discovered that his Medicare Advantage plan did not cover that doctor.1

Your initial Medicare choice may become hard to change

So, logically, he decided to switch to original Medicare for 2020 because it would allow him to see any provider. And that was when he ran into trouble.

His bladder cancer, considered a pre-existing condition, precluded him from being able to buy Medigap coverage. And that, in turn, made it impractical to switch to original Medicare.

He ultimately received treatment at four different hospitals soon after his diagnosis and made a late switch to an Advantage plan that did include his preferred physician.1

But he had to spend excessive time and energy on those administrative details just at the time he was trying to process an aggressive bladder cancer diagnosis. Those of us who’ve been there know that bladder cancer alone is enough to deal with.

How Medicare Advantage Plans compare to original Medicare

Medicare, the federal insurance program for people over age 65, has historically functioned as a traditional, fee-for-service insurance plan (“original Medicare”). In recent years, though, HMO-style plans (offered through private insurers such as BlueCross BlueShield, Humana, or UnitedHealthcare) called Medicare Advantage plans, have become popular.2

Medicare Advantage Plans often cost about the same as traditional Medicare but often offer added features such as coverage for gym memberships, hearing aids, dental, and vision care. It’s understandable why these options would be appealing, especially to healthy seniors.

Participants in original Medicare typically buy Medigap coverage

Most participants in original Medicare buy supplemental coverage – called Medigap coverage – to protect against excessive out-of-pocket expenses.

But there’s a catch: it is only for the first six months after you initially enroll in Medicare Part B (the part for outpatient services) that a Medigap plan cannot reject you.3

Pre-existing conditions

After that time frame, the Medigap plans can deny you based on pre-existing conditions. Only four states – Connecticut, Massachusetts, Maine, and New York – prohibit such denials.

The patient in the story was in Colorado and therefore, unable to switch to original Medicare because of his bladder cancer diagnosis. He had not realized that his original decision to select a Medicare Advantage plan essentially could not be changed.

Medicare Advantage Plans have become more popular

Medicare Advantage plans have become increasingly popular in recent years, according to a Kaiser Family Foundation analysis. About 36 percent of all Medicare beneficiaries have enrolled such plans.2 Since they often offer additional benefits not covered by original Medicare at the same cost, it's understandable why these plans can seem appealing.

But a cancer diagnosis can drastically change your priorities.

When you get sick, your costs could be higher than with original Medicare

The Kaiser Family Foundation analysis also found that half of Medicare Advantage patients would end up paying more in out-of-pocket-costs for a five-day inpatient hospital stay than patients in original Medicare. And if the stay were 10 days, 72 percent of Medicare Advantage patients would pay more.2

Another little known “catch” of Medicare Advantage Plans is the concept of “step therapy” for Part B (outpatient) medications.4 This is a requirement that a patient first try a less expensive medicine.

Concerns around "step therapy"

This could limit your quick access to the newest bladder cancer treatments. Because treatments, especially for metastatic disease, have changed significantly in recent years, making sure a plan allows you to access to cutting-edge treatments is worth researching.

In addition to noting the “step therapy” limitations that Advantage plans may impose on cancer patients, an excellent 2018 CancerCare paper also noted that the inspector general of the Department of Health and Human Services found that Advantage plans are likely to require pre-authorizations and have a history of inappropriately denying care at relatively high rates. The paper concludes that cancer patients often find that original Medicare is their best choice.5

Do your homework, especially if you are enrolling in Medicare for the first time

Take some time and do your research. List the doctors you currently see and the treatments you have received in recent years. If your bladder cancer were to progress and you were to need surgery or treatment with newer drugs, would the plan you are considering cover those? Would you be required to obtain a pre-authorization each time? At which nearby hospitals could you receive treatment?

Consider your options carefully. In addition to not knowing our future health, we also don’t know how any given plan may expand or reduce its offerings. All we can do is make the best decision based on current information. But doing your research will help you feel that you made an informed decision.

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This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The BladderCancer.net team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

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