Connect
Comment receiving replies
When you have an Advantage plan it is through an insurance company they receive a set amount per year for all of your Part B
care, based on a formula with some additions for preexisting conditions. If they spend less than Medicare gives them, they profit. If they spend more, they have a loss. The insurance company determines who their preferred providers are. If the doctor helps the insurance company keep costs low, they may get a bonus at the end of the year, spend too much and they get removed from the preferred provider list, so have fewer patients.
So the question becomes, is the doctor really looking out for patient's best interest or trying to help the insurance company cut costs?
Here is one thing you can do - look at the prescription drug formulary to see whether the drug is covered by Medicare Part B or Part D. That controls how the drug is to be dispensed and paid for.
Who knew getting older could be so complicated?
Replies to "When you have an Advantage plan it is through an insurance company they receive a set..."
Connect
I did not ask anything about preferred providers but your explanation is not my understanding of PPO. So if you would share the source of your information, I would appreciate it.
My understanding of the consumer /patient benefit of a PPO is that referrals are not needed to see doctors who are otherwise in the insurers network. This is in contrast to an Advantage 'HMO' where the PCP must refer you to others for any services.
How PPO works in practice can be a bit of a mystery,
However, the point of my question had to do with whether it is kosher for a doctor who accepts an Advantage plan to then decide which part of an Advantage plan he prefers to use. I hope //think you are correct that that is NOT something the doctor decides. If Evenity is covered by Medicare Part B, then it does not seem the doctor can simply decide NO, you must procure the medication via Part D.
I guess this raises the question: can Evenity be procured/processed under either Part B or Part D?
The original poster seems to think there is much more out of her pocket when under Part D and that is why she is quitting treatment. I do not see how Part D, with its new $2000 cap, can be more expensive than Part B so someone needs to crunch the numbers with the original poster.
That is in part why I suggested she contact the SHIP in her state or the Medicare Rights Center....(along with the other reason about her doctor making such a decision about which Part he wants to use and the insurer saying that is OK.)
The way Medicare works in this country is an unpardonable sin....