Financial discussions/tips concerning expensive treatment

I have a Medicare Advantage Plan through BC/BS but Evenity is paid for by Medicare part B because it is given in the office. Charge to me is 80% of the cost until I hit "catastrophic," and I am close! I'll let you all know what happens in the donut hole, where I currently am!

Hi Windy. Now I am really confused. The only terms like "catastrophic" and "donut hole" I know about suggest payment for a prescription medication under your Part D coverage, not as a Part B outpatient medical procedure. How certain are you it is being treated under Part B rather than as a Part D drug?

When I received a Prolia injection in my doctor's office, it was processed under Part D. When I received a Prolia injection at an infusion center, it was processed as Part B medical service.

Does anyone else feel we are living in a Medicare Alice In Wonderland situation?

This forum really needs someone very knowledgeable about Medicare to step in and try to make sense about all this in a more generally helpful way. There seems to be too many variables from one person to another that makes each individual situation unique and also there seems to be quite a bit of simple misinformation.

For example, Medicare Part B pays 80% of the eligible amount (after annual deductible) and you or someone on your behalf pays the other 20%. Please consult your friend Mr. Google which will lead you to the authoritative HHS info.

IF you do not pay that other 20% then you have either a supplemental plan (private insurance or employee retirement plan) or another governmental program that does pay or a pharma program. The other governmental programs are state-specific and usually income-dependent....hence creating much of the variation about what and how much is covered. The pharma programs appear to be here today and gone tomorrow.

IF you go to an infusion center to receive your osteo treatment, there is a rather complicated formula for whether Medicare considers this a Part B benefit or whether the treatment is covered under your drug plan.....I do not recall all the specifics but one of the factors I do remember about Part B eligibility is whether you have had a previous fracture.

Medicare Advantage is required to cover the same medical benefits as original Medicare. How you pay for those medical benefits is different.

Medical providers are the absolute worst source of info about the financial picture of medical care. Inasmuch as they all seem to have a similarly vacuous response, I suspect there may be a course at med school that teaches a practitioner what to say when a patient brings this up as a consideration.

If I had the time at present, I would contact the Medicare Rights Center. In my opinion, they have the most reliable info about Medicare coverage and cost. Perhaps someone here could convince a staff member at that Center to be assigned to this forum to help sort out all the coverage and cost questions that come up. I have no available time to do this until after the new year.

On the bright side of those receiving Prolia treatment, the patent is set to expire in early 2025 so there may then be available a generic like what is available for Fosomax and Bonita.

rjd,
I agree that we need a Medicare/insurance expert to advise us. That would be great. The Medicare rights website is very helpful.
AARP has a website that addresses all of it.
As far as receiving Evenity at an infusion center, that’s what I am currently doing. My Part B covers it at 100% and I have not had a fracture.
Also, the Advantage plans are required to cover what Traditional Medicare would cover, but not necessarily at the same amount. Where Traditional Medicare would cover at 100%, an Advantage plan might cover at 50% or 75%.
I live in a poor state. Maybe the poorest in the country. As a social worker for 45 years, I am an advocate for the financially disadvantaged. In my state, low income seniors on Medicare also qualify for Medicaid. Medicaid differs from state to state. The Medicare/Medicaid combination is the best coverage anyone could have. These beneficiaries are completely covered and need no other insurance. In my city, in the poorest areas, I see billboards advertising Advantage plans with this message:
“Hey! If you have both Medicaid and Medicare,_________ Advantage plan can make your benefits even better!”
False. These beneficiaries are giving ip 100% coverage to venture into the Great Unknown of Insurance.

Hi Windy. Now I am really confused. The only terms like "catastrophic" and "donut hole" I know about suggest payment for a prescription medication under your Part D coverage, not as a Part B outpatient medical procedure. How certain are you it is being treated under Part B rather than as a Part D drug?

When I received a Prolia injection in my doctor's office, it was processed under Part D. When I received a Prolia injection at an infusion center, it was processed as Part B medical service.

Does anyone else feel we are living in a Medicare Alice In Wonderland situation?

@nature girl5-Forteo and Tymlos are injections taken everyday vs Evenity given 1x per month- it is the expectation that one would do it by themselves, and for obvious reasons that would need to be .
Thank you for the suggestion of the talk show . I will certainly try to tune in!!

@rjd I am confused too. I think my Evenity will be in the doctor's office, not an infusion center, but was told by my Medicare Advantage plan that it is covered by Medicare Part B. I expect to pay 20%. I"ll let you know. It's in a week and a half.

I thought donut hole terminology applied to both regular Medicare and Advantage plans but maybe someone can confirm or deny this!

@rjd I am confused too. I think my Evenity will be in the doctor's office, not an infusion center, but was told by my Medicare Advantage plan that it is covered by Medicare Part B. I expect to pay 20%. I"ll let you know. It's in a week and a half.

I thought donut hole terminology applied to both regular Medicare and Advantage plans but maybe someone can confirm or deny this!

It would not be unheard of for the customer service person you speak with at the insurance company to be wrong. I would telephone again....both your doctor's office and the insurance company.

As I understand it, Susan is correct....location seems to determine how drug treatment claim is paid and what your share might be AND whether your payment counts in meeting your annual out of pocket limit.

Also, other insurance company personnel who deal with the medical provider's billing department also may not have it right. This is why whenever a provider wants me to pay for co-insurance/copay prior to service for anything other than a doctor's office visit, I decline and state that I will pay what is owed after the claim is processed and the EOB is issued.

The 'donut hole' terminology does apply to both Medicare and Advantage plans. Susan has it right as I understand it. The difference is between Medicare Part B (most medical services provided outside of hospital as described in your Advantage Plan and no donut hole) and Part D.

I have AARP/United Medicare Advantage and they occasionally test my patience on claims processing. Seems to me like there are some games being played.....wonder whether it coincides with quarterly revenue reporting to shareholders.......shocking isn't it?