MRF-Logo2019-Horizontal-RGB
Medicare Advantage Plans and Clinical Trial Participation
REGISTER
The information on this site is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. Content within the patient forum is user-generated and has not been reviewed by medical professionals. Other sections of the Melanoma Research Foundation website include information that has been reviewed by medical professionals as appropriate. All medical decisions should be made in consultation with your doctor or other qualified medical professional.

Medicare Advantage Plans and Clinical Trial Participation

› Forums › General Melanoma Community › Medicare Advantage Plans and Clinical Trial Participation

  • Post
    • April 25, 2012 at 11:23 pm
    Eileen L
    Participant

      I am continuing my battle with Kaiser to get approval for participation in the Genentech BRAF/MEK trial. I just found out some information that makes me feel a bit better about all of this.

      I am continuing my battle with Kaiser to get approval for participation in the Genentech BRAF/MEK trial. I just found out some information that makes me feel a bit better about all of this.

      I am a Kaiser member through a Medicare Advantage Plan. Medicare regulations states that when you participate in a trial at a Medicare approved facility, the facility bills Medicare directly. If it is an outpatient service, Medicare will pay 80% of the costs as long as the service is something Medicare would usually cover. The Medicare Advantage plan may chose to cover the other 20%, and you need to go through whatever their approval process is for going to an outside service.

      For me, this is fantastic since I was looking at potentially paying out of pocket for the first two months of this trial for services not covered by the study. The items that weren't covered included a PET/CT scan, which is big $$$! Twenty percent of big $$$ sounds better than 100% of big $$$! My stress level around this approval just plummeted!!!!

      I had an Alice in Wonderland type of day with pushing the approval process forward, I had a health plan representative tell me the health plan never pays for any expenses related to a trial, which is totally against California law! Then I had my doctor's nurse confirm that he is not going to advocate for me with the health plan approval process because he just doesn't support participation in Phase I clinical trials! So I am trying to get to speak to the physician who is reviewing the request for the health plan to make my case. All this is way more than anybody should have to do just to get approval for a covered service.

      That's it for now. Take care everyone, and keep up the good fight!

      Eileen L

    Viewing 11 reply threads
    • Replies
        • April 26, 2012 at 12:15 am
        aldakota22
        Participant

          What a bummer.With all the issues in front of you its BS that you have to fight like hell to get coverage you need.Keep fighting.Pray someone steps up to the plate for you and does the right thing.  Al

          • April 26, 2012 at 12:15 am
          aldakota22
          Participant

            What a bummer.With all the issues in front of you its BS that you have to fight like hell to get coverage you need.Keep fighting.Pray someone steps up to the plate for you and does the right thing.  Al

            • April 26, 2012 at 12:15 am
            aldakota22
            Participant

              What a bummer.With all the issues in front of you its BS that you have to fight like hell to get coverage you need.Keep fighting.Pray someone steps up to the plate for you and does the right thing.  Al

              • April 26, 2012 at 4:24 pm
              palmspringswalt
              Participant

                "because he just doesn't support participation in Phase I clinical trials" – Have you considered finding a different doct?  Clinical trial participation is a personal decision that's difficult enough without not having support of your doctor!

                Thanks for posting your "battle" with your Medicare Advantage Plan as I have had issues and know I will continue to have issues with my plan.   My own HMO plan basically says no, no, no to any out of network treatment.  I've won my first appeal using the Medicare appeal process.  If you do need to appeal anything, your appeal needs to be based on Medicare rules that the plan must follow.  You're not at the point.  Keep asking your doctors and their staff on how to fight your plan.  They have many patients in your situation so they have experience on the best approaches.  Good Luck!  I hope your planned treatment is moving forward!!!

                  • April 26, 2012 at 4:38 pm
                  Eileen L
                  Participant

                    Thanks for the encouragement and advice. As posted above, Kaiser did approve my participation in the trial. My whole battle could have been avoided if my doctor supported my decision to participate in the trial. I will indeed be looking for a different oncologist once the dust has settled. I can't believe I spent three precious days fighting the system because I didn't have a physician advocate in my corner!

                    Good luck with your HMO battles. It's a shame that we have to fight to get our basic Medicare rights/services.

                    Eileen L

                    • April 26, 2012 at 4:38 pm
                    Eileen L
                    Participant

                      Thanks for the encouragement and advice. As posted above, Kaiser did approve my participation in the trial. My whole battle could have been avoided if my doctor supported my decision to participate in the trial. I will indeed be looking for a different oncologist once the dust has settled. I can't believe I spent three precious days fighting the system because I didn't have a physician advocate in my corner!

                      Good luck with your HMO battles. It's a shame that we have to fight to get our basic Medicare rights/services.

                      Eileen L

                      • April 26, 2012 at 4:38 pm
                      Eileen L
                      Participant

                        Thanks for the encouragement and advice. As posted above, Kaiser did approve my participation in the trial. My whole battle could have been avoided if my doctor supported my decision to participate in the trial. I will indeed be looking for a different oncologist once the dust has settled. I can't believe I spent three precious days fighting the system because I didn't have a physician advocate in my corner!

                        Good luck with your HMO battles. It's a shame that we have to fight to get our basic Medicare rights/services.

                        Eileen L

                      • April 26, 2012 at 4:24 pm
                      palmspringswalt
                      Participant

                        "because he just doesn't support participation in Phase I clinical trials" – Have you considered finding a different doct?  Clinical trial participation is a personal decision that's difficult enough without not having support of your doctor!

                        Thanks for posting your "battle" with your Medicare Advantage Plan as I have had issues and know I will continue to have issues with my plan.   My own HMO plan basically says no, no, no to any out of network treatment.  I've won my first appeal using the Medicare appeal process.  If you do need to appeal anything, your appeal needs to be based on Medicare rules that the plan must follow.  You're not at the point.  Keep asking your doctors and their staff on how to fight your plan.  They have many patients in your situation so they have experience on the best approaches.  Good Luck!  I hope your planned treatment is moving forward!!!

                        • April 26, 2012 at 4:24 pm
                        palmspringswalt
                        Participant

                          "because he just doesn't support participation in Phase I clinical trials" – Have you considered finding a different doct?  Clinical trial participation is a personal decision that's difficult enough without not having support of your doctor!

                          Thanks for posting your "battle" with your Medicare Advantage Plan as I have had issues and know I will continue to have issues with my plan.   My own HMO plan basically says no, no, no to any out of network treatment.  I've won my first appeal using the Medicare appeal process.  If you do need to appeal anything, your appeal needs to be based on Medicare rules that the plan must follow.  You're not at the point.  Keep asking your doctors and their staff on how to fight your plan.  They have many patients in your situation so they have experience on the best approaches.  Good Luck!  I hope your planned treatment is moving forward!!!

                          • April 27, 2012 at 6:48 pm
                          MaryD
                          Participant

                            Oh my gosh Eileen – I'm so sorry you're having to go through all this to get what you need – it's ridiculous. And then your doctor saying he doesn't believe in phase 1 trials – how does he think any drug ever gets approved ??  – it has to start somewhere!    Clearly he doesn't understand melanoma very well as participation in clincial trials is almost the standard of care for us.

                            Well I know your tenacity is going to pay off and you will get into this trial one way or the other.   Sending good thoughts and prayers that everything falls into place soon!

                            Best regards,

                            Mary

                            • April 27, 2012 at 6:48 pm
                            MaryD
                            Participant

                              Oh my gosh Eileen – I'm so sorry you're having to go through all this to get what you need – it's ridiculous. And then your doctor saying he doesn't believe in phase 1 trials – how does he think any drug ever gets approved ??  – it has to start somewhere!    Clearly he doesn't understand melanoma very well as participation in clincial trials is almost the standard of care for us.

                              Well I know your tenacity is going to pay off and you will get into this trial one way or the other.   Sending good thoughts and prayers that everything falls into place soon!

                              Best regards,

                              Mary

                              • April 27, 2012 at 6:48 pm
                              MaryD
                              Participant

                                Oh my gosh Eileen – I'm so sorry you're having to go through all this to get what you need – it's ridiculous. And then your doctor saying he doesn't believe in phase 1 trials – how does he think any drug ever gets approved ??  – it has to start somewhere!    Clearly he doesn't understand melanoma very well as participation in clincial trials is almost the standard of care for us.

                                Well I know your tenacity is going to pay off and you will get into this trial one way or the other.   Sending good thoughts and prayers that everything falls into place soon!

                                Best regards,

                                Mary

                                • July 13, 2013 at 9:22 am
                                kellasloane
                                Participant

                                  Medicare is one of the many federal plans that are fast going to being out of funding. Numerous solutions have been recommended, including privatized Medicare plans that would issue vouchers for recipients to purchase insurance with. However, a study has discovered that privatizing it would lead to premium increases for most recipients.

                                  • July 13, 2013 at 9:22 am
                                  kellasloane
                                  Participant

                                    Medicare is one of the many federal plans that are fast going to being out of funding. Numerous solutions have been recommended, including privatized Medicare plans that would issue vouchers for recipients to purchase insurance with. However, a study has discovered that privatizing it would lead to premium increases for most recipients.

                                    • July 13, 2013 at 9:22 am
                                    kellasloane
                                    Participant

                                      Medicare is one of the many federal plans that are fast going to being out of funding. Numerous solutions have been recommended, including privatized Medicare plans that would issue vouchers for recipients to purchase insurance with. However, a study has discovered that privatizing it would lead to premium increases for most recipients.

                                  Viewing 11 reply threads
                                  • You must be logged in to reply to this topic.
                                  About the MRF Patient Forum

                                  The MRF Patient Forum is the oldest and largest online community of people affected by melanoma. It is designed to provide peer support and information to caregivers, patients, family and friends. There is no better place to discuss different parts of your journey with this cancer and find the friends and support resources to make that journey more bearable.

                                  The information on the forum is open and accessible to everyone. To add a new topic or to post a reply, you must be a registered user. Please note that you will be able to post both topics and replies anonymously even though you are logged in. All posts must abide by MRF posting policies.

                                  Popular Topics