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Medicare Advantage Plans and Clinical Trial Participation

Forums General Melanoma Community Medicare Advantage Plans and Clinical Trial Participation

  • Post
    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

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  • Replies
      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

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      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

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      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

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      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!!!

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      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!!!

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      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!!!

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        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

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        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

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        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

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      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

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      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

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      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

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      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.

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      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.

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      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.

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