Editorial: Medicare Advantage Plans Gouging Cancer Patients

Florida-based WellCare advertises that its “Concert” Medicare health plan has a limit of $3,750 on the amount enrollees will spend out of pocket during the year. The plan’s Summary of Benefits, as well as the information on Medicare.gov, the government-sponsored plan finder, says “Contact the plan for services that apply.”

So we did.

We were told that all spending on medical services—doctor visits, hospital stays, etc.—would count toward the out-of-pocket spending limit. We asked if spending on chemotherapy drugs that are obtained at the doctor’s office would count towards the spending limit. Yes, we were told, spending on those drugs would also count.

That is not true. Chemotherapy drugs are specifically excluded from the annual cap on enrollee out-of-pocket spending, information we found buried in the 155 page WellCare Evidence of Coverage document.

So we called again, twice. On the next call, we were told that the limit covered hospital care, doctor visits and other spending on medical care. Only when we specifically asked if chemotherapy drugs were excluded were we told that there is no cap on how much enrollees may have to spend for these drugs. The last time we called, we were again told that chemotherapy costs counted toward the out-of-pocket limit. 

This sad little story raises a few questions:

Why is the cancer coverage provided by a private Medicare health plan a secret that can be learned neither on Medicare.gov nor in the Summary of Benefits, the principal document consumers use to compare plans?

Why do consumers have to roll the dice with poorly trained customer service representatives to get crucial (mis)information on plan coverage?

The Centers for Medicare & Medicaid (CMS) knows full well that consumers can not readily get accurate information on what services are excluded from the financial protection of an out-of-pocket limit. CMS, after all, is in charge of the information on Medicare.gov and establishes the rules for what information is supplied, or omitted, from plan marketing materials. The Medicare Rights Center warned CMS officials in January 2008 that plan customer service representatives could not be relied on to provide accurate information. When the next marketing season begins October 1, will CMS ensure that consumers receive accurate information on what medical services are covered, and which are excluded, from the financial protection provided by an out-of-pocket limit?

And why are private Medicare health plans even allowed to exclude chemotherapy from the out-of-pocket limit? Chemotherapy drugs can cost upwards of $50,000 for a treatment. Under the Concert plan, enrollees would have to pay $10,000 for such a treatment, on top of their other copayments and drug costs. The Government Accountability Office found that roughly one-third of Medicare Advantage plans exclude spending on Part B drugs—chemotherapy and other high-cost medicines— from the annual  out-of-pocket limit, if the plans provide any limit on enrollee spending at all.

Under Original Medicare, consumers can buy supplemental insurance to cover their cost sharing for chemotherapy and other medical care. Such coverage is unavailable with a private Medicare health plan. 

CMS is required to ensure that Medicare Advantage plans do not design benefit packages that discriminate against people with serious illnesses. Cancer is a serious illness. A benefit package that specifically excludes enrollee spending on cancer treatment from financial protection is discriminatory.

Why does CMS allow WellCare to receive government subsidies to provide coverage that discriminates against cancer patients?

-From: “Sticking It to Cancer Patients”, Asclepios, Your Weekly Medicare Consumer Advocacy Update, Medicare Rights Center, August 07, 2008.

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