Merck Retirees: Will Your Treatments be Covered Under a Medicare Advantage Plan?

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As Merck employees near retirement, you need a plan for managing company benefits and maximizing retirement savings - and Tyson Mavar of the Retirement Group can put you on the right path.

For Merck employees, planning for retirement involves more than savings - Paul Bergeron of the Retirement Group says it's important to weigh all the options for creating a comprehensive retirement plan.

In this article, we will discuss:

• 1. The impact of prior authorization on Medicare Advantage plans and access to medical treatments.

• 2. CMS proposed improvements to electronic prior authorization process.

• 3. Why Medicare Advantage insurers should be held accountable for using prior authorization tools.

Understanding insurance plans is critical in today's complicated healthcare environment - especially for Merck employees approaching retirement. The plans, called Medicare Advantage plans, have become popular with people over 60 because they provide additional coverage beyond traditional Medicare. Yet prior authorization must be understood in order to obtain medical treatments and services under these plans. This report examines prior authorization in Medicare Advantage, highlights concerns, and proposes improvements.

The Impact of Prior Authorization:

According to a Kaiser Family Foundation report, in 2021 physicians submitted more than 35 million prior authorization requests for Medicare Advantage plans. Around 6% were denied entirely or in part. Most denials were because of inadequate documentation submitted by physicians. Yet most appeals resulted in full or partial reversals of initial denials, suggesting that appeals were largely successful.

Prior authorization may help manage costs and prevent superfluous care but it has also created barriers and delays to essential medical treatments. They affect patients with complex medical needs, limited English proficiency, or rural residents with poor access to specialists. CMS proposes two rules that will enhance electronic prior authorization and decision-making transparency for Medicare Advantage and some other insurers.

Proposed Improvements by CMS:

CMS encourages Medicare Advantage insurers to use prior authorization tools fairly and transparently. The proposed rules address obstacles and delays for patients while ensuring medical necessity of healthcare services. By promoting transparency in decision making and electronic prior authorization, CMS hopes to achieve cost containment while preserving timely access to care.

The Need for Accountability:

Industry experts and advocates have emphasized the need to hold Medicare Advantage insurers accountable for prior authorization use. Medicare education and advocacy organization 65 Incorporated's president Diane Omdahl says CMS must ensure the proper and transparent use of those tools. Emily Stewart, executive director of the National consumer health advocacy organization Community Catalyst, agrees that prior authorization must be considered in evaluating the impact on patient care for at-risk and underserved populations.

Patient Care & Access: A Balanced Approach.

A compromise must be struck between using prior authorization to assure medical necessity while minimizing problems for patients. Complex patients or patients with limited specialist access may experience confusion, increased costs, and treatment delays. Despite the benefits of prior authorization in establishing the need for healthcare services, Justice in Aging senior attorney Anna Grizzle says the challenges it creates must be addressed, especially with certain populations of patients.

Making Informed Choices:

The choice between Medicare Advantage plans and traditional Medicare with a Medigap supplement is important for those approaching retirement age. People enrolled in original Medicare and Medigap rarely need prior authorization. Knowing the nuances of prior authorization in Medicare Advantage is therefore important when making a decision about healthcare coverage.

Understanding how prior authorization impacts Medicare Advantage plans is critical for those over 60 - including Merck professionals - as the healthcare landscape changes. Prior authorization helps with cost containment and medical necessity; but its execution has to be just, transparent, and equitable. CMS has proposed enhancements for electronic prior authorization procedure and decision transparency. The ultimate goal is to balance optimizing patient care with reducing barriers to accessing needed medical treatments. Keep informed and shop around for retirees' health insurance.

A recent American Medical Association study found that denial of medical remedies by Medicare Advantage plans could have serious consequences. In fact, one-third of physicians polled said the long and complex process of getting prior authorization from insurance companies led to decreased patient care. Such a scary statistic highlights the dangers and obstacles prior authorization requirements may create for people seeking urgent and critical care. (As reported by the American Medical Association in 2021)

Learn what prior authorization does for Medicare Advantage plans. See how physicians made more than 35 million requests - 6% were denied - for expedient care. A Kaiser Family Foundation report shows successful appeals of approval. Find out proposed CMS rules to improve electronic prior authorization and transparency. Understand barriers and delays to necessary treatments that healthcare advocates fear. Examine the delicate equilibrium between cost control and quality care for complex medical cases. Look at Medicare Advantage plans versus traditional Medicare and Medigap as you approach retirement. Be aware of proposed CMS enhancements and the importance of accountability in healthcare insurance.

Imagine Medicare Advantage plans denying 6% of treatments as if you were planning a trip to a five-star resort. Upon arrival, you find out the resort requires prior authorization for some activities despite everything else looking great. This requirement helps the resort maintain standards and controls costs but it delays and limits your enjoyment of your vacation. Merck retirees can ensure easier access to the resort amenities by promoting transparent and equitable prior authorization processes, as CMS seeks to improve that system for Medicare Advantage plans. It's opening the door to a carefree vacation without frills.

Added Fact:

New research from the Medicare Rights Center published in 2023 highlights something that Merck retirees should know about Medicare Advantage plans. And while such plans can offer full coverage, they may have network caps that limit your choice of providers, the study found. Check to see if your preferred doctors and hospitals are in-network so your treatments will be covered. Understanding network limitations may help retirees make educated decisions about their retirement healthcare coverage to reduce unexpected costs and access preferred healthcare providers.

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Added Analogy:

Picture yourself planning a worldwide reunion at an exclusive resort. All the activities and amenities at the resort sound fun - except some require prior permission. It's like retirement navigating the maze of Medicare Advantage plans. Such plans come with a bunch of benefits like the resort's but may have network restrictions like prior authorization for certain activities. You can get comprehensive care but your preferred providers must be in the plan's network. Like how you might want to double-check that friends can come along for the reunion fun without incident, Merck retirees need to know if their treatments are covered under a Medicare Advantage plan and if their doctors are in-network. This care ensures a comfortable retirement - like that dream reunion at the resort.

Sources:

1. Biniek, Jeannie Fuglesten, et al. 'Nearly 50 Million Prior Authorization Requests Were Sent to Medicare Advantage Insurers in 2023.'  Kaiser Family Foundation , 28 Jan. 2025,  www.kff.org/medicare/issue-brief/nearly-50-million-prior-authorization-requests-were-sent-to-medicare-advantage-insurers-in-2023 .

2. 'Prior Authorization Denials Big in Medicare Advantage.'  American Medical Association , 23 Sept. 2024,  www.ama-assn.org/practice-management/prior-authorization/prior-authorization-denials-big-medicare-advantage .

3. Centers for Medicare & Medicaid Services. 'CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F).'  Centers for Medicare & Medicaid Services , 17 Jan. 2024,  www.cms.gov/priorities/key-initiatives/burden-reduction/interoperability/policies-and-regulations/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f .

4. 'Prior Authorization Final Rule Will Improve Patient Access, Alleviate Hospital Administrative Burdens.'  American Hospital Association , 15 Feb. 2024,  www.aha.org/news/blog/2024-02-15-prior-authorization-final-rule-will-improve-patient-access-alleviate-hospital-administrative-burdens .

5. 'A Deeper Dive on Prior Authorization in Medicare Advantage.'  Better Medicare Alliance , June 2021,  bettermedicarealliance.org/blog-posts/a-deeper-dive-on-prior-authorization-in-medicare-advantage .