ObjectivesUpon completion of this discussion forum the participants:• Will learn about governmental programs and avenues toward accessingcare and their eligibility criteria.• Will have the tools to reduce and manage their outstanding medical costs.• Will better understand the real benefits and opportunities of the HealthCare Reform Act relative to cancer care.• Will become informed of federal laws and provisions that protect their rightto health coverage ensuring continuity of care.• Will understand more about the approval process for Social SecurityDisability.
Financial and Insurance Brendan Bietry LIVESTRONG Senior Case ManagerImplications for Patient Advocate Foundation the Cancer Survivor
Our Mission: To Serve Patients • Patient Advocate Foundation seeks to safeguard patients through effective mediation assuring access to care, maintenance of employment and preservation of their Our financial stability relative to their diagnosis of life threateningMission or debilitating diseases. • Since our inception in 1996, PAF has provided direct, sustained patient assistance to more than 500,000 patients and touched millions more American lives through the PAF Our website, online chats and outreach events.Impact 3
Direct Patient Services offered by PAF• Brokering resources to supplement the limits of insurance and to assure access to care for the uninsured• Resolving debt crisis relative to a diagnosis• Negotiating access to pharmaceutical agents, chemotherapy, medical devices and surgical procedures• Resolving insurance issues in the public and private sector• Negotiating pre-authorization approvals• Providing assistance in facilitating and expediting the appeals process • Health insurance denials • Social Security Disability• Negotiating resolutions to coding and billing errors
The UNinsured Public Benefits, Safety Nets & Charity Care • County Indigent Medical Assistance/Community Hospital Charity/Sliding Scale fee discounts• Medicaid (SSI linked and Share-of-Cost /Breast & Cervical/Medicare savings programs/Long-term care Medicaid) • Pharmaceutical and Durable Medical Equipment and Supply Assistance for the uninsured www.needymeds.org
Utilization of Hospital Support Staff• If you need help, a good place to start is with the social worker, financial counselor or nurse at the hospital where you are being treated. (These people are the most knowledgeable about community resources who might offer help as well as internal programs funds the hospital may have to help cancer patients)• Remember: Do not ignore the bill. If you receive a hospital bill, it is important that you do not ignore it. Hospitals have the right to refer your bill to a collections agency if it is not paid. Instead, make sure to call your hospitals billing office right away to ask about payment plan options and financial discounts. Know your rights under the Fair Debt Collections Act! www.ftc.gov/bcp/edu/pubs/consumer/credit/cre27.pdf
Medicaid Government-sponsored medical insuranceprogram based on financial need. To receiveMedicaid, your income and assets must be belowa certain level. It covers hospital care, physician’sfees, prescription drugs, home care and manyother services. In order to qualify, you must be aUS resident. Medicaid is only valid in the state inwhich it is issued. You can go to your local countyDepartment of Social Services for an application.
Work transitions and the Self-employedCOBRA : Group policy extension of 18 months + 11 months = 29 months (Medicare eligibility) – for those deemed disabled within the initial 2 months of the COBRA extension.HIPAA portability : Guarantees that certain individuals will have access to, and can renew, individual health insurance policies.Guaranteed Issue : Group insurance in which all members of a small group who meet certain conditions automatically receive coverage without individual underwriting (in most states groups of 2-50 employees) www.statehealthfacts.org
Your medical expenses may be tax-deductible. Medical costs that are not covered by insurance policies sometimes can be deducted from annual income before taxes. Currently, they must exceed 7.5% of your adjusted gross income to be deductible. So, if your income is $30,000, then you could deduct out-of-pocket medical costs that exceed $2,250. Medical costs include doctor’s bills, drugs, medical supplies and anything related, including transportation and lodging. Your local IRS office, tax consultants or certified public accountants can help you with the specifics; or see www.irs.gov and download Publication 502, Medical and Dental Expenses
Social Security Disability Benefits Disability Evaluation under Social Security:Factors: Age, Education, Work Background, Disability (inability to perform gainful work activity). Requires that the applicant be unable to perform gainful work activity for 12 months from the onset date of disability. http://www.ssa.gov/disability/professionals/bluebook/165 medical conditions (47 are forms of Cancers) currently qualify for expedited processing of Social Security Disability benefits: http://www.ssa.gov/compassionateallowances/conditions.htm
Social Security Disability Evaluation • Local Social Security office (in person, Initial telephone or on-line) application • Local Social Security office (non- medical eligibility check – work credits, Phone interview age, marital status, etc..) • Disability Determination Services DDS office (evaluates disability)
Timeline for evaluation (approval/denial/appeals process) • Expedited processing (8-10 days for “flagged” cases) – QDD processing Approval • Standard processing (4-6 months) • Reconsideration (1st level) – appellant submits with added medical records/assessments nd Denial and • Some states will allow the appellant to skip to a 2 recourse level Hearing with an Administrative Law Judge (ALJ) • Appellant may hire a Disability attorney, represent him/herself and/or appoint an unpaid 3rd party to ALJ assist in furthering his/her case (Patient Advocate Hearing Foundation)
Medicare• A government-sponsored medical insurance program usually for people who are aged 65 or older. People of any age who have been disabled and have received Social Security Disability payments for 24 months are also eligible. Benefits vary from person to person. Medicare provides basic health coverage, but it doesn’t pay for all health expenses. Call 1.800.MEDICARE (1.800.633.4227) or visit www.medicare.gov.
The Underinsured & Patient Assistance Co-Payment Assistance: Non-profit and pharmaceutical funding exists: privately and governmentally insured (Medicare); disease specific funds ever-changing ***Premium Assistance: www.healthwellfoundation.org www.lls.org *** Disease-specific charity: Diagnosis specific and usually need-based Patients typically must be in active care or limited post-treatment timeframe Funding for medical expense assistance and household stabilization National charities for families with children or pediatric cancer patients Monies for special populations: musicians, artists, flight attendants, Registered Nurses, truckdrivers, federal employees, etc… 14
Our Mission: Supplement the limits of health insurance • The PAF Co-Pay Relief Program (CPR) exists to provide direct financial CPR assistance to insured patients who cannot afford the co-payments and co-Mission insurance required to access prescribed pharmaceutical therapies. 15
How the Program Operates ramå CPR provides cash co- å Professional CPR Call payment assistance for Counselors assist patients in insured patients unable to completing application forms use their prescription drug and securing authorizations benefits due to inability to needed to verify medical and pay their co-payments. financial necessity to qualifyå Patients, physicians, and patients. pharmacies can contact å Upon Approval, payments are CPR™ directly to initiate a made directly to the doctor, request for assistance. pharmacy or patient.å A 24 hour secured web å CPR provides assistance to based patient portal to allow both commercially and patients another option to government insured patients enroll. including Medicare Part D beneficiaries. 16
CPR Open Disease Funds CPR currently offers assistance in 19 disease funds including:• Breast Cancer • Myelodysplastic Syndrome• Chemotherapy Induced (MDS, and other pre-leukemia Anemia/Neutropenia diseases)• Colon Cancer • Non-Muscle Invasive Bladder Cancer• Cutaneous T-Cell Lymphoma • Osteoporosis• Hepatitis C • Pain• Hormone Suppression Therapy • Prostate Cancer• Kidney Cancer • Rheumatoid Arthritis• Lung Cancer (Non-small cell • Sarcoma Lung Cancers)• Multiple Myeloma 17
National Underinsured Resource Directoryhttp://patientadvocate.org/help4u.php 18
National Underinsured Resource Directory Pull Out CardsSeven pull out cards werecreated based on thetopics commonlyaddressed by PAFpatients based on needsand issues of theunderinsured population.Each card offers actionsteps or suggestions tocompliment the resourcesthey will be provided. 19
http://link.brightcove.com/services/player/bcpid1875349721?bctid=608833805001 Health Care ReformUninsured Adults ages 19-64Texas: 30% Travis: 25.5% Austin: 27% U.S. uninsured: 19.5%
The Uninsurable – High Risk PoolsFEDERAL Pre-Existing Condition Insurance Plan (PCIP) Qualifying health condition; uninsured 6 mos prior to enrollment Comprehensive benefits; capped out-of-pocket costs; plan options https://www.pcip.gov/StatePlans.html www.healthcare.govState Issued HIGH RISK INSURANCE POOL Viable option when COBRA expires (19th month) Comprehensive benefits; plan options For the insured with high deductible/catastrophic coverage‼ COST PROHIBITIVE PREMIUMS www.naship.org
¡Cover the Uninsured! Premium rates for Texas2011 monthly PCIP premium rates by age enrollee, effective 7/1/2011.Benefits are effective the 1st day of the following month upon enrollment. www.pcip.gov/StatePlans Age Standard Option Extended HSA Option Option 0 to 18 $133 $179 $138 19 to 34 $199 $268 $207 35 to 44 $239 $323 $248 45 to 54 $306 $412 $318 55+ $426 $572 $442
Looking forward - ACA• Health Insurance Exchanges (2014) The Healthcare Reform Act requires that health insurance exchanges be established in each state. Individuals and small employers will be able to enroll into the exchange. Small employers are defined as those with no more than 100 employees. Larger employers will be able to enroll into the exchange in 2017.• Premium Subsidies (2014) Premium and cost-sharing subsidies will make health insurance more affordable for every family with annual incomes between 133% and 200% Federal Poverty Level that purchase plans through the exchange.
www.insureustoday.orgcontact us at 866-207-8023 25