Upon completion of this discussion forum, participants will: - Learn about governmental programs and eligibility criteria for accessing care - Gain tools to reduce and manage outstanding medical costs - Better understand benefits of the ACA relative to cancer care - Become informed of laws protecting their right to health coverage - Understand the Social Security Disability approval process

1. Objectives
Upon completion of this discussion forum the participants:
• Will learn about governmental programs and avenues toward accessing
care 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 Health
Care Reform Act relative to cancer care.
• Will become informed of federal laws and provisions that protect their right
to health coverage ensuring continuity of care.
• Will understand more about the approval process for Social Security
Disability.

2. Financial and
Insurance Brendan Bietry
LIVESTRONG Senior Case Manager
Implications for Patient Advocate Foundation
the Cancer
Survivor

3. 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 threatening
Mission 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

4. 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

5. 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

6. 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 hospital's 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

7. Medicaid
Government-sponsored medical insurance
program based on financial need. To receive
Medicaid, your income and assets must be below
a certain level. It covers hospital care, physician’s
fees, prescription drugs, home care and many
other services. In order to qualify, you must be a
US resident. Medicaid is only valid in the state in
which it is issued. You can go to your local county
Department of Social Services for an application.

8. Work transitions and the Self-employed
COBRA : 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

9. 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

10. 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

11. 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)

12. 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)

13. 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.

14. 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

15. 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

16. How the Program Operates ram
å 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 qualify
å 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

17. 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

18. National Underinsured Resource
Directory
http://patientadvocate.org/help4u.php
18

19. National Underinsured Resource
Directory Pull Out Cards
Seven pull out cards were
created based on the
topics commonly
addressed by PAF
patients based on needs
and issues of the
underinsured population.
Each card offers action
steps or suggestions to
compliment the resources
they will be provided.
19

20. http://link.brightcove.com/services/player/bcpid1875349721?bctid=608833805001
Health Care Reform
Uninsured Adults ages 19-64
Texas: 30% Travis: 25.5% Austin: 27% U.S. uninsured: 19.5%

21. The Uninsurable – High Risk Pools
FEDERAL 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.gov
State 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

22. Risk Pool Implementation

23. ¡Cover the Uninsured!
Premium rates for Texas
2011 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

24. 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.

25. www.insureustoday.org
contact us at 866-207-8023
25

26. Contact Us
421 Butler Farm Road 421 Butler Farm Road
Hampton, VA 23666 Hampton, VA 23666
Phone: 1-800-532-5274 Phone: 1-866-512-3861
Fax: (757) 873-8999 Fax: (757) 952-0118
Internet: Internet: www.copays.org
www.patientadvocate.org E-Mail: cpr@patientadvocate.org
info@patientadvocate.org
26