financial concerns community education class
DESCRIPTION
TRANSCRIPT
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.
Financial and Insurance
Implications for the Cancer
Survivor
Brendan Bietry LIVESTRONG Senior Case Manager
Patient Advocate Foundation
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Our Mission: To Serve Patients
Our Mission
• Patient Advocate Foundation seeks to safeguard patients through effective mediation assuring access to care, maintenance of employment and preservation of their financial stability relative to their diagnosis of life threatening or debilitating diseases.
Our Impact
• 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 website, online chats and outreach events.
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 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
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.
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
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
Initial application
• Local Social Security office (in person, telephone or on-line)
Phone interview
• Local Social Security office (non-medical eligibility check – work credits, age, marital status, etc..)
DDS office
• Disability Determination Services (evaluates disability)
Timeline for evaluation (approval/denial/appeals process)
Approval
• Expedited processing (8-10 days for “flagged” cases) – QDD processing
• Standard processing (4-6 months)
Denial and recourse
• Reconsideration (1st level) – appellant submits with added medical records/assessments
• Some states will allow the appellant to skip to a 2nd level Hearing with an Administrative Law Judge (ALJ)
ALJ Hearing
• Appellant may hire a Disability attorney, represent him/herself and/or appoint an unpaid 3rd party to assist in furthering his/her case (Patient Advocate 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
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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…
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CPR Mission
• The PAF Co-Pay Relief Program (CPR) exists to provide direct financial assistance to insured patients who cannot afford the co-payments and co-insurance required to access prescribed pharmaceutical therapies.
Our Mission: Supplement the limits of health insurance
å Professional CPR Call Counselors assist patients in completing application forms and securing authorizations needed to verify medical and financial necessity to qualify patients.
å Upon Approval, payments are made directly to the doctor, pharmacy or patient.
å CPR provides assistance to both commercially and government insured patients including Medicare Part D beneficiaries.
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å CPR provides cash co-payment assistance for insured patients unable to use their prescription drug benefits due to inability to pay their co-payments.
å Patients, physicians, and pharmacies can contact CPR™ directly to initiate a request for assistance.
å A 24 hour secured web based patient portal to allow patients another option to enroll.
ram How the Program Operates
• Breast Cancer • Chemotherapy Induced
Anemia/Neutropenia • Colon Cancer • Cutaneous T-Cell Lymphoma • Hepatitis C • Hormone Suppression
Therapy • Kidney Cancer • Lung Cancer (Non-small cell
Lung Cancers) • Multiple Myeloma
• Myelodysplastic Syndrome
(MDS, and other pre-leukemia diseases)
• Non-Muscle Invasive Bladder Cancer
• Osteoporosis • Pain • Prostate Cancer • Rheumatoid Arthritis • Sarcoma
CPR currently offers assistance in 19 disease funds including:
CPR Open Disease Funds
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National Underinsured Resource
Directory
18 http://patientadvocate.org/help4u.php
National Underinsured Resource
Directory Pull Out Cards
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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.
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%
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
Risk Pool Implementation
¡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 Option
HSA 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.org
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contact us at 866-207-8023
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421 Butler Farm Road Hampton, VA 23666
Phone: 1-866-512-3861
Fax: (757) 952-0118 Internet: www.copays.org
E-Mail: [email protected]
Contact Us
421 Butler Farm Road Hampton, VA 23666
Phone: 1-800-532-5274
Fax: (757) 873-8999
Internet:
www.patientadvocate.org