Embed Size (px)
Citation preview
Confidential. For internal use only.
Managing the Cost of IBD
Carrie Keneipp
Manager of the Family Financial Advocates
Cincinnati Children’s Hospital
Hope Love
Family Financial Advocate
Cincinnati Children’s Hospital
Lori Butterfield
Education, Support & Advocacy Manager
Crohn's & Colitis Foundation
The Challenges in Paying for IBD Treatments
• Rising costs of health care
• High Deductible/HSA plans
• Co-insurance Costs
• Multiple co-payments for specialties and multi-discipline clinics
• Exceptions under insurance plans
• Non-covered items and services
• Maxed out therapies
Financial Advocates
• Work with chronic care patients and their families to lower the financial burden of medical bills.
• Assess families for local, state, and federal resources they may qualify for
• Assist in applying, tracking, and utilizing resources once approved.
• Serve as a direct point of contact for all resource/billing needs
Why Would a Family Need Additional Resources?
They already have insurance or Medicaid
…Isn’t that enough?
A Quicker Primer on Insurance
Understanding Insurance: Private
Understanding Insurance: Private
• Association Health Plans (AHP)
• Small employers that band together to form association
• Not subject to same requirements as those on Health Insurance Marketplace (ie. Prescription drug coverage)
• Required to cover preventative care, allow children <26yo
• Premiums can vary based on gender, age, location, occupation
• Short Term Limited Duration Health Plans
• Cover short gap in insurance coverage
• Similar to AHP do not have same requirements as Health Insurance Marketplace plans
• Can deny coverage and charge more based on health status
Understanding Insurance: Private
HMO
PPO
POS
Fee for service
High deductible
Understanding Insurance: Public
Medicaid Medicare
Federally and State-funded Federally-funded
Coverage varies state to state Nationwide coverage
consistency
Benefits low income, pregnancy,
disabled
Benefits > 65 years, disabled,
end-stage-renal disease
Understanding Insurance: Medicare
https://site.crohnscolitisfoundation.org/assets/pdfs/ibd-insurance-checklist.pdf
Resource: Insurance Checklist
When Insurance Isn’t Enough
Primary Insurance Limitations
• Incontinence supplies
• Specialized car seats
• Formula thickeners
• Certain medications
• Respite Care
• In-home nursing services
• Bath chairs
• Ramps
• Walker/stander combos
• J-seats
• Diapers
• Home modifications
• Vehicle modifications
• Portable suction
• C-pap
• Transportation
• Therapies
• Communication devices
• Adapted equipment
• Strollers
Resource Options
• Social Security
• All Medicaid Programs and Waivers
• Title V
• Hospital Financial Assistance
• Developmental Disability Services
• Nonprofits
• Infusion Assistance Programs
• Medicare Supplemental Insurance
Supplemental Security Income (SSI) Program
• Provides cash to meet basic needs: food, clothing, and shelter.
• Designed to help aged, blind, and disabled people, who have little or no income and meet these requirements:
• Must be financially eligible
• Must be a U.S. citizen, national, or a certain category of alien.
• Must be a resident of one of the 50 States, District of Columbia, or the northern Mariana Islands.
• Must not be absent from the country for a full calendar month or more than 30 consecutive days.
Medicaid
Traditional Medicaid Programs
• Covers children up to age 19
• Covers both insured and uninsured depending on where family’s income falls on the Federal Poverty Level Guidelines
Alternative Medicaid Programs
• Medicaid Spend-Down (Medicaid Disability)
• MAGI (Medicaid expansion for adults over 19)
• Institutionalized Medicaid
• Medicaid Waiver
Ohio Home Care Waiver• Must have skilled nursing need in the home
• Patient (not parents) must be financially eligible for Medicaid
• Includes:
1. Medicaid
2. Private Duty Nursing
3. Allowance for Home Modifications and Equipment
BCMHBureau for Children with Medical Handicaps
Diagnostic Program
• Rule out or diagnose condition
• Based on eligibility of diagnosis (not income)
• Up to 6 months of coverage
Treatment Program
• 1 year of coverage (renewable every year until age 21)
• Must qualify medically and financially
• Covers services involved with treatment of condition
• Permanent Ohio resident
• Ages 0-21
• Patients who have, or may have, a chronic medical condition
CCHMC Discount
• Families who reside in Ohio -OR- the primary service area receive 49% BAI discount:
• OH: Hamilton, Warren, Clermont, Butler
• KY: Kenton, Campbell, Boone
• IN: Dearborn
• No application needed
• No income guidelines
• Discount applied to all balances after insurance
• Families outside of Ohio and the primary service area receive an automatic 25% BAI discount- no application required.
CCHMC’s Financial Assistance Program
• Eligible families will qualify for a 100% discount
• Families must reside in Ohio -OR- within our primary service area:
• OH: Hamilton, Warren, Clermont, Butler
• KY: Kenton, Campbell, Boone
• IN: Dearborn
• Services must be deemed medically necessary by state regulations
• Family must be under 200% of the FPL
Developmental Disability (DD) Services
• Assists patients from birth to adulthood
• Every county has a separate board of DD services; and each differ in the amount of funding in services available
• All have a wait list for waiver services
• Wait list times differ by county: 7-20 years
• This is due to the fact that counties must fund a percentage of the waivers allotted
• Families should ask for Family Support Dollar Services for help with copays, diapers, equipment, etc.
• Families must ask for a Case Manager
DD Waivers
Individual Options Waiver
• Spending limit is determined based on individual assessed needs
Level 1 Waiver
• Spending limit up to $5000
• Offers additional services Medicaid doesn’t cover:• Respite care, home modifications, equipment, etc.
Approval = Medicaid Card
Non-Profits• Purpose: To assist with items that other programs or agencies do not
cover.
• Types: Every nonprofit designates the funds for specific groups, individuals, diagnoses, or items.
• Income Guidelines: Vary depending upon the non-profit
• Applications: Some are online and some are by mail
• Process: Non-profits take time. FFAs will screen families and direct them towards the non-profits they may qualify for.
Medicare Supplemental Insurance: Medigap
• Private insurance that supplements original Medicare and covers “gaps” in Medicare coverage
• Must have Parts A and B to purchase a Medigap policy
• Does not offer prescription drug coverage
A Quick Primer on Prescription Drug Coverage
Drugs are arranged by each insurance company into tiers:
Tier 1: Methotrexate
Tier 2: Ustekinumab
(Stelara)Tier 3: Tofacitinib
(Xeljanz)Tier 4: Budesonide
(Uceris)
Generic
Preferred
Non preferred
Specialty
Why Do My Prescriptions Get Denied?
Your insurance has a preferred list of medications call a formularyDrug not covered due to formulary
• Provider can submit an exception based on medical necessity
• Ask provider to consider formulary drug
• Can pay out of pocket or review alternative filling opportunities Possibly might need to appeal denial
Drug is on formulary but pharmacy will not fill medication?
• Prior authorization is required
• Caution when getting from non-US based pharmacy- we can’t verify it is the exact same
What is “Step Therapy”?If your insurance mandates you have to try and fail a certain drug before they will cover the drug your doctor originally prescribed
New Ohio law in effect in 2020
Prescribed drug should be approved if:
• Other drug is contraindicated
• If you previously tried and failed that drug
• Are currently stable on a drug on the formulary
• Appeals must be responded to in 48 in emergencies and 10 calendar days in all other cases.
Medical vs. Pharmacy Benefit Coverage?
The cost of infusion medications includes
A. Cost of drug
B. Facility's fee to infuse the drug
Medical Pharmacy
Medications given in office or
infusion center
Self-administered medications
Can be injection/infusion Can be oral, injection or any
route patient can handle at home
Co-Pay Accumulator Programs
Sue’s
medication
costs $200
Sue pays her $25
co-pay
Sue uses her co-
pay card
to pay the other
$175
Only $25 is
applied to
Sue’s
deductible
Copay Assistance Programs
Infusion CoPay Assistance
• Created by the drug maker to assist Family with their out of pocket expenses for the drug
• Program Details/Guidelines:
• Participation is not determined by income
• Patient has to have commercial insurance
• Drug has to be a covered benefit under the plan
• Can not participate in government funded medical plan such as Medicaid, Medicare, Tricare or BCMH Treatment Letter
Janssen CarePath (formally RemiStart)
Drug Name: Infliximab (Remicade)
Required Documents: Explanation of Benefits & Itemized Statement
Enrollment Option: Online, Phone, Advocate
Effective Retro Date: 120 days from day application received
Member Responsibility: $5
Annual Max Benefit: $20K
Payment Option: Mastercard
Payment Issued: 7-10 business days
Entyvio Connect
Drug Name: Vendolizumab (Entyvio)
Required Documents: Explanation of Benefits & UB04
Effective Retro Date: 365 days
Enrollment Option: Paper
Member Responsibility: no more than $50
Annual Max Benefit: $10K
Payment Option: Check to hospital
Payment Issued: 7-10 business days
Pfizer enCompass
Drug Name: Infliximab-DYYB (Inflectra)
Required Documents: Explanation of Benefits & Pfizer Claim Form
Effective Retro Date: 90 days
Enrollment Option: Paper
Member Responsibility: $0
Annual Max Benefit: $20K
Payment Option: Check to Family
Payment Issued: 7-10 business days
Working Together For Success
How Financial Advocates Can Help
• Address short term and long term needs
• Clean up old balances
• Serve as one point of contact for all billing issues
• Answer questions about various resources
• Advocate on behalf of our families
When to Seek an Advocate
• Family is uninsured
• Patient is hospitalized for 25 days or longer
• Family has one or more child with a chronic healthcare condition
• Family has one insurance payer, a high deductible plan, and/or high prescription costs
• Family has DME needs
• Family has many outstanding medical bills
Crohn’s & Colitis Foundation Resources
Videos & Information on:
• Understanding Insurance
• Assistance Programs
• Co-Pay Accumulator Programs
• What to do if you are denied
• NEW! – Older Adult & Young Adults & Insurance
Visit our Website
www.crohnscolitisfoundation.org
Call our IBD Help Center
1-888-MY-GUT-PAIN
(888-694-8872, extension 8)
Thank You!
????
