Insurance & Financial Assistance - Amyloidosis Support · 2019-10-30 · Insurance & Financial...

Insurance & Financial Assistance

Monica Bryant, Esq. COO, Triage Cancer

This presentation provides general information on the topics presented. The authors and presenters are not engaged in rendering any legal, medical, or professional services by its presentation or distribution. Although this content was reviewed by a professional, it should not be used as a substitute for professional services.

1 © 2019 Triage Cancer

About Triage Cancer


Triage Cancer is a national,

nonprofit organization that

provides education on the

legal and practical issues that

may impact individuals

diagnosed with cancer and

their caregivers.

Triage Cancer Educational Events


In-person educational events for:

• Patients & survivors

• Caregivers

• Advocates

• Health care professionals

• & others

http://TriageCancer.org/Events

http://triagecancer.org/Events-Calendar

Triage Cancer Conferences


In-person educational events for:

• Patients & survivors

• Caregivers

• Advocates

• Health care professionals

• & others

Topics:

• Being an Advocate

• Health Insurance

• Finances

• Being Prepared

• Employment

• Disability Insurance

Free CEs for nurses, social workers, & attorneys

Oakland, CA ~ March 21, 2020

Atlanta, GA ~ October 10, 2020

Chicago, IL ~ October 17, 2020

https://TriageCancer.org/Conferences

http://triagecancer.org/Conferences

http://triagecancer.org/Conferences

Triage Cancer Webinar Series


Full Schedule & Registration at https://TriageCancer.org/Webinars

Recordings of Past Webinars https://TriageCancer.org/Past-Webinars

Free CEs for nurses and social workers

• November 20 – Caring for Caregivers

• December 5 – Protecting Your Wallet After Cancer

https://triagecancer.org/webinars

https://triagecancer.org/Past-Webinars



Triage Cancer Materials


Quick Guides:

• ADA

• Reasonable Accommodations

• Chemo Brain

• Disclosure

• FMLA

• FMLA & Other Benefits



• COBRA

• Medicare

• Clinical Trials

• Medical Marijuana

• Bankruptcy

• Estate Planning

• Stress Management

• Legal Assistance

• Advocacy

• Legislative Advocacy

• Scientific Advocacy

https://TriageCancer.org/QuickGuides

Order form at:

TriageCancer.org/MaterialRequest

Checklists:

• Getting Organized

• Reasonable

Accommodations

Spreadsheets

• Financial Big Picture


Appeals Tracking Form

https://triagecancer.org/QuickGuides

Triage Cancer Animated Videos


https://TriageCancer.org/AnimatedVideos

7

English & Spanish versions; with Tagalog subtitles

https://triagecancer.org/AnimatedVideos

Triage Cancer International, National, & State Resources


• State Government & State Legislative Information

• State Comprehensive Cancer Control Program & Plan


• Employment

• Estate Planning


• Medicaid & Medicare

• Clinical Trials

• Legal Assistance

• Advocacy

• Cancer Survivorship Research

• Cancer Community Partners https://triagecancer.org/resources

https://triagecancer.org/resources

Triage Cancer Chart of State Laws


Employment, disability and health insurance, estate planning, & more

https://TriageCancer.org/StateLaws

https://triagecancer.org/StateLaws

CancerFinances.org


“Financial Toxicity:” New Term, Old Problem


2013 - Researchers from Duke:

“Out-of-pocket expenses might have such an

impact on the cancer experience as to warrant a

new term: "financial toxicity." Out-of-pocket

expenses related to treatment are akin to physical

toxicity, in that costs can diminish quality of life.”

Contributors to Financial Toxicity


• Health Insurance Status

• Adequate coverage to minimize out-of-pocket costs

• Consumer Protections

• Medical Bills

• Employment Changes

• To work or not to work - accommodations


• Life Changes

• Marriage/divorce, moving, graduating from school, etc.

Quick Guide to Addressing Financial Toxicity Insurance Coverage –

In-Network Expenses

• What is your monthly premium?

• What is your out-of-pocket maximum for in-network medical expenses?

• What is your deductible?

• What is your cost-share/co-insurance amount?

• What are your co-pays for specific types of care (e.g., office visit, specialist, ER, etc.)?

• Do you have a separate deductible or out-of-pocket maximum for prescription drugs?

• Are your providers in-network?

• Is your pharmacy in-network?

• Does your plan have tiers or providers?

Insurance Coverage –

Out-of-Network Expenses

• Does your insurance policy cover out-of-network medical expenses?

• If yes, at what percentage?

• Does out-of-network care apply to your out-of-pocket maximum?

• Is there a separate out-of-pocket maximum for out-of-network care?

• Do you have an opportunity to change your health insurance coverage so that these expenses are no longer out-of-network (e.g. move to a spouse’s plan or another employer plan during open enrollment)?

Practical Issues

• Do you travel for treatment (e.g., parking, tolls, mileage, lodging, air or ground transportation)?

• Do you need durable medical equipment (e.g., crutches, wheelchairs, prostheses, etc.?

• Do you need items to address the comfort and cosmetic side effects (e.g., wigs, hats, skin care, etc.)

• What do complementary therapies cost (e.g., massage, acupuncture, etc.)?

• Does your insurance cover any of these expenses?

• Do you have a supplemental health insurance plan that covers medical and/or other expenses?

Personal Issues

• Do you have minor children?

• Are you caring for aging parents or other family members?

• Do you need help taking care of our home (e.g., cleaning, gardening, repairs, snow removal, etc.)?

• Do you need help with meal preparation or other errands (e.g., grocery shopping, laundry, etc.)?

• Do you have a support system who could help you (e.g., family, friends, neighbors, co-workers, etc.)?

• Do your caregivers have access to paid or unpaid family leave through their employer or a federal or state law?

• Do you need to hire an attorney to prepare estate planning document?

Employment &

Disability Insurance

• How many employees does your employer have?

• What state do you live in?

• What are your goals regarding work?

• Do you want or need to work through treatment?

• Are you eligible for reasonable accommodations?

• Do you want or need to take time off?

• What are your employer’s policies for taking time off?

• Are you eligible for FMLA leave?

• Do you have access to private, state, or federal disability insurance options?

• Will your employer hold your job for you while you receive disability benefits?

13 © 2019 Triage Cancer https://triagecancer.org/Checklist-FinancialToxicity

Don’t Understand Health Insurance? You Are Not Alone.


• Only 23% understood terms used in

their health policy

• Only 50% knew their monthly premium

• Only a few understood acronyms: HMO

(36%), PPO (20%) & HSA (11%) (eHealth,

2008)

• When asked to define insurance terms

and calculate their bill only 50% got it

right (The Regence Group, 2008)

Health Insurance Terms


• In-Network vs. Out-of-Network

• Allowed Amount or Contracted Amount

• Pre-authorization

Health Insurance Terms

Cost to Have Health Insurance

• Premium – each month

Costs When You Use Your Health Insurance

• Deductible – each year (fixed $ amount)

• Co-Payment – each time you get care (fixed $ amount)

• Co-Insurance or Cost-Share – each time you get care (%)

• Out-of-Pocket Maximum* =

deductible + co-payments + co-insurance

© 2019 Triage Cancer

*usually only for in-network services

Case Study: Dan

Dan’s Plan: Deductible = $2,000

Co-insurance = 80/20 plan

OOP Max = $8,000

If Dan has a $102,000 hospital bill, what does he pay?

1. His deductible of $2,000

$102,000-$2,000 = $100,000 left

2. His co-insurance amount of 20%

20% of $100,000 = $20,000

But OOP max is only $8,000. So, he would only pay the $2,000 deductible + $6,000 of the $20,000 co-insurance amount, for a total of $8,000.


Types of Managed Care Plans


Smaller network of providers

PCP referral to specialists

Lower costs (i.e., premiums, co-pays, deductibles)

HMOs can be a staff model (e.g., Kaiser) or a group/ network model (e.g., Anthem)

Larger network of providers = more choice

But no out-of-network coverage

PCP not necessary

Higher costs

Larger network of providers = more choice

May have some out-of-network coverage

(e.g., 50%)

PCP not necessary

Higher costs

PPO

(Preferred Provider Organization) HMO

(Health Maintenance Organization)

EPO

(Exclusive Provider Organization)

Most U.S. citizens & lawfully present must have health insurance


ACA Requirement to Have Health Insurance

How much is the penalty?

Fine collected through IRS

annual taxes

What coverage counts?

Employer or Individual Plans COBRA/HIPAA Plans

Medicare, Medicaid, Veterans Health High Risk Pools, & others

Latest news:

Individual Mandate

penalty dropped to

$0 in 2019

Year Adult

Penalty

Child

Penalty

Family

Max

or % of Income,

whichever is more

2014 $95 $47.50 $285 1%

2015 $325 $162.50 $975 2%

2016, 2017, 2018 $695 $347.50 $2,085 2.5%

2019 $0

Consumer Protections & Benefits

1. No lifetime or annual limits

2. No rescissions (cancellations)

3. Young adults can stay on parent’s plan until 26

4. Free preventative care (except grandfathered plans)

• No co-pays, co-insurance, or deductibles

• Ex: immunizations, blood pressure, diabetes, cholesterol, cancer

• USPSTF Rated A/B (+ Mammography for women 40+)

• www.healthcare.gov/coverage/preventive-care-benefits

5. Clinical trials coverage

6. External appeals


http://www.healthcare.gov/coverage/preventive-care-benefits





Health Insurance Rights (after 1/1/14)

1. Premium Rating

• Individual vs. Family Plan

• Geographic Location (Ex: LA has 8 regions)

• Age (64 can only be charged 3 times more than a 21 year old)

• Tobacco (some states have eliminated this – CA, DC, etc. )

2. No Pre-Existing Condition Denials/Exclusions

• Insurance companies cannot look at:

•Pre-existing condition (physical or mental) or health history

•Gender or age


Latest news: Texas vs. US

ACA Unconstitutional?

22

https://triagecancer.org/texas-ruling-aca-cancer-community

Feb. 26, 2018: Texas AG + 17 other Republican state AGs (AL, AR, AZ, FL, GA, IN, KS, LA, MO, NE, ND, SC, SD, TN, UT, WV), 2 governors (ME, MS), & 2 individual plaintiffs challenged constitutionality of ACA

June 7, 2018: U.S. DOJ said it won’t defend ACA in court

June 8, 2018: California AG + 16 Democratic state AGs intervene to defend ACA (CT, DC, DE, HI, IL, KY, MA, MN, NJ, NY, NC, OR, RI, VT, VA, WA).

Dec. 14, 2018: TX judge ruled entire ACA unconstitutional but then stayed ruling until an appeal, which keeps the ACA in effect

December 2018: California AG + 16 Democratic state AGs file appeal to 5th Circuit 2 states withdraw: WI & ME

Feb/ March 2019: US House of Rep & 4 states (IA, MI, CO, NV) join defense of the ACA; U.S. DOJ says “strike it

all down”

July 9, 2019: 5th Circuit Court of Appeals heard case. Any ruling will likely be appealed to the US Supreme Court










Where We Get Health Insurance


Insurance

Company

Government: Medicare, Medicaid, Military, IHS, High

Risk Pools, etc.

Employer

2017 – 58.5 million people on Medicare

• Eligibility

• U.S. Citizen or legal resident, AND • Legal residents = live in U.S. for at least 5 years in

a row, including the 5 years just before applying

• Be • 65+ years old, or

• On SSDI 2+ years, or

• Have ESRD or ALS

• www.Medicare.gov

• 4 Parts to Medicare

Medicare

© 2019 Triage Cancer 24

http://www.medicare.gov/

Medicare Part A - 2020

• Hospital Insurance

– Hospital stay

– Skilled nursing facility stay

– Hospice

– Home health services

– Nursing home care (limited)

• Cost

– Premium:

• $0 – if at least 40 work quarters

• $253 – if 30-39 work quarters

• $460 – if less than 30 work quarters

– Deductible: $1,420 per benefit period

– Cost Share: varies on days in-patient

– Late enrollment penalty of 10% for twice the # of years you were

eligible for Part A, but didn’t sign up

Medicare Part B - 2020

• Medical Insurance

– Services from doctors

• Some preventive services

– Outpatient care

– Home health care

– Durable medical equipment

• Cost

– Premium: $144.30/month (most people – based on income)

– Deductible: $197/year

– Cost Share: 80/20%

– No out-of-pocket maximum!

– Late enrollment penalty of 10% for each full 12-month period you

were eligible for Part B, but didn’t sign up – paid for life!

• Medicare A +B = Original Medicare = fee for service

Medicare Part D - 2020

• Prescription drug coverage added to Medicare

• Provided by private insurance companies

• Cost

• Premium: varies by plan (nat’l average $33.50) • Based on 2017 income

• Deductible: $435

• Copayments vary based on plan

• Late enrollment penalty of 1% of national average monthly premium

x # of full months you were eligible for Part D, but didn’t sign up

Initial Coverage

Deductible The Donut Hole Catastrophic Coverage

Patient pays $295 deductible out of pocket

Until total drug costs = $2,700

After total out-of-pocket drug costs = $4,350

Medicare Part D – Donut Hole before ACA

Patient pays 100%

Medicare pays 0%

Patient pays 25%

Medicare pays 75%

Patient pays greater of 5% or $2.40 generic/ $6 brand

Medicare pays 95%


1. Free Wellness Visit

2. Free Preventative Care

3. Lowers the cost of prescription drugs

ACA Medicare Benefits

Year What you pay for brand name drugs in the coverage gap

What you pay for generic drugs in the coverage gap

2009 100% 100%

2018 35% 44%

2019 30% 37%

2020 25% 25%

Year What you pay for brand name drugs in the coverage gap

What you pay for generic drugs in the coverage gap

2009 100% 100%

2018 35% 44%

2019 25% 37%

2020 25% 25%


Initial Coverage Deductible Catastrophic Coverage

Patient pays $435 deductible out of pocket

After total out-of-pocket drug costs = $6,350

Medicare Part D – Donut Hole 2020

Patient pays 25%

Medicare pays 75%

Patient pays greater of 5% or $3.60 generic/ $8.90 brand

Medicare pays 95%

Medicare Part C – 2019

• Medicare Advantage Plans (1982)

– HMO/PPO

– Includes all benefits/services covered under Parts A & B

– Sometimes includes Part D (Rx coverage)

– Run by Medicare-approved private insurance companies

– Specific network of providers

– May include extra benefits and services for an extra cost

• Cost

– Premium: varies (you pay your usual Part B premium, and maybe more;

some plans pay a portion of your Part B premium)

– Deductible & cost-share: varies by plan

– 2020 Out of Pocket Maximum ≯ $6,700 in-network

• Once someone enrolls in MA, they’re locked in for the year. Exception: special

disenrollment period from 1/1-2/14 (anyone who leaves during this time must

go back to original Medicare


What are the differences between plans?

• Networks of doctors and hospitals • Check to make sure your doctors are covered by the plan

you choose

• Co-payments

• Prescription drug coverage • Which drugs are covered?

• Is there a separate drug deductible?


Pros Cons

Out-of-pocket maximum is at most $6,700 a year

Could have a smaller network of providers = out of network providers not part of OOP max

Many plans cost exactly the same amount as a Part B plan

Plans are difficult to compare since no two plans are alike

Usually includes drug coverage (without separate premium/deductible)

Usually only localized coverage (i.e., no nationwide coverage)

Many include hearing, dental, and vision Primarily HMO plans that require PCP referrals to see specialist

Can include “extras” (e.g., gym membership) Plan can change drug and medical coverage each year

Can switch to another MA plan or original Medicare during open enrollment

May not be able to get Medigap later b/c of pre-existing condition limitation

Weighing Options: Medicare Advantage


Case Study: Jimmy


• Jimmy is almost 65, lives in Chicago, and is weighing his Medicare options. He is about to start chemo

that will last 1 year. He has heard that his IV chemo treatment is covered under Medicare Part B, but

Part B has an 80/20 cost-share. His drug costs will be $10,000 per month. He isn’t interested in a

Medicare Advantage plan, because he spends part of the year in FL. He wants a Medicare option with

the lowest out-of-pocket costs.

• Option 1: Original Medicare

– Part B monthly premium = $135.50 per month x 12 = $1,626

– Part B deductible = $185

– Part B cost share (just for his chemo) = $10,000 x 20% = $2,000 x 12 months = $24,000

– Total for Part B and chemo cost-share = $25,811

• Option 2: Original Medicare + Medigap Plan F, which costs $300 per month

– Part B monthly premium = $135.50 per month x 12 = $1,626

– $300 x 12 months = $3,600 (picks up Part B deductible and 20% cost share)

– Total for Part B and Medigap Plan F = $5,226


Medigap Plans

• Can have waiting periods to cover pre-existing conditions of

up to 6 months • Except if you sign up when first eligible for Medicare

• Can reduce waiting period with creditable coverage without a 63

day gap in coverage

• Can have pre-existing condition exclusions in some cases • https://www.medicare.gov/find-a-plan/staticpages/learn/rights-and-

protections.aspx

• May not be available to people under 65 years old receiving

Medicare due to a disability • No requirement to issue: AL, AK, AZ, AR, DC, ID, IN, IA, KS, KY,

MT, NE, NV, NM, ND, OH, RI, SC, UT, VA, WA, WV, WY

https://www.medicare.gov/find-a-plan/staticpages/learn/rights-and-protections.aspx









Medicare Options: Pick a Lane

Lane 1: Original Medicare

Do you want an Rx plan (Part D)?

Do you want a Medigap plan?

Lane 2: Medicare Advantage (Part C)

Do you also need an Rx plan (Part D)?


Medicare: Change Lanes During Open Enrollment

Lane 1: Original Medicare

Do you want an Rx plan (Part D)?

Do you want a Medigap plan?

Lane 2: Medicare Advantage (Part C)

Do you also need an Rx plan (Part D)?


Help Paying for Medicare Parts A & B

• Medicare savings programs (MSP) • Helps pay for premiums, sometimes deductibles, co-payments, and cost-

share amount. • Four types of MSPs:

• Qualified Medicare Beneficiary (QMB) Program helps eligible individuals pay for Part A and Part B premiums, as well as deductibles, coinsurance, and co-payments

• Specified Low-Income Medicare Beneficiary (SLMB) Program helps eligible individuals pay for Part B premiums.

• Qualifying Individual (QI) Program helps pay the Part B premiums for certain individuals who are not eligible for Medicaid.

• Qualified Disabled and Working Individuals (QDWI) Program helps eligible individuals pay their Part A premiums.


Help Paying for Medicare Part D

• Low-Income Subsidy (aka Extra Help): pays some premiums, deductibles, co-payments, and cost-share amounts

• May be automatically enrolled in full or partial Extra Help

• Full Extra Help: pay no more than $3.40 for each generic/$8.50 for each brand-name covered drug/no premiums or deductibles (in 2019)

• www.ssa.gov/benefits/medicare/prescriptionhelp

• State Pharmaceutical Assistance Programs (SPAP): pays some premiums or drug costs

• Programs are not available in every state www.medicare.gov/pharmaceutical-assistance-program/state-programs.aspx


http://www.ssa.gov/benefits/medicare/prescriptionhelp

http://www.medicare.gov/pharmaceutical-assistance-program/state-programs.aspx







Triage Cancer Resources on Medicare


• Webinar: Medicare – An In-Depth Look

https://triagecancer.org/past-webinars

• Quick Guide to Medicare: https://triagecancer.org/quickguide-Medicare

• Quick Guide to Medigap: https://triagecancer.org/quickguide-Medigap





https://triagecancer.org/quickguide-Medicare



https://triagecancer.org/quickguide-Medigap




Where to go for help

• Medicare & You www.medicare.gov/medicare-and-you

• Visit the Medicare Plan Finder http://Medicare.gov/find-a-plan

• 1-800-MEDICARE (800-633-4227) and say “Agent”

• State Health Insurance Assistance Program (SHIP)

• https://triagecancer.org


http://www.medicare.gov/medicare-and-you





http://medicare.gov/find-a-plan






https://triagecancer.org/

New Health Insurance Options - #2

• “Exchanges” = insurance shopping mall

• Benefits:

• Cap on OOP max: $8,200 individual / $16,400 family (2020)

• Financial help

• Premium tax credits

• Cost-sharing subsidies


State Health Insurance Marketplaces

Standardized cost-share:

Catastrophic coverage (under 30 or $ hardship)


Marketplace Plan Options

When to Enroll?

• Employer plans: Varies (often in the Fall)

• Medicaid applications accepted year round

• Medicare: Oct. 15 – Dec. 7

• Marketplace plans are calendar year coverage

• 2020 Marketplace Open Enrollment: Nov. 1 – Dec. 15, 2019

• Some states may be longer

Marketplace Special Enrollment Period

When you have a life-changing event . . .

. . . you have 60 days to enroll in Marketplace plan

Comparing Plan Options


Marketplace

Plan

Marketplace

Plan

Employer Plan

Employer Plan

Marketplace

Plan

Employer

Plan

Medicare

Plan

Medicare

Plan

Do the Math! The Math Matters!

Total potential costs for year = 12 months of premiums + OOP max

#1: $173x12 = $2,076 + OOP = $6,000 Total = $8,076

#2: $271x12 = $3,252 + OOP = $5,200 Total = $8,452

#3: $398x12 = $4,776 + OOP = $1,150 Total = $5,926


What are the differences between plans?


• Cost – Premium, Out of Pocket, Co-Pay, Deductibles,

Cost-Share

• Networks of doctors and hospitals – Check to make sure your doctors are covered by

the plan you choose

• Prescription drug coverage – Which drugs are covered?

– Is there a separate drug deductible?

Review Your Options Every Year


When making changes between plans, it is important to leverage deductibles

and out-of-pocket maximums

External Appeals - ACA AKA: Independent Medical Review or External Medical Review

• Denials of coverage

– Internal appeals (ERISA – employer plans)

– External appeals (ACA and/or state law – all private plans)

• State Health Insurance Agency: www.triagecancer.org/stateresources

• Reasons for External Appeals

– Medical judgement

– Experimental or investigational

– Cancellation of coverage based on application info

Triage Cancer Webinar on “When an Insurance Company Says No” Quick Guide to Appeals https://triagecancer.org/QuickGuide-Appeals

http://www.triagecancer.org/stateresources

https://triagecancer.org/QuickGuide-Appeals



Triage Cancer Drug Discount Card

• In partnership with NeedyMeds

• Free drug discount card offers a discount of up to 80% at more than 63,000 pharmacies nationwide

• Use instead of insurance coverage to lower out-of-pocket costs

• Anyone can use the card, regardless of income or insurance status

• Registration not required

• Card can be used to save on prescription drugs, over-the-counter drugs, and medical supplies written on a prescription form


http://TriageCancer.org/drugdiscount

http://triagecancer.org/drugdiscount

http://triagecancer.org/drugdiscount

Financial Assistance Options

• Local, state, county, & community organizations

• Cancer organizations o Zero Prostate Cancer

o American Cancer Society

o Cancer Support Community Help Line

o CancerCare

• Private programs o Patient Services, Inc.

o Healthwell Foundation

• Fundraising o GoFundMe or Life Extraordinary

• Pharmaceutical & Specialty Pharmacy assistance programs

• Prior authorization & benefits resources

• Sample billing and coding information

• Resources for denials and appeals

• Referrals to appropriate patient assistance options

• Co-pay assistance

• Ex: For commercially insured patients may pay $0 for oral products

• Free drugs

• Ex: for Medicare patients free medication, Medicare Extra Help, other foundations

• Ex: for uninsured patients help finding coverage, 90 day-1 year supply

• Free Trial Vouchers

• Connection to help with transportation, lodging, etc.

Financial Assistance Options

Other Contributors to Financial Toxicity


• Health Insurance Status

• Managing Medical Bills

• Consumer Rights

• Employment Changes

• To work or not to work - accommodations


• Life Changes

• Marriage/divorce, moving, graduating from school, etc.

Visit TriageCancer.org

Continued Relationship with Triage Cancer

• Attend More Webinars • https://TriageCancer.org/webinars

• Read our Blog • https://TriageCancer.org/blog

• Order Materials • https://TriageCancer.org/materialrequest

• Connect on Social Media • Twitter: @TriageCancer

• Facebook: @TriageCancer

• Instagram: @TriageCancer




https://triagecancer.org/blog

https://triagecancer.org/blog

http://triagecancer.org/materialrequest

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Insurance & Financial Assistance - Amyloidosis Support · 2019-10-30 · Insurance & Financial...

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