Financial Considerations for Transplant Patients. September 18 th, 2017

Transcription

1 Financial Considerations for Transplant Patients September 18 th, 2017

2 Presenters and Panelists Transplant Financial Counselors: Brian Koderl Veronica Drinka Transplant Clinical Social Workers: Jessica Duttkin Maureen Garvey Government Programs Counselor: Cameron Lang

3 Transplant Financial Counselors How do we help patients navigate the financial side of transplantation?

4 Terminology Referral: permission to leave the insurance network while still receiving benefits at the in-network level Prior Authorization: clinical review conducted to determine if scheduled services are appropriate for diagnosis HMO: Health Maintenance Organization manages patient s care PPO: Preferred Provider Organization a plan that has in and out of network benefits. Generally a referral is not required to access different providers

5 HMO vs PPO

6 Terminology Co-pay: a set cost based on a given service Labs, radiology, ER visit, x-ray Coinsurance: a cost sharing agreement between you and your insurance plan that says you ll split the cost of care with them at a certain percentage up to the maximum out of pocket In-network: patient is receiving services from providers within insurance s contracted network Out of network: patient receiving care from outside of their contracted network of providers

7 Types of Insurance Plans Employer Group Health Plan Commercial Coverage Medicare/Medicaid Medicare advantage/replacement plan Medicare Supplement

8 Affordable Care Act Plans Marketplace Commonly known as Obamacare HMO/PPO plans possible Based on income some people are eligible for premium or out of pocket assistance Potential issues with access to services across state lines

9 Medicare and Kidney Transplant End Stage Renal Disease (ESRD) Coordination of Benefits (COB) Who signs you up? What you need: A + B + D + Secondary Coverage Inpatient + Outpatient + Immunosuppressant Local Social Security Office closest to where you live:

10 Open Enrollment General open enrollment: (October 15 th -December 15 th ) or check EGHP Marketplace open enrollment: (November 1 st -December 15 th ) Medicare Part D open enrollment: (October 15 th December 15 th ) Medicare Part B open enrollment: (January 1 st - March 31 st ) Becomes effective July 1st

11 The Role of the Transplant Financial Counselor (TFC): Review insurance coverage for authorization requirements prior to an evaluation Set up case management/coordination Meet with patients on the day of evaluation for key guidance and education Provide coaching on how patient s insurance coverage processes the claims for the care they are receiving and introduce patients to other financial resources Obtain insurance approval for active transplant listing

12 TFC Role: Common Scenarios My Out of Pocket (OOP) is too high I don t have a secondary coverage I m not in-network Aging and Disability Resource Center State Health Insurance Program

13 Transplant Billing Resources Living donation who is billed? Use our Patient Business Services as a resource: Explanation of Benefits (EOB) vs Actual Bill Use MyChart as a resource for EOBs and accumulations towards deductible and max out of pocket (if enrolled in Unity)

14 UW Transplant Clinical Social Work Team How do we help patients navigate common financial roadblocks?

15 Medication Billing Issues Patients who had Medicare at the time of transplant will have their immunosuppression medications billed through Part B, which covers 80%. The remaining 20% can be billed to a supplement Advantage/Replacement plans do not always provide adequate coverage for the 20% Some pharmacies are not able to bill Part B or they mistakenly bill Part D Depending on your insurance, you may need a prior authorization for your medications. This may be denied and need an appeal

16 Medication Coverage Patient is enrolled in a plan that does not provide adequate coverage for medications High co-pay High deductibles * Medicare part D enrolled patients often experience the coverage gap or donut hole.

17 Social Security Disability Once eligible for disability and receive first check, either before or after transplant, there is a 24 month period until eligible to enroll in Medicare (except ESRD) Disability status is not indefinite. There is a review by Social Security Administration at specific intervals depending on the reason for disability status Some patients may experience a gap between when they are no longer considered disabled and when eligible for Medicare based on age

18 Affordable Care Act-Marketplace Some people receive a subsidy to help pay for plans through the marketplace (Affordable Care Act plans). When they switch to Medicare, they may not receive assistance with their monthly premiums.

19 Insurance Benefits Some insurance plans provide additional benefits such as: Travel/lodging Travel/lodging benefits for living donors

20 Hidden Costs Lodging - required local stay before or after transplant Travel - frequent trips to transplant center Food Time off work - lost wages Time off work for caregiver/support person -lost wages Dependent Care Care for pets Potential re-hospitalizations

21 How We Can Help

22 Assistance-Are You Eligible? Extra Help - Medicare part D SLMB QMB Medicaid SeniorCare Wisconsin Chronic Disease Program

23 Co-pay Cards Prescription Co-pay Cards For commercial insurance Some insurance companies will not approve brand name medications.

24 Prescription Assistance Programs Prescription Assistance Programs Medication Assistance Program can assist if using UW Health out-patient pharmacy or mail order pharmacy

25 Choosing a Supplement Medigap Helpline Wisconsin helpline that provides counseling on Medicare, Medicare supplement insurance, employer based health insurance, Medicare advantage plans, long term care insurance Aging and Disability Resource Center (ADRC) found in every Wisconsin county. Benefit specialists provide individualized counseling and advocacy, Medicare and other benefits

26 Choosing a Part D Plan Wisconsin Medigap Part D and Prescription Drug Helpline - age 60 and over: Wisconsin helpline that answers questions for residents 60 and over about prescription coverage and Medicare part D Disability Drug Benefit Helpline: Helpline that offers information for those under age 60 who are eligible for Medicare due to disability

27 Fundraising Cover out of pocket expenses not paid by insurance Best done prior to transplant Decide where to keep money raised - tax exempt accounts

28 Transplant Assistance Funds Offer benefits: Help you figure out how much money to raise Teach your fundraising team how to raise money Keep money in tax exempt account Ensure that access to government programs is not affected Give matching funds if your each specific goals Provide materials to assist in raising awareness around organ donation

29 Fundraising Organizations Children s Organ Transplant Association (21 and younger) Help Hope Live National Foundation for Transplants

30 Q & A Presenters and Panelists will take questions from the audience Webinar attendees can submit questions using the WebEx Q & A feature

31 Thank You for Attending!