Understanding Your Healthcare Benefits. A Patient s Guide

Transcription

1 A Patient s Guide Understanding Your Healthcare Benefits This guide provides useful information about how health insurance assists with paying for treatments

2 TABLE OF CONTENTS 2 What Is Health Insurance? 3 Common Types of Health Insurance 4 Understanding Insurance Coverage 5 What Will You Be Asked to Pay? 6 Treatment Approval Process 7 Insurance Checklist 8 Understanding Your Explanation of Benefits (EOB) and Medicare Summary Notice (MSN) 9 Which Insurance Pays First? 10 Handling Disputes Related to Your Treatment 12 How You Pay for Your Medications 13 Coverage for Oral Drugs 16 Coverage for Intravenous (IV) Infusion Drugs 17 Coverage for Subcutaneous (SC) Injection Drugs 18 Coverage for Treatments Including Both IV and Oral Drugs 19 Assistance From BMS Access Support 20 Enrolling in BMS Access Support 21 Glossary 22 References What Is Health Insurance? Health insurance helps pay for medical services and medications. It is like other types of insurance, such as car or homeowners insurance. You pay a certain amount of money on a regular basis a premium and your health plan pays for a portion of your medical bills. You may also have other costs based on your medical needs. We will discuss these topics in this guide. In the United States, there are two types of health insurance: Public health insurance government-run programs, such as Medicare and Medicaid offered by Centers for Medicare & Medicaid Services (CMS), the Veterans Health Administration (VHA), TRICARE, and the Department of Defense (DoD) Private health insurance also called commercial insurance such as plans offered by employers 2

3 Common Types of Health Insurance Public (Federal or State) State Medicaid Provides health insurance coverage to low-income people Medicare Covers people Aged 65 and older Aged <65 years with certain disabilities With end-stage renal disease Veterans Health Administration/TRICARE/ Department of Defense Provide benefits to people, including Veterans Active-duty service members National Guard and Reserve members Retirees Families of retirees Medicare Part A Medicare Part B* Medicare Part C Medicare Part D Hospital insurance covers inpatient services Medical insurance covers medically necessary and preventive services, including doctor visits and drugs that must be given by a doctor Medicare Advantage Plans allow Medicare benefits through managed care plans Prescription drug coverage provides an outpatient prescription drug benefit Private (Commercial) Group Health Insurance Employer-sponsored health plans This chart includes the most common types of insurance; it does not include all types. * Medicare-eligible patients must enroll in Part B to receive Part B benefits. Eligibility requirements vary based on the type of coverage (public or private) and the plan you have purchased. Check with your plan to confirm your eligibility. Individually Purchased Insurance You buy health insurance directly from a health plan As a patient, you should know what is covered by your health insurance. 3

4 Understanding Insurance Coverage It is important to know which medical and pharmacy services are covered under your health insurance plan. Your coverage is usually explained in one of the following documents, though it could vary depending on your health plan: Evidence of Coverage (EOC), which may also be called a Certificate of Insurance This is a legal document that tells you which services and treatments are included or not included in your benefits Summary Plan Description If you have health insurance sponsored through an employer, you may only receive a summary of your benefits. This is not a legal document. You can request the EOC from your Human Resources department to find out more about your coverage Your health plan will provide you with a health insurance card as proof of insurance. Doctors offices use this information to process your healthcare claims. Some cards include the costs you may need to pay for different services or drugs. Sample Commercial Insurance Card Sample Medicare Universal Identification Card HEALTH INSURANCE NAME OF BENEFICIARY JOHN DOE CLAIM NUMBER A XXX-XXXX SEX MALE IS ENTITLED TO EFFECTIVE DATE HOSPITAL MEDICAL SIGN HERE 4

5 What Will You Be Asked to Pay? You may be asked to pay for some of the cost of your treatment. The amount you pay will depend on your insurance coverage. Your Evidence of Coverage or Summary Plan Description will tell you what your annual deductible is, if any, and about other possible costs. Your annual deductible is the amount you pay out-of-pocket each year before your health plan pays your claims. You may also pay a monthly premium fee for your insurance. The amount that you are required to pay for your treatment may vary based on: Office visit Cost of drug and administration (how the treatment is given; eg, whether it is a pill or an infusion into the bloodstream) Deductible (the cost of the office visit or infusion costs) Co-pay Coinsurance Other costs, depending on your insurance coverage Figuring out what you will be asked to pay can be complicated. Please work with your doctor s office to understand how much you may have to pay. Here is an example of how your costs may be figured: Office visit and/or infusion cost Deductible The amount you pay for treatment out-of-pocket each year before your health plan pays claims Once your deductible has been met Coinsurance A percentage of the costs you may pay for a drug or service OR Co-payment A set amount you pay for a drug or service 5

6 Treatment Approval Process Many health plans may require an approval for treatment before starting therapy. Your doctor s office can help you with the approval for treatment in two common ways: precertification or prior authorization. These steps may be needed throughout your treatment. In this process, your doctor s office or hospital may ask for the following basic information about you: Precertification If required, your doctor s office confirms your benefits and coverage before you start treatment. Prior authorization (PA) If required, your doctor s office provides the health plan with your medical history, diagnosis, and treatment plan to show that the treatment they chose for you is medically necessary and will be used correctly. First and last name Gender (male/female) Date of birth Daytime phone number Address US citizenship or legal residency (yes/no) Social Security Number 6

7 Insurance Checklist You can use the checklist below to ensure that you give your doctor all of the information he or she needs to have about your insurance coverage. INSURANCE CHECKLIST Primary/Secondary Insurance Information Primary insurance carrier Plan name Subscriber number Group number Secondary insurance carrier Plan name Subscriber number Group number If you have Medicare coverage: Check all that apply: Part A Part B Part D Medicare Part C (Medicare Advantage) Medicare policy number Effective date If you have Medicare Part D or Medicare Part C (Medicare Advantage), you may need to provide the following information: Insurance name Phone number ID/policy number Policyholder Primary/secondary insurance information State, veteran, or other plan 7

8 Understanding Your Explanation of Benefits (EOB) and Medicare Summary Notice (MSN) After you have received treatment, your health plan will send you an EOB or MSN. They are records of the services you received. They are not bills. The EOB or MSN tells you how much your plan covered for those services, the reason(s) services are not being covered, and how much you may need to pay. The EOB or MSN is an important document to use if you disagree with your plan s decision on your claim. Sample EOB and MSN forms are shown here: Sample EOB Notice Sample MSN Notice 8

9 Which Insurance Pays First? Coordination of Benefits is a way to figure out which health plan or insurance policy will pay first if two health plans cover the same benefits. If one of the plans is a Medicare health plan, federal law may decide which plan pays first. The amount that each plan pays is based on your insurance coverage. The Coordination of Benefits form you receive from your health plan will tell you which plan is your primary health plan the one that pays first. The other plan is your secondary health plan the one that pays second. Your doctor s office can work with your health plans to coordinate your benefits on your behalf. The table below explains how Medicare works with other health insurance plans. KNOW WHO PAYS FIRST If you have retiree insurance (insurance from former employment) Medicare pays first. If you re 65 or older, have group health plan coverage based on your or your spouse s current employment If you re under 65 and disabled, have group health plan coverage based on your or a family member s current employment The employer has 20 or more employees The employer has fewer than 20 employees The employer has 100 or more employees The employer has fewer than 100 employees Your group health plan pays first. Medicare pays first. Your group health plan pays first. Medicare pays first. If you have Medicare because of End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant) Your group health plan will pay first for the first 30 months after you become eligible to join Medicare. Medicare will pay first after this 30-month period. Important: In some cases, your employer may join with other employers or unions to form a multiple employer plan. If this happens, only one of the employers or unions in the multiple employer plan has to have the required number of employees for the group health plan to pay first. For more information, contact your employer or union benefits administrator. 9

10 Handling Disputes Related to Your Treatment There may be times when your health plan denies coverage (refuses to pay) or underpays (pays less than what is needed) for a certain treatment. Your health plan should let you and your doctor know in writing if this happens. The plan must also explain the reason for the denial and tell you how to file an appeal. Usually your doctor s office will file the appeal for you. But there may be times when you need to get involved or you may want to file the appeal yourself. You have a right to do this under the law. Bristol-Myers Squibb (BMS) offers a program called BMS Access Support that can help you and your doctor with the access and reimbursement process. You can find out more by visiting 10

11 Handling Disputes Related to Your Treatment (cont d) What if your Medicare Part D drug plan will not cover your medication? Medicare Part D is the federal government s voluntary prescription drug benefit program that helps pay the cost of prescription drugs and prescription drug insurance premiums (fees) Medicare Part D drug plans are run by private insurance companies. Each company has to follow Medicare s rules for drug coverage, but each has its own set of rules, restrictions, and co-payments However, you have certain rights, such as the right to file an appeal if your Medicare drug plan will not cover a drug, or covers the drug at a higher cost than you think you should pay You can ask for a coverage determination, which is a written explanation of your drug coverage benefits You or the doctor who prescribed the medication can ask for an exception if: You need a drug that is not on your plan s list of covered medications You believe that you should pay less for a more expensive drug because you can t take any of the less expensive drugs for the same condition Request for Medicare Prescription Drug Coverage Determination REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: [Insert plan address(es)] Fax Number: [Insert plan fax number(s)] You may also ask us for a coverage determination by phone at [insert plan telephone number] or through our website at [insert plan web address]. Who May Make a Request: Your prescriber may ask us for a coverage determination on your behalf. If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative. Contact us to learn how to name a representative. Enrollee s Information Enrollee s Name Date of Birth Enrollee s Address City State Zip Code Phone Enrollee s Member ID # Talk to your doctor if you have questions about drug coverage or filing an appeal. Medicare has information on how to file an appeal at Complete the following section ONLY if the person making this request is not the enrollee or prescriber: Requestor s Name Requestor s Relationship to Enrollee Address City State Zip Code Phone Representation documentation for requests made by someone other than enrollee or the enrollee s prescriber: Attach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent). For more information on appointing a representative, contact your plan or Medicare. Name of prescription drug you are requesting (if known, include strength and quantity requested per month): 11

12 How You Pay for Your Medications If your treatment consists of 2 or more drugs, you may have to make arrangements to receive and pay for each drug separately. Each drug in your treatment may: Be given differently for example, it may be a pill that is swallowed, a liquid that is infused into a vein, or a liquid injected under the skin Be taken on different days of the week or during different weeks in a treatment cycle Require special permission or approval from your insurance plan Require different amounts of cost-sharing (co-pays or coinsurance) Each drug you are prescribed has its own co-pay and coinsurance costs depending on which parts of your insurance plan are providing coverage, and on the benefits provided by the insurance plan. Different parts of your insurance plan may also have their own deductibles for the year. A deductible is the amount you pay out-of-pocket each year, before health insurance starts paying its share. In this section, we will discuss how each type of drug may be covered and what part of the cost you have to pay based on the type of healthcare coverage you have. How you may receive drugs for your treatment Following your diagnosis, your healthcare team will explain how each drug you are prescribed is given to you and how often it is taken during the treatment cycle. DRUGS COME IN 3 COMMON FORMS Pills (also known as oral drugs) are usually taken at home or sometimes at a doctor s office Intravenous infusions (into the veins, abbreviated IV) are usually given at a clinic or doctor s office Subcutaneous injections (under the skin) can be given either in a doctor s office or self-injected at home 12

13 Coverage for Oral Drugs If you are prescribed an oral drug, you will take this drug as prescribed. No doctor s appointment is necessary, but you may need to purchase the drug through a specialty pharmacy. Specialty pharmacies provide certain drugs and patient support services (for example, education and monitoring) that may not be available in your local drug store. Often, you don t need to pick up your medication in person. Instead, it can be mailed directly to your home, and a pharmacist can provide advice and support to you on the phone. How is your oral drug covered? Coverage for oral drugs is usually included in prescription drug benefits. For instance, people eligible for Medicare can sign up for prescription drug coverage through a Medicare Part D plan. There are many different Part D plans available. Some cover a greater portion of your drug costs than others, but may have higher monthly fees. What will you pay for each oral drug? Under Medicare Part D plans, you pay a separate co-pay and/or coinsurance for each drug you are taking, after the deductible* (if your plan has one) is paid for the year. If you have commercial prescription drug coverage (that is, none of your drug coverage is from Medicare, Medicaid, or other government-funded health plans), you may be eligible for co-pay assistance programs offered by drug manufacturers for some drugs. If you have Medicare, Medicaid, or another government-funded health plan, no direct co-pay assistance is available. However, if you are considered by Medicare as a low-income patient, you may receive low-income subsidies, which means lower out-of-pocket costs, or almost no out-of-pocket costs, depending on your income. *See glossary on page 21 for definition. 13

14 Coverage for Oral Drugs (cont d) Medicare Part D coverage and the donut hole If you are receiving oral drugs as part of your treatment and you have a Medicare Part D plan, you will pay part of the cost of oral drugs and Part D will pay part. These amounts will change as you go through the year, as shown in the diagram below. Starting with the first bite of the donut (your onetime deductible payment), you may pay different amounts each month, depending on how much has been paid for all of your oral drugs so far that year. The amount paid is the total of what you have paid and what Medicare Part D has paid. Each part of the donut shows the portion of the cost you will pay at different points in the year. Medicare changes these reimbursement rates every year. For calendar year 2017, the table on the next page shows an example of what your payments could look like as you pass from one part of the donut to the next. Note that as soon as a total of $8,071 has been spent (in 2017), you will be past the donut hole. Now you are covered by what Medicare calls catastrophic or very high levels of coverage for the rest of your treatment during the year. Under catastrophic coverage, you pay only 5% of the remaining cost of oral drugs, while the health plan pays the other 95%. WHAT YOU CAN EXPECT TO PAY 100% Deductible up to $400 25% Initial Coverage Period 40% Donut Hole 5% Catastrophic Coverage $401 to $3,700 $3,701 to $8,071 More than $8,071 Dollar amounts are total of ALL Part D covered charges paid by you AND Medicare in a calendar year. 14

15 Coverage for Oral Drugs (cont d) Under Part D coverage, what the patient pays and what Medicare covers In 2017, for example, if you receive an oral drug that costs $10,000 per month for 12 months, the table below shows how much you will pay and how much Part D will pay. Patient Deductible $0 to $400 Initial Coverage Period $401 to $3,700 Donut Hole $3,701 to $8,701 Catastrophic Coverage Over $8,701 Total Cost Month 1 Amount in Section $400 $3,300 $4,371 $1,929 $10,000/1 month Patient Pays $400 (100%) $825 (25%) $1,748 (40%) $96 (5%) $3,069/1 month Part D Pays $0 (0%) $2,475 (75%) $2,622 (60%) $1,832 (95%) $6,929/1 month Months 2-12 Amount in Section $10,000 $110,000/11 months Patient Pays $0 (already past in month 1) $500/month (5%) $5,500/11 months Part D Pays $9,500/month (95%) $104,500/11 months The total cost to you for this oral drug in month 1, calculated by adding all 4 sections of the donut, is $3,069. For the remaining 11 months of the year you will pay a total of $5,500. Therefore, your total cost for the whole year will be $8,569. More than one-third of your cost, however, falls in the first month of treatment as you pass through the deductible, initial coverage period, donut hole, and reach catastrophic coverage. You may find, as in this example, that after 1 month of treatment you have already reached the point where catastrophic coverage begins. After this point, your costs will go down for the rest of the year and Part D will pay almost all (95%) of the remaining cost. 15

16 Coverage for Intravenous (IV) Infusion Drugs If you are prescribed a drug given by intravenous (IV) infusion, it will most likely be given to you either in a hospital outpatient department or at your doctor s office. Many drugs are given by IV infusion because this is the most rapid way to get a drug into your bloodstream. Other drugs you are taking or even vitamins and herbal supplements may prevent the treatment from working effectively. Please make sure you ask your doctor what other drugs or supplements you may take during the treatment period. How is your IV infusion covered? Coverage for IV infusions is usually included in an insurance plan s medical benefits because these drugs are usually given at a doctor s office or clinic. For instance, if you have Medicare and you receive your IV infusions at a doctor s office or clinic, your infusions would be included in your Medicare Part B coverage. However, if you receive your IV infusions while you are admitted to a hospital, these infusions would be included in your Medicare Part A coverage. What will you pay for each IV drug? Each commercial insurance plan is different when it comes to your out-of-pocket costs for treatments and procedures. Typically, you will pay a co-pay or coinsurance for the visit when you receive your infusion. There may or may not be additional fees for the infusion itself. You may be eligible for co-pay assistance programs offered by drug manufacturers for some drugs. If you are enrolled in Medicare Part B with no extra insurance coverage, you will be responsible for 20% coinsurance for each drug and 20% for each infusion, after the annual deductible is paid. If you choose to sign up for Medigap-type coverage for additional benefits, however, you may pay $0 for the drug and $0 for the infusion, after the deductible is paid A large majority (almost 90%) of Medicare patients have some type of additional insurance such as Medigap (or a similar plan), which reduces the out-of-pocket costs for office-administered drugs such as infusions 16

17 Coverage for Subcutaneous (SC) Injection Drugs Some drugs can be given as subcutaneous (SC) injections, almost like a vaccination, either at home or in the doctor s office. Injections can be covered by either medical or prescription drug benefits (such as Medicare Part B and Part D), depending on whether they are given in your doctor s office or at your home. Some patients feel more comfortable receiving their injections from a healthcare professional at a doctor s office. Others prefer to give themselves SC injections at home. If you prefer this option, a nurse in your doctor s office will show you how to inject yourself correctly. When the nurse feels confident that you can give yourself an injection in a safe and effective way, you may be allowed to do it yourself at home. What will you pay for each SC injectable drug? If you get your SC injections at the office, you will have the same co-pays and coinsurance as for an intravenous (IV) infusion, described on page 16. If you give yourself the SC injection at home, then the coverage is the same as for an oral drug, described previously. 17

18 Coverage for Treatments Including Both IV and Oral Drugs A Medicare example: coverage of 2- or 3-drug treatments that include both IV and oral drugs Your doctor may prescribe a treatment consisting of 2 or more drugs, some of which may be intravenous (IV) infusions and some of which may be oral drugs. In such cases, the drugs given by IV infusion will fall under your medical benefits (such as Medicare Part B), and the oral drugs will fall under your prescription drug benefits (such as Medicare Part D). Each drug must be obtained separately and has different co-pay and coinsurance requirements, as shown in the table below. FACTS ABOUT IV AND ORAL DRUGS IN ONE REGIMEN How drugs are covered Where patient gets the drug Health plan management Cost to patient IV Medical Benefit or Medicare Part B Considered medically necessary by your doctor and approved by the Food and Drug Administration From the doctor s office or infusion clinic Permission from the health plan or use of drugs on a healthcare plan s formulary first is required For patients who have Medigap insurance, the cost may be $0. For patients with Part B alone, the cost is 20% coinsurance for drug and infusion, after deductible is paid for the year Oral Pharmacy Benefit or Medicare Part D Must be listed on the approved drug list of your Part D drug plan Usually from a specialty pharmacy. (Some oral drugs may be available at your local pharmacy) Permission from your health plan is needed, use of drugs on a healthcare plan s formulary first is required, and the number of pills you may receive at any one time is limited May be high depending on health plan requirement for co-pays, coinsurance, and deductible; see donut hole diagram on page 14 18

19 Assistance From BMS Access Support BMS Access Support from Bristol-Myers Squibb can help identify programs that may be able to help you manage the cost of your treatment. BMS Access Support provides these opportunities based on your insurance coverage. For patients with commercial (private) insurance BMS product co-pay programs may be available For patients with Federal Healthcare Programs They are not eligible for co-pay assistance programs sponsored by Bristol-Myers Squibb However, BMS Access Support can help refer patients to an independent foundation that offers support for their individual needs For patients without prescription drug coverage BMS Access Support can make a referral to independent charitable foundations that may be able to provide financial support, including the Bristol-Myers Squibb Patient Assistance Foundation (BMSPAF) BMSPAF is a charitable organization that provides free medicine to eligible uninsured patients who have an established financial hardship. To learn more about BMSPAF, please visit It is important to note that these charitable foundations are independent from Bristol-Myers Squibb Company. Each foundation, including BMSPAF, has its own eligibility criteria and evaluation process Bristol-Myers Squibb cannot guarantee that a patient will receive assistance 19

20 Enrolling in BMS Access Support 1 Your doctor s office will need your name, address, insurance carrier, and member identification number. 2 You and your doctor s office complete the BMS Access Support enrollment form. 3 BMS Access Support conducts a benefits review, which will typically determine what is covered by your insurance plan. For more information or to apply for assistance, call BMS Access Support at , 8 AM to 8 PM ET, Monday Friday, or visit 20

21 Glossary Access: Your ability to receive healthcare coverage for a particular drug or medical service Coinsurance: The percentage of a drug s cost (for example, 20%) you pay through coverage from certain health plans Co-pay: The dollar amount you pay for each drug or medical service included in your treatment. An appointment with a doctor or receiving an infusion is considered a medical service Deductible: The amount you pay for your healthcare each year, before the health plan starts to pay its share. Each health plan may have a different deductible amount Formulary: A list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits (also called a drug list) Intravenous (IV) infusion: Injection of drugs directly into your veins with a needle. Done by a healthcare professional in a hospital, clinic, or doctor s office Medicare Part B: The part of Medicare that covers medically necessary and preventive services. This includes doctor visits and drugs that are given by doctors at their office Medicare Part D: The part of Medicare that covers prescription drugs for outpatients (patients not admitted to a hospital) Medicare Part D donut hole: This is the point (in the year 2017) when $3,700 has been spent by you and Part D for all of your drug costs. You will now pay 40% of the cost of branded drugs until $8,071 in total costs is spent for the year. At that point, you will leave the donut hole and will pay only 5% of all remaining drug costs for the year Subcutaneous (SC) injection: Injection of a drug under your skin with a small needle. Can be done either by a healthcare professional in an office or by yourself at home, if you are taught how to do it by a healthcare professional 21

22 References Academy of Managed Care Pharmacy. Concepts: prior authorization. Cancer.Net. Working With a Specialty Pharmacy. CMS.gov. Coordination of Benefits brochure. CMS.gov. Guidance to States on the Low-Income Subsidy. LowIncSubMedicarePresCov/Downloads/StateLISGuidance pdf. CMS.gov. How Medicare prescription drug coverage works with a Medicare Advantage Plan or Medicare Cost Plan. CMS.gov. Medicare and You CMS.gov. Medicare Modernization Act Final Guidelines: Formularies. PrescriptionDrugCovContra/downloads/FormularyGuidance.pdf. CMS.gov. What s Medicare? What s Medicaid? Health Affairs. Market watch: how risky is individual health insurance? Healthcare.gov. Glossary: health insurance.. HHS.gov. Appealing health plan decisions. appealing-health-plan-decisions/index.html. Kaiser Family Foundation. Fact Sheet: The Medicare Part D Prescription Drug Benefit. The-Medicare-Part-D-Prescription-Drug-Benefit. Kaiser Family Foundation. Medicare Part D Prescription Drug Plans: The Marketplace in 2013 and Key Trends, Kaiser Family Foundation. Retiree Health Benefits at the Crossroads. Mayo Clinic. Glossary of Billing and Insurance Terms. Medicare.gov. Costs for Medicare Drug Coverage. Medicare.gov. Medicare prescription drug coverage appeals. Medicare.gov. Medicare Summary Notice. Medicare.gov. Medicare 2017 costs at a glance. Premera Blue Cross. Understanding your explanation of benefits. explanation-of-benefits. Roswell Park Cancer Institute. What to Expect at the Chemotherapy and Infusion Center. chemoinfusion/what-expect. Suchanek D. The Rise and Role of Specialty Pharmacy. Biotechnology Healthcare. October TRICARE Choices in the United States handbook. file:///c:/users/dordean/downloads/choices_hb%20(1).pdf. U.S. Department of Labor. Health Plans and Benefits. U.S. Department of Veterans Affairs. Health Benefits. Zane Benefits. Summary Plan Description What is It? 22

23 Do You Have Questions About Your Insurance or Coverage? If you have questions or are not sure what programs are available to you, please contact BMS Access Support for a person-to-person conversation about your insurance coverage and your options. Call , 8 AM to 8 PM ET, Monday Friday, and speak with a Care Coordinator Visit Access Support and Access Support logo are registered trademarks of Bristol-Myers Squibb Company Bristol-Myers Squibb Company. All rights reserved. MMUS /17