Oplinc

Patient Assistance Resources

On March 23, 2007, the U.S. Census Bureau issued health insurance coverage estimates showing that in 2005, 44.8 million people, or 15.3 percent of the population, were without health insurance. It is estimated that another 15 million people are “underinsured”.

The increasing numbers of uninsured and underinsured cancer patients is of great concern to the oncology community. This edition of the Best Practices Review newsletter focuses on patient assistance services and resources that may be available to your patients as well as practical information for your business department.

Setting Financial Guidelines for Patient Assistance in the Medical Office
Many practices offer discounts to patients who are uninsured or underinsured and who have limited financial resources. If your practice offers financial assistance to patients it is suggested that the discount of charges be based on written practice policy. While the criteria for determining the patient’s eligibility for a discount is left to the practice the Office of Inspector General (OIG) states that the criteria must be applied uniformly to both Medicare and non-Medicare patients.

The OIG clearly states that offering a discount to an uninsured patient will not implicate the federal anti-kickback statute, so long as the discount is not linked in any way to referrals of federal health care program business.

On the other hand, providers who routinely waive or discount copayments or deductibles for Medicare or other federal health program beneficiaries may run afoul of both the Federal False Claims Act and the Federal anti-kickback law.

The routine waiver of copayments or deductibles may provide a financial incentive for federal program patients to receive services at the waiving practice. Therefore, routine waivers can be an inducement. Inducements violate the anti-kickback law and subject the provider to civil and criminal fines and exclusion from the federal health care programs. Providers may however, discount or waive copayments or deductibles for these patients when financial hardship is demonstrated. 

Carefully review your private payer contracts prior to implementing any discount or patient assistance programs for patients covered under managed care contracts. These contracts may require certain financial hardship assessments be made prior to extending any discounts.

Most hospitals and physician practices use the federal poverty guidelines when structuring their discount determinations. See inset for more information on the federal poverty guidelines. 

Finally, have your healthcare attorney review your written Patient Assistance policy for adherence to all applicable federal and state laws and regulations.

Resources:
Hospital Discounts Offered to Patients Who Cannot Afford To Pay Their Hospital Bills

OIG Fraud Alert: Routine Waiver of Part B Copayments/Deductibles

OIG Q&A on Charges for the Uninsured

The Federal Poverty Guidelines

The poverty guidelines are issued each year in the Federal Register by the Department of Health and Human Services (HHS).  The guidelines are a simplification of the poverty thresholds for use for administrative purposes such as determining financial eligibility for certain federal programs. 

The HHS poverty guidelines or percentage multiples of them (such as 125 percent, 150 percent, or 185 percent), are used as an eligibility criterion by a number of federal programs including the following Department of Health and Human Services programs:

Low-Income Home Energy Assistance Program (LIHEAP)

Community Food and Nutrition Program

PARTS of Medicaid

Hill-Burton Uncompensated Services Program

AIDS Drug Assistance Program

State Children’s Health Insurance Program

Medicare – Prescription Drug Coverage
(subsidized portion only)

Community Health Centers

Migrant Health Centers

2007 Poverty Guidelines

Persons
in Family or Household

48 Contiguous
States and D.C.

Alaska

Hawaii

1

$10,210

$12,770

$11,750

2

13,690

17,120

15,750

3

17,170

21,470

19,750

4

20,650

25,820

23,750

5

24,130

30,170

27,750

6

27,610

34,520

31,750

7

31,090

38,870

35,750

8

34,570

43,220

39,750

For each additional
person, add

 3,480

 4,350

 4,000

SOURCE: 
Federal Register, Vol. 72, No. 15, January 24, 2007, pp. 3147–3148

Identifying Financially Vulnerable Patients

Identifying financially vulnerable patients prior to initiation of treatment benefits both the patient and the practice.

Through the initial intake process:

Identify patients with no insurance, poor insurance

  • High co-insurance
  • Reduced coverage benefits
  • Patient running out of lifetime maximum benefit

Identify patients with no 2nd insurance

  • And secondary policies that do not pick up all balances after primary

Identify patients with special coverage issues

  • Cobra
  • Health Savings Accounts
  • Medicaid

Prior to treatment verify:

  • Patient coverage benefits – specific to treatment plan
  • Deductible
  • Patient cost-sharing, co-pays/co-insurance, means for patient to pay
  • Benefit limits
  • Site of service restrictions
    • Hospitals
    • Labs
    • Drugs (Pharmacy Benefit Management programs)
  • Prior authorization requirements
  • Identify any coverage issues particular to the patient’s specific treatment plan
    • Medical necessity (diagnoses)
    • Pre-existing clauses etc.

Establish a practice policy for indigent care, if it includes discounting to financially qualified patients:

  • Apply it equally
  • Monitor it

Financial Counseling in Patient Assistance

Payers are beginning to incorporate the requirement for physicians to provide estimated financial liability information to patients prior to treatment in their provider manual and contracts. Equally important is the opportunity to identify those patients who will require financial assistance or special considerations before they incur the expenses.

Patients should be provided an estimate of the cost of treatment prior to receiving the first treatment. The estimate should include anticipated lab, drug, hospital and physician charges based on the patient’s treatment plan. An updated cost estimate should be provided if the treatment plan changes.

Financial Counselors should explain to the patient that the actual cost to the patient may vary as the estimate is based on expected services and expected insurance payments.

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Help for Uninsured Women with Breast or Cervical Cancer

Help for Uninsured Women with Breast or Cervical Cancer

On October 24, 2000, the Breast and Cervical Cancer Prevention and Treatment Act (BCCPT) of 2000 was signed into law. The Act, which became effective October 1, 2000, gives states the option to provide medical assistance through Medicaid to eligible women who were screened through the Centers for Disease Control and Prevention's (CDC) National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and found to have breast or cervical cancer, including pre-cancerous conditions.

In 2002 Congress passed a technical amendment to the BCCPT Act. The Native American Breast and Cervical Cancer Treatment Technical Amendment Act of 2001, extends benefits of the BCCPT Act to American Indian and Alaska Native women.

To be eligible for Medicaid under this option, the woman must:

  • Have been screened for and found to have breast or cervical cancer, including precancerous conditions, through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP)
  • Be under age 65; and
  • Be uninsured and otherwise not eligible for Medicaid

Participation in the BCCPT is optional for states. States that do participate receive an enhanced matching rate for women who enroll. Under the BCCPT law, women whose cancers were found through the CDC’s NBCCEDP may be eligible for Medicaid benefits for the duration of their cancer treatment.

The National Breast Cancer Coalition (NBCC) reports that as of May 2004, all 50 states and the District of Columbia have passed legislation to opt in to the CDC’s Treatment Program.

Resources:

National Breast and Cervical Cancer Early Detection Program

Medicaid Special Coverage Conditions – BCCPT

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Helpful Resources
National Patient Advocate Foundation
Web site www.patientadvocate.org
Phone (800) 532-5274
Fax (757) 873-8999
Email help@patientadvocate.org
Patient Advocate Foundation (PAF) is a national non-profit organization that provides case managment assistance to patients diagnosed with chronic, life-threatening/debilitating conditions assuring access to care, maintenance of employment and preservation of financial stability. Their website contains links to many helpful resources for patients and caregivers.
Co-Pay Relief 
Web site www.copays.org
Phone 866-512-3861
Fax (757) 952-0119
Email pap@patientadvocate.org
Part of PAF, The Co-Pay Relief (CPR)program provides co-pay assistance to insured Americans who qualify financially & medically. CPR can provide premium & co-pay assistance for patients with certain diagnoses.  Physicians and patients can initate a request for assistance.
CancerCare
Web site www.cancercare.org   
Phone 800-813-4673
Fax 212-712-8495
Email info@cancercare.org
CancerCare is a national non-profit organization. They provide limited grants for certain expenses related to cancer treatment.  
NeedyMeds.Com
Web site www.needymeds.com
Phone No phone help-line
Fax 419-858-7221
Email info@needymeds.com
NeedyMeds.Com does not supply medications or financial assistance. They provide a comprehensive listing of drugs and dosages that are available through patient assistance programs. They provide detailed information about the patient assistance program including, the program name, contact information, application forms, eligibility guidelines and the application process and requirements.
Partnership for Prescription Assistance
Web site www.pparx.org
Phone 888-477-2669
Fax 419-858-7221
Email info@needymeds.com
The Partnership for Prescription Assistance offers a single point of access to more than 475 public and private patient assistance programs, including more than 180 programs offered by pharmaceutical companies.
Angel Flight American
Web site www.angelflightamerica.org
Phone 877-8587788
Fax 214-234-8459
Email execdir@angelflightamerica.org 
Angel Flight America arranges free flights transporting qualified patients and their families to specialized medical treatment facilities. 
Corporate Angel Network
Web site www.corpangelnetwork.org
Phone 914-328-1313
Fax 914-328-3938
Email info@corpangelnetwork.org
Corporate Angel Network provides free flights transporting qualified cancer patients and their families to treatment facilities. 
U.S.  Social Security Administration
Web site www.ssa.gov
Phone 800-772-1213
Fax  
Email
Individuals who are disabled for 6 months or longer may qualify for benefits. Certain cancer diagnoses qualify. 
Patient Services Incorporated
Web site www.uneedpsi.org
Phone 800-366-7741
Fax 800-744-5407
Email uneedpsi@uneedpsi.org
Patient Services Inc., provides the following programs which will complement any established and existing "patient assistance program": Premium Assistance Program, Copayment Assistance Program.
RxAssist
Web site www.rxassist.org
Phone 401-729-3284
Fax 401-729-2955
Email info@rxassist.org
RxAssist is a national nonprofit resource center containing a comprehensive database of patient assistance programs.
The Leukemia & Lymphoma Society
Web site www.leukemia-lymphoma.org
Phone 800-955-4572
Fax  
Email
The Leukemia & Lymphoma Society provides supplementary financial assistance to patients in significant financial need. The Patient Financial Aid program covers specific drugs related to the treatment/control of leukemia, Hodgkin and non-Hodgkin lymphoma and myeloma.
American Cancer Society
Web site www.cancer.org
Phone 866-228-4327
Fax  
Email
The American Cancer Society operates offices throughout the nation. The ACS can help patients locate various types of assistance.
The United Way
Web site www.uwint.org
Phone 703-519-0092
Fax 703-519-0097
Email uwi@unitedway.org
The United Way is an international organization that can help patients locate various types of assistance.
Healthwell Foundation
Web site www.healthwellfoundation.org
Phone 800-675-8416
Fax 800-282-7692
Email info@healthwellfoundation.org
Healthwell Foundation is a non-profit, charitable organization that helps individuals afford prescription medications they are taking for specific illnesses. The Foundation provides financial assistance to eligible patients to cover certain out-of-pocket health care costs, including prescription drug co-insurance, co-payments & deductibles, and health insurance premiums. Lists of disease states & medications covered are available on their website. An on-line application is also available.
Association of Community Cancer Centers
Web site www.accc-cancer.org
Phone  
Fax  
Email
ACCC maintains a detailed list of reimbursement assistance programs for oncology-related services. The companies listed have programs for physicians and in some cases patients
Chronic Disease Fund
Web site www.cdfund.org
Phone 877-968-7233
Fax  
Email info@cdfund.org
The Chronic Disease Fund provides assistance to under-insured patients with chronic or life altering diseases that require the use of expensive, specialty therapeutics. Covered diagnoses include MDS. Provides co-pay assistance, free drugs to financially qualified patients. Limited diagnoses covered.
Patient Access Network Foundation
Web site www.patientaccessnetwork.org
Phone 866-316-7263
Fax 866-316-7261
Email contact@patientaccessnetwork.org
The Patient Access Network Foundation is a non-profit organization dedicated to assisting insured patients who are unable to afford their out-of-pocket costs associated with their treatment needs. Applicants must meet certain financial, medical and insurance criteria. A list of covered drugs and diagnoses is available on their website.
Access To Benefits Coalition
Web site www.accesstobenefits.org
Phone 202-479-6670
Fax 202-479-0735 
Email info@accesstobenefits.org
The Access to Benefits Coalition is a national program (available in 37 states) dedicated to helping Medicare beneficiaries with limited means identify and apply for all available resources for accessing prescription drugs and reducing their costs.
State Health Insurance Assistance Programs
Web site www.shiptalk.org
Phone  
Fax  
Email
The State Health Insurance Assistance Program (SHIP) is a national program that offers one-on-one counseling and assistance to people with Medicare and their families. Patients can be referred to their state’s SHIP by contacting 1-800-Medicare and asking for health insurance counseling. Patients & others can get state specific information through the SHIP website.
Joe's House
Web site www.joeshouse.org
Phone 877-563-7468
Fax  
Email info@joeshouse.org
Joe's House website lists accommodations that cater to cancer patients, their families, and caregivers and provides a centralized list of appropriate housing.
Cancer Legal Resources Center
Web site www.lls.edu/academics/candp/clrc.html
Phone 866-843-2572
Fax  
Email clrc@lls.edu
The Cancer Legal Resource Center provides free and confidential information and resources on cancer-related legal issues to people with cancer, their families, friends, employers, health care professionals, and others coping with cancer. Callers can receive information about relevant laws and resources for their particular situation.
Centers for Disease Control & Prevention
Web site www.cdc.gov/cancer/nbccedp/guidance.htm
Phone 800-232-4636
Fax 770-488-4760
Email cdcinfo@cdc.gov

The CDC provides low-income, uninsured, and underserved women access to screening and diagnostic services, to detect breast and cervical cancer, through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). The Breast and Cervical Cancer Prevention and Treatment Act of 2000 gives states the option to provide medical assistance through Medicaid to eligible women who were screened through the CDCs National Breast and Cervical Cancer Early Detection Program (NBCCEDP). See article on this program in this issue.

Federal Laws Protecting Medical Insurance Coverage

The American Cancer Society has provided the following information on federal laws that may protect medical insurance coverage when a person changes or loses a job, or loses benefits as a result of a reduction in the hours worked.

Consolidated Omnibus Budget and Reconciliation Act of 1986 (COBRA)

COBRA gives qualified employees and their families the right to temporarily continue health insurance coverage at group rates when coverage is lost due to certain specific events or qualifying events, such as voluntary or involuntary job loss, reducing work hours, divorce or legal separation, the covered person becoming entitled to Medicare or the death of the employee. COBRA allows people to continue coverage of their group medical insurance for a period of up to 18 months or 29 months if a beneficiary is considered disabled.

The law generally covers health plans maintained by private-sector employers with 20 or more employees, employee organizations, or state or local governments. The employer must notify an employee of its availability, within 30 days after the qualifying event.

COBRA must be elected by the former employee within 60 days of stopping employment. Continuing insurance coverage is available if the premium is paid and until the individual becomes covered under another group policy.

Patients should be advised that the cost of the COBRA premium is usually far less than the cost of treatment should they let their health policy lapse.

COBRA is administered by the U.S. Department of Labor, COBRA information & FAQs are available on their Web site.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA)

This bill has several clauses that can possibly benefit cancer patients:

  • Individuals who have had group medical insurance for at least 12 months prior to changing jobs are guaranteed coverage with a new employer who also offers group insurance. There is no waiting period and a dependent cannot be denied coverage because of a preexisting health problem.
  • If a cancer patient was previously uninsured and takes a job with an employer offering group insurance, the waiting period for preexisting conditions cannot be longer than 12 months.
  • Insurers are required to renew coverage for all employers and individuals when premiums are paid.
  • The act also guarantees the availability of group insurance coverage for employers of small businesses of 2 to 50 people.

For more information about HIPAA contact your state department or commission of insurance.

The Family and Medical Leave Act of 1993 (FMLA)

FMLA requires employers (with at least 50 employees) to provide up to 12 weeks of unpaid, job-protected leave to eligible employees for certain family and medical reasons. Employees are eligible if they have worked for a covered employer for at least 1250 hours in the previous 12 months.

For the time period of the FMLA leave, the employer must maintain the employee's medical insurance coverage under any company group health plan. This act is regulated by the U.S. Department of Labor's Wage and Hour Division. They can provide additional information. Check the telephone directory in your area under U.S. Government, Department of Labor.

The Americans with Disabilities Act of 1990 (ADA)

The ADA act offers protection against discrimination in the workplace to anyone who has, or has had, certain disabilities, including any diagnosis of cancer. Parents of dependent children with cancer are also protected under this law. It requires private employers who employ 15 or more people, labor unions, employment agencies, and government agencies to treat employees equally, including the benefits offered them, without regard to their disabling condition or medical history.

It also does not allow employers to screen out potential employees who have children with disabilities. This act, along with the Family and Medical Leave Act, makes it easier to change jobs and move from one group insurance arrangement to another. This law is administered by the U.S. Equal Employment Opportunity Commission (EEOC). The American Cancer Society also publishes information for cancer patients on the Americans with Disabilities Act.

Source:
The American Cancer Society

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Prescription Drug Plan - Part D Assistance

Certain Medicare beneficiaries may qualify for Medicare’s Low-Income Subsidy (LIS), or “extra help”. Through the LIS program Medicare helps pay for the Medicare drug plan’s monthly premium, deductible and copayments.

Medicare patients automatically qualify if they:

  • Have both Medicare & Medicaid, or
  • Get help from Medicaid paying their Medicare premiums through a Medicare savings program, or
  • Get Supplemental Security Income (SSI) benefits & have Medicare

Medicare beneficiaries who do not automatically qualify for the LIS may still qualify for extra help based on their income and resources. However, these individuals must apply to the Social Security Administration (SSA) or their State Medical Assistance (Medicaid) office to find out if they are eligible for extra help.

SSA says that individuals should apply for extra help if:

  • They have Medicare Part A and/or Medicare Part B, and
  • They live in one of the 50 states or the District of Columbia, and
  • Combined savings, investments, and real estate (other than the home) are not worth more than $11,710, if you are single, or $23,410 if you are married and living with your spouse.  

The National Council on Aging (NCOA) reports that as of January 31, 2007 between 3.4 and 4.4 million Medicare beneficiaries who qualify for the LIS have not applied for the subsidy.

Medicare beneficiaries can apply on-line at www.ssa.gov. Anyone who has the beneficiary’s information can complete the on-line application and there is no deadline to apply for the LIS.

Resources:

CMS Low Income Subsidy

The National Senior Citizens Law Center

The National Council on Aging

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Billing Medicare for Administration of Free Drug

Billing Medicare for Administration of “Free” Drug

Medicare patients that lack secondary coverage may qualify for drug manufacturers patient assistance programs. These programs will often supply the qualified patient’s drugs at no cost. The drugs are sent to the physician clinic to be administered to the patient.

Drugs obtained free through these programs cannot be billed to Medicare, however the administration of the drug is payable by Medicare if the drug would have been covered.  As stated in Chapter 15, Section 60.1 of the Medicare Benefit Policy Manual (Publication 100-02), “…the administration of a drug, regardless of the source, is a service that represents an expense to the physician. Therefore, the administration of a drug is payable if the drug would have been covered if the physician purchased it.”

Medicare carriers differ on how they want these services reported. Check with your carrier to determine what information should be included on the claim when you are billing only for the administration of the drug.

 

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CONTACT US
Risë Marie Cleland
Rise@Oplinc.com

Oplinc
300 West 8th Street, Unit 419
Vancouver, WA 98660-3440
580.695.0632 phone
360-993-5065 fax
www.Oplinc.com

 

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UPCOMING ISSUE
Comments and suggestions for future issues are welcome, please forward correspondence to Risë Marie Cleland by email at: Rise@Oplinc.com

 

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NEWSLETTER ARCHIVES
Volume 3 Issue 1
Volume 2 Issue 7
Volume 2 Issue 6
Resource Guide Issue 5
Volume 2 Issue 4
Volume 2 Issue 3
Volume 2 Issue 2
Volume 2 Issue 1

 

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ABOUT THE EDITOR
Risë Marie Cleland is the founder and President of Oplinc, a national organization of oncology professionals. Through Oplinc Ms. Cleland publishes the weekly Oplinc Fax Tracts focusing on the timely dissemination of information pertaining to billing, reimbursement and practice management in the oncology office and Oplinc’s Best Practices Review, which provides a more in-depth look at the issues and challenges facing oncology practices. Ms. Cleland also works as a consultant and advisor for physician practices, pharmaceutical companies and distributors.

 

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IMPORTANT NOTICE
Please note that this newsletter is presented for informational purposes only. It is not intended to provide coding, billing or legal advice. Regulations and policies concerning Medicare reimbursement are a rapidly changing area of the law. While we have made every effort to be current as of the issue date, the information may not be as current or comprehensive when you review it. Please consult with your legal counsel for any specific reimbursement information. For Medicare regulations visit: www.cms.hhs.gov.

 

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Volume 3, Issue 2
Patient Assistance
Resource Guide

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