Here - National PKU Alliance

Report
Insurance Challenges
and
Ways to Succeed
Beth Rader
Sean Corry
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Introductions
• Raenette Franco, CBCS Certified Biller
Coder Specialist/Reimbursement Consultant
o New Jersey
• Beth Rader, Independent Consultant
o San Francisco
• Sean Corry, Insurance Broker, PKU Dad
o Seattle
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Here’s What We’ll Talk About
• Today we’ll talk about insurance coverage:
o Different types of coverage
o Tips, skills, and strategies to address challenges
o Where you might find some help
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
When Coverage Works…
1. Covered
Benefit?
2. Medically
Necessary?
3. Processed
Correctly?
Paid!
But when coverage doesn’t work,
the answer lies in one of these areas
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure

Do You Have Coverage For
Medical Foods?
1. Covered
Benefit?
2. Medically
Necessary?
3. Processed
Correctly?
Paid!
Key Questions:
• What kind of insurance do you have?
• Does your insurance policy cover Enteral Formula/Medical
foods? Or provide HCPCS Codes to identify the service
such as B4155, B4157, B4162, S9435.
• Are there any exclusions for Enteral Formula/Medical Foods?
• How does the insurance policy cover medical foods?
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Improving the lives of individuals with PKU and pursuing a cure
Obtaining the Proper Coverage
Information
• Most insurance companies require a prior
authorization before coverage benefits.
• Even if your insurance company does not
require a prior authorization ask for a predetermination to ensure your Enteral
Formula/Medical food is covered in writing.
• Ask if you have Pharmacy Benefits just in
case you may have both benefits. If you have
both, go for the most affordable route.
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Improving the lives of individuals with PKU and pursuing a cure
Not Covered? Ask for exception
• If you are not covered due to exclusions, ask
your employer for a medical exception removal
for Enteral Formula/Medical Foods due to your
disorder.
• Provide your employer a Letter of Medical
Necessity from your Physician that describes
the importance for your Enteral
Formula/Medical Foods.
• Some ERISA Plans may make an exception.
• Ask to speak to the Medical Review
Department.
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Covered Benefit
Just Like a Snowflake…
No Two Issues are the Same
• Laws differ from state to state
• Coverage differs from state to state
• Sometimes only Federal laws applies
• The insurance companies handle PKU coverage in
different ways
• Insurance coverage can be complicated!
• NPKUA provides Reimbursement assistance. Please
contact our Reimbursement Coaches Team.
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Covered Benefit
Types of Coverage
• Government (i.e. Medicaid, Medicare, Etc.)
• Private Insurance
o Individual or family plans
• Includes “High Risk Pools”
o Group Coverage (Employer-based)
• Insured Plans, regulated by the states
• Self-Insured Employers - Also called “self-funded” or
“ERISA plans”
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Improving the lives of individuals with PKU and pursuing a cure
Covered Benefit
Does Your Insurance Plan Include
Medical Food as a Covered Benefit?
It depends on your plan, but rule of thumb:
• Government
•
- except for Medicare, chances are
good that medical food is covered
Private insurance
o Varies widely
o Depends on state and the specific insurance
• We’ll explain how to find whether your
plan must cover medical foods
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Improving the lives of individuals with PKU and pursuing a cure
Covered Benefit
Deciding About Coverage:
Sometimes You Have Choices
• When can you evaluate your options?
o When individual coverage is available to you
o When you get a new job with benefits
o During “Open Enrollment” at work
More options should be available in 2014
when federal
Health Reform really kicks in!
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Improving the lives of individuals with PKU and pursuing a cure
Covered Benefit
Evaluating Insurance Options
• Does the plan have the coverage you need?
o Medical services, like clinic visits and blood draws
o Formula only?
o Low-protein foods?
• Ask about PKU coverage before you take a job
• Find out how medical foods covered
o As a medical service?
o As a pharmacy benefit?
o Are only specific brands covered?
o Any exclusions?
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Covered Benefit
Evaluating Potential Coverage
• Find out what your cost-sharing will be
o Deductibles – must pay out-of-pocket before
coverage.
o Benefit maximum Caps or Limits (you pay out-ofpocket after cap/limit is reached).
o $ Copayments or % Coinsurance
• Caution with individual health plans
o Rx may be an optional benefit
o Rx may have coverage limitations
• (Remember, Kuvan is a prescription drug)
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Where Can We Read
About PKU Coverage?
Covered Benefit
• The “Summary of Benefits”
o Only a few pages long
o Offers only the plan highlights
o Will probably NOT tell you what you need to know
“This is only a brief summary of the major
benefits provided by our plans. For information
and details, please refer to the Benefit Booklet
or the Insurance Contract.”
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Improving the lives of individuals with PKU and pursuing a cure
Digging Deeper
for Coverage Information
Covered Benefit
• The Benefits Booklet
o Sometimes called an “Insurance Certificate” or
“Evidence of Coverage”
o ALWAYS keep the benefits booklet for coverage
details in writing.
o Usually not given to you for many weeks AFTER
coverage begins
o Many pages long
o Should give at least a brief description of coverage
for PKU formula and/or medical foods
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Improving the lives of individuals with PKU and pursuing a cure
Covered Benefit
Benefit Booklet Example
Page 21 of a “Benefits Booklet”
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Improving the lives of individuals with PKU and pursuing a cure
Covered Benefit
Might There Be Even MORE Detail?
• The Insurance Contract
o This is for insured plans, either individual or
group
• The “Plan Document”
o This is for self-insured (ERISA) plans
• These are usually big documents, and spell
out almost all the details of coverage.
• Sign-up/Enroll on your insured plan online.
• Can you get a copy? From where?
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Improving the lives of individuals with PKU and pursuing a cure
Covered Benefit
Claims With Employers That
Manage Their Own Medical Plan*
• The “Plan Document” determines coverage
• Many plan trustees have never heard of PKU
or dealt with a claim for medical foods
o “Trustees” are the ones running the plan
• If they do not cover PKU medical foods, you
might be able to change their minds!
* Self-Insured Employers? See appendix slides for more details
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Covered Benefit
Convincing Employers*
•
•
Ask them to reconsider:
Ask your employer for a medical exception removal for
Enteral Formula/Medical Foods due to your disorder.
o Tell them PKU is very rare.
• If they provide coverage, their costs will be limited
because they probably don’t have other PKUers
o Being off diet leads to severe, progressive mental
retardation, depression, impulse control disorder, phobias,
epilepsy, tremors, and other disorders
o Diet is the only sure treatment!
* Self-Insured Employers? See appendix slides for more details
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Covered Benefit
More Reasons for Employers*
• Also tell them:
o A treated person with PKU lives a normal,
productive life
o It is less costly to cover medical foods than to
cover the illnesses that come from being off diet
o It is the right thing to do!
* Self-Insured Employers? See appendix slides for more details
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Covered Benefit
Could We Get National Coverage?
• NPKUA is working on this!
• Some of you may have participated in the
Regional HHS meetings last summer
• Your support and effort may play a key role
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Covered Benefit
NPKUA Efforts For National Coverage
• Legislation: Medical Foods Equity Act
• Conversations at Regional HHS meetings
o Washington, Atlanta, Chicago, Denver
• Working with lobbying firm to meet with
National HHS
• Advocacy table at NPKUA Conference
o What does access to medical food mean to you?
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Medical Necessity
Is Your Prescription Medically Necessary?
1. Covered
Benefit? 
2. Medically
Necessary?
3. Processed
Correctly?
Key Questions:
• Do you have a Letter of Medical Necessity (LOMN)?
• Do you have a Prescription?
• Do you have clinical notes?
• What are your plan’s rules for assuring coverage?
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Paid!
What documents are needed for Medical
Necessity? And Why?
• Letter of Medical Necessity (LOMN) is the
most important piece of document needed
to determine medical necessity. It is provided
from your physician.
• Prescription is the basis for the service and
coverage.
• Clinical notes show that you are following
through with your dietary management and
nutritional therapy.
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Medical Necessity
Why Wouldn’t Medical
Food Be “Medically Necessary?”
• The plan may have specific criteria that
hasn’t been met
• Diagnosis issues
• Age and gender restrictions
• Particular items not on the plan’s formulary
• We will discuss how to appeal
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Process Issues
Coverage Process
1. Covered
Benefit?

www.npkua.org
2. Medically
Necessary?

3. Processed
Correctly?
Improving the lives of individuals with PKU and pursuing a cure
Paid!
Process Issues
Claims Processing Issues
Issues with claims processing could include:
• Incomplete claim form
• Coding error
• Missing documentation attached to claim
• Medical food is mis-categorized (food
supplement, diet aid)
• Other misunderstandings
What can you do?
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Tools to Use
Be Prepared
• It is common for a claim to go wrong
• Know your coverage, and get everyone on
board – Talk with:
o The insurance company
o Your clinic professionals
o Your pharmacist, etc.
o The company (or companies) providing the
medical foods
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Improving the lives of individuals with PKU and pursuing a cure
Tools to Use
Keep Copies of Everything
• Get a written prescription for formula/food
o Keep a copy for yourself, in case the original gets
lost
o May need to get your Rx “renewed” occasionally
• Copy the label of your medical food
product
• Copy your invoice
o This can help solve billing and coding issues
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Claims Denials
Claims Denials
• Even if you have coverage, a claim may be
denied due to medical necessity or
processing issues!
• Remember, PKU claims are not common
• May be an annoying administrative error
• Carefully read your Explanation of Benefits
(EOB) for any descriptive errors.
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Claims Denials
Claims Denials
• Claims mistakes can be corrected!
o Simply denied in error
o Coding problems
o Mistaken for “Food Supplement”
o Missing authorization numbers or provider
National provider numbers (NPI).
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
How to Interact With
Your Insurance Company
Claims Denials
• Be able to explain PKU & dietary treatment
• Be able to explain what “medical food” is
o Not a “food supplement!”
o It is “prescribed” by your doctor or clinic
o Provide a Letter of Medical Necessity that explains medical
foods and the importance (provided by your physician).
o It’s covered by the plan! (Show them where)
o Provide your “Evidence of Coverage” from your insurance
summary booklet.
• If transferred to another person, be prepared to start
•
again start at the beginning.
ALWAYS obtain a name & reference number.
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Claims Denials
Claims Denials: First Steps
• Read your policy (again)
o What’s covered, what’s not
o How to file an appeal
• Call “member services”
o Ask them to walk you through your coverage
o Ask for an explanation of the denial
o Determine if a “phone appeal” can be started
o Ask if your physician can contact the medical
review director.
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Claims Denials
Claims Denials: First Steps
• Does your insurer need more information?
o Ask what information you should collect
o Ask what information your providers should
submit:
• Health history?
• Letter of Medical Necessity
• A treatment plan?
• Other details?
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Claims Denials
Put It In Writing
• A clear statement why the denial should be
reversed
• Be thorough - cover all the bases
• Make it factual, not emotional
o State law apply?
o Error regarding medical necessity?
o Cannot tolerate “that” formula; need to switch
to another
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Improving the lives of individuals with PKU and pursuing a cure
Claims Denials
Organization and Details Count
• Make copies
• Ask for written confirmation of phone calls
• Keep a notebook names, dates of calls, etc.
• Keep a Letter of Medical Necessity (golden
key to coverage)
• Verify their promises to follow-up
o If they don’t call you when promised, call them!
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Claims Denials
Possible Second Appeals
• 41states plus the District of Columbia have
set up independent review boards to handle
appeals
• It is not uncommon for state appeals to
overturn insurance company denials
• Same rules for you – keep good records, be
persistent
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Claims Denials
You Are Not Alone
• Your clinic
• The human resources department
• Your health insurance broker
• State Insurance Commissioner
• The medical food or pharmaceutical company
• NPKUA
o Tools on the website
o New Insurance Coach
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Resources
The New NPKUA Insurance Coaches
• Goal: Insurance Coaches in Every State or Region
• Timing: Starting Fall 2013, as Coaches are on board and
go through orientation
• What you can expect if you sign up:
o Orientation and training
o Resources to help (sample letters, information about the law)
• Call NPKUA to see if there is a Coach in your state
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Resources
Resources For Patients
Organization
Category
Reimbursement Contact
NPKUA
Patient Advocacy for PKU
www.npkua.org
Call: 1-715-437-0477
Patient Advocacy Foundation
Patient Advocacy General
www.patientadvocate.org
Call:1-800-532-5274
Compassion*Works – MFRS
Patient Advocacy – Medical Food
Reimbursement Specialists &
Consultant
Call: 973.402.3984
Email: [email protected]
Abbott
Medical Food Products
http://www.abbottpatientassistancefoundation.org/medical_n
utritionals.asp
Applied Nutrition
Medical Food Products
Call: 1-800-605-0410
Email: [email protected]
Website: www.medicalfood.com/coverage.php
Cambrooke Foods
Medical Food Products
Call 1-866-4-LOW-PRO
Mead Johnson Nutrition
Medical Food Products
Nutricia now partners with
Applied Nutrition
Medical Food Products
Call: 1-800-356-7354, ext. 1200
Vitaflo
Medical Food Products
Call: 1-888-VITAFLO
BioMarin
Pharmaceutical
http://www.kuvan.com/patients/parent-caregivers-patientsupport-a-assistance-programs.html
Call: 1-877-MY-KUVAN
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Financial Assistance Programs
Organization
Category
Contact
Mead Johnson
Helping Hands Program for Special Kids (Mead
Johnson provides infant nutrition to babies
with special needs.
•
•
[email protected]
(812) 429-6399, Monday through Friday,
7:30 AM to 4:00 PM, CST/CDT.
Newborn Screening Programs in the U.S.
U.S. wide programs that will provide or assist
with metabolic foods/formula (per state). Call
and ask for metabolic formula/foods assistance
in your state. Or click on the hyperlink to your
right.
•
http://genes-r-us.uthscsa.edu/sites/genes-rus/files/state_contacts.pdf.
National Newborn Screening and Global
Resource Center. 3907 Galacia Drive,
Austin, TX 78759 ( 512) 345-5685..
Medicaid – Medical Needy Programs
For people who are not eligible for Medicaid.
Contact your local department of Human
Services, for assistance with Medically Needy
programs (spend-down).
• http://www.medicaid.gov/.
( Click on State Profiles, then the website
above)
Apria/Coram Healthcare – Self-Pay Pricing .
Financial Hardship Program have but can’t
afford co-insurance.
Self-Pay Pricing for uninsured & Financial
Hardship Program for insured people that can’t
afford their co-pay/co-ins.
East Coast 888 334-7978 (option #1 New
Referral)
West Coast 888-942-7742 (option #1 New
Referral)
•
FOR ANY QUESTIONS, PLEASE CONTACT OUR NPKUA, INSURANCE ADVOCATES/COACHES.
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Coverage Process Roadmap
Yes
Covered
Benefit?
Yes
Medically
Necessary?
Processed
Correctly?
Yes

No - Deny
No - Deny
No - Deny
We want to help you get there!
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
We’ll Stop Here,
But More in the Appendix
• The slides in the appendix provide a high
level look at:
o Types of coverage
• Government, Group, Individual
• Insured and Self-funded
o State Mandated Benefits
o Self-Insured Employers
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Questions?
Time For More Discussion
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Appendix
Why is insurance coverage
so complicated?
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Types of Coverage
• Government
o Medicaid and Medicare
o Title V: Children with Special
• Individual or family plans
o Includes “High Risk Pools”
• Group Coverage (Employer-based)
o Insured Plans, regulated by the states
o Self-Insured Employers
• Also called “self-funded” or “ERISA plans”
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Government Insurance - Types
• Low Income Help: Medicaid, WIC, Title 5
o Health coverage for lower-income individuals and
families
o Coverage varies by state, can be very complicated
o Medical Needy Programs through Medicaid
• Medicare
o Health coverage for people 65 or older, people
under 65 with certain conditions or disabilities
• Federal/Military employees and retirees
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Improving the lives of individuals with PKU and pursuing a cure
Government PKU Coverage
• Medicare
o Medical Food generally not covered except in
rare circumstances
• Medicaid – rules vary state by state
• Plans for federal employees
o Regulated by Congressional law or administrative
policies
• It is very complicated and mysterious!
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Private Insurance:
Individual (or Family) Coverage
• Buy directly from an insurance company
o Coverage for PKU may be required
• More limited benefits
o Compared to group coverage
• Currently, most people have to pass a health
screen to get individual coverage
• An alternative: A state “high risk pool”
o Guaranteed coverage but may be expensive!
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Employer-Based or Group Coverage
• Many people have health insurance coverage
through their employer’s plan
• Health Savings Account plan (HSA) High deductible
plan.
• Generally, two types of employer plans:
o An INSURED plan, subject to state “insurance
mandates”
o A SELF-FUNDED plan, not subject to state
“insurance mandates”
• Also called “Self-insured” or “ERISA plans”
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
What’s an Insurance Mandate?
• It is a law that requires insurance coverage for
treatment of a specific health condition
• Most benefit mandates come from state law
o PKU medical food is an example in many states
• Some mandates come from federal law
o E.g., equal coverage for mental health
o There is no federal mandate for PKU coverage
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Improving the lives of individuals with PKU and pursuing a cure
State Insurance Mandates
• The apply only to “insured plans,” when an employer
buys coverage from an insurance company
• To be insured plan:
o For a specific monthly premium,
o The insurance company promises to cover all the medical
claims, whatever they may be.
o This means that the insurance company is assuming this
claims risk. This is regulated by state laws
• Sometimes mandates apply to individual coverage,
group coverage, or both
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Improving the lives of individuals with PKU and pursuing a cure
Why Were PKU Mandates Needed?
• PKU is rare and not well understood
• Formula (and now medical foods) are the
only treatment
• They are not “prescription drugs”
o As a category, prescription drugs are almost
always covered
(This is why Kuvan coverage is generally available)
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Improving the lives of individuals with PKU and pursuing a cure
State Insurance Mandates for PKU





 

  
Yellow: Formula only
 : No Mandate
www.npkua.org
Blue:
Formula and low-pro foods
Pink:
Low-pro foods only!
Improving the lives of individuals with PKU and pursuing a cure
Self-Insurance is Different
• Some employers “self-insure.” They don’t
buy “insurance” from an insurance company
o Design their own medical plan
o Assume the claims risk themselves
o They “self-insure”
• They are subject only to federal law
• They are NOT subject to state mandates
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Self-Insured Employers
• The employer decides what will be covered,
and what will not
• Some self-insured plans cover PKU medical
foods
• Many do not cover PKU medical foods
o Sometime on purpose
o Sometimes they’ve never heard of PKU
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure
Which Employers Self-Insure?
• Generally, it is the larger employers:
o 82.1% of employers with 500 + employees
o 25.7% of employers with 100 to 499 employees
o 13% of employers with fewer than 100 employees also
self-insure
• Nearly 60% of all U.S. employees are covered by self-
•
•
insured plans!
Remember – not subject to state mandates.
However, there may be a chance with health insures
discretion.
Contact member services **
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Improving the lives of individuals with PKU and pursuing a cure
NPKUA Coverage Resource Center
• For one on one coverage support and more
coverage information, please feel free to
contact our Reimbursement Coaches.
•
Call NPKUA to see if there is a Coach in your state
We want to help you get there!
www.npkua.org
Improving the lives of individuals with PKU and pursuing a cure

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