insurance challenges and ways to succeed
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Insurance Challenges and Ways to Succeed . Beth Rader Sean Corry. Introductions. Beth Rader , Independent Consultant San Francisco Sean Corry , Insurance Broker, PKU Dad Seattle. Here’s What W e’ll T alk About. Today we’ll talk about insurance coverage: - PowerPoint PPT PresentationTRANSCRIPT
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Insurance Challenges
and Ways to Succeed
Beth RaderSean Corry
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Introductions•Beth Rader, Independent
Consultant oSan Francisco
•Sean Corry, Insurance Broker, PKU DadoSeattle
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Here’s What We’ll Talk About•Today we’ll talk about insurance
coverage: oDifferent types of coverageoTips, skills, and strategies to address
challengesoWhere you might find some help
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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1. Covered Benefit?
2. Medically
Necessary?
3. Processed Correctly?
Paid!
When Coverage Works…
But when coverage doesn’t work, the answer lies in one of these areas
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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1. Covered Benefit?
2. Medically
Necessary?
3. Processed Correctly?
Paid!
Do You Have Coverage For Medical Foods?
Key Questions:• What kind of insurance do you have?• Does your insurance policy cover medical foods? • How does the insurance policy cover medical foods?
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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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!
Covered Benefit
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Types of Coverage•Government•Private Insuranceo Individual or family plans• Includes “High Risk Pools”
oGroup Coverage (Employer-based)• Insured Plans, regulated by the states• Self-Insured Employers - Also called “self-
funded” or “ERISA plans”
Covered Benefit
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Does Your Insurance Plan IncludeMedical 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 insuranceo Varies widelyo Depends on state and the specific insurance
•We’ll explain how to find whether your plan must cover medical foods
Covered Benefit
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Deciding About Coverage:Sometimes You Have Choices
•When can you evaluate your options?oWhen individual coverage is available to youoWhen you get a new job with benefitsoDuring “Open Enrollment” at work
More options should be available in 2014 when federal
Health Reform really kicks in!
Covered Benefit
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Evaluating Insurance Options•Does the plan have the coverage you need?oMedical services, like clinic visits and blood drawso Formula only?o Low-protein foods?
•Ask about PKU coverage before you take a job•Find out how medical foods covered oAs a medical service?oAs a pharmacy benefit?oAre only specific brands covered?
Covered Benefit
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Evaluating Potential Coverage•Find out what your cost-sharing will beoDeductiblesoBenefit Caps (you pay everything after cap
is hit)o$ Copayments or % Coinsurance
•Caution with individual health plansoRx may be an optional benefit oRx may have coverage limitations • (Remember, Kuvan is a prescription drug)
Covered Benefit
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Where Can We Read About PKU Coverage?
•The “Summary of Benefits” oOnly a few pages longoOffers only the plan highlightsoWill 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.”
Covered Benefit
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Digging Deeper for Coverage Information
•The Benefits Booklet oSometimes called an “Insurance
Certificate” or “Evidence of Coverage”oUsually not given to you for many weeks
AFTER coverage beginsoMany pages longoShould give at least a brief description of
coverage for PKU formula and/or medical foods
Covered Benefit
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Benefit Booklet ExampleCovered Benefit
Page 21 of a “Benefits Booklet”
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Might There Be Even MORE Detail?•The Insurance Contract oThis is for insured plans, either individual
or group•The “Plan Document”oThis is for self-insured (ERISA) plans
•These are usually big documents, and spell out almost all the details of coverage
•Can you get a copy? From where?
Covered Benefit
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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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 foodso“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
Covered Benefit
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Convincing Employers*•Ask them to reconsider. Tell them:oPKU is very rare. • If they provide coverage, their costs will be
limited because they probably don’t have other PKUers
oBeing off diet leads to severe, progressive mental retardation, depression, impulse control disorder, phobias, epilepsy, tremors, and other disorders
oDiet is the only sure treatment!
Covered Benefit
* Self-Insured Employers? See appendix slides for more details
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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More Reasons for Employers*•Also tell them:oA treated person with PKU lives a
normal, productive lifeo 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!
Covered Benefit
* Self-Insured Employers? See appendix slides for more details
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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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
Covered Benefit
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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NPKUA Efforts For National Coverage •Legislation: Medical Foods Equity Act•Conversations at Regional HHS
meetingsoWashington, Atlanta, Chicago, Denver
•Working with lobbying firm to meet with National HHS
•Advocacy table at NPKUA ConferenceoWhat does access to medical food mean to
you?
Covered Benefit
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Is Your Prescription Medically Necessary?
1. Covered Benefit? 2. Medically Necessary?3. Processed Correctly?
Paid!
Medical Necessity
Key Questions:• Do you have a prescription?• What are your plan’s rules for assuring coverage?
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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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
Medical Necessity
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Coverage Process1. Covered Benefit?
2. Medically Necessary?
3. Processed Correctly?Paid!
Process Issues
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Claims Processing IssuesIssues 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?
Process Issues
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Be Prepared•It is common for a claim to go
wrong•Know your coverage, and get
everyone on board – Talk with: oThe insurance companyoYour clinic professionalsoYour pharmacist, etc.oThe company (or companies) providing
the medical foods
Tools to Use
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Keep Copies of Everything•Get a written prescription for
formula/food oKeep a copy for yourself, in case the original
gets lostoMay need to get your Rx “renewed”
occasionally•Copy the label of your medical food
product•Copy your invoiceoThis can help solve billing and coding issues
Tools to Use
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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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
Claims Denials
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Claims Denials•Claims mistakes can be corrected!oSimply denied in erroroCoding problemsoMistaken for “Food Supplement”
Claims Denials
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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How to Interact With Your Insurance Company
•Be able to explain PKU & dietary treatment•Be able to explain what “medical food” isoNot a “food supplement!”o It is “prescribed” by your doctor or clinico It’s covered by the plan! (Show them where)
•If transferred to another person, be prepared to start again start at the beginning
Claims Denials
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Claims Denials: First Steps•Read your policy (again)oWhat’s covered, what’s notoHow to file an appeal
•Call “member services”oAsk them to walk you through your
coverageoAsk for an explanation of the denialoDetermine if a “phone appeal” can be
started
Claims Denials
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Claims Denials: First Steps•Does your insurer need more
information?oAsk what information you should
collectoAsk what information your providers
should submit:• Health history? • A treatment plan? • Other details?
Claims Denials
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Put It In Writing•A clear statement why the denial
should be reversed •Be thorough - cover all the bases•Make it factual, not emotionaloState law apply?oError regarding medical necessity?oCannot tolerate “that” formula; need
to switch to another
Claims Denials
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Organization and Details Count•Make copies
•Ask for written confirmation of phone calls
•Keep a notebook names, dates of calls, etc.
•Verify their promises to follow-up o If they don’t call you when promised,
call them!
Claims Denials
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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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
Claims Denials
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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You Are Not Alone•Your clinic•The human resources department•Your health insurance broker•State Insurance Commissioner•The medical food or pharmaceutical
company•NPKUA oTools on the websiteoNew Insurance Coach
Claims Denials
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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The New NPKUA Insurance Coaches
•Goal: Insurance Coaches in Every State or Region•Timing: Starting Fall 2012, as Coaches are on board
and go through orientation•What you can expect if you sign up:
o Orientation and trainingo Resources to help (sample letters, information about the
law)
•Call NPKUA to see if there is a Coach in your state
Resources
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Resources For PatientsOrganization Category Reimbursement ContactNPKUA Patient Advocacy for PKU www.npkua.org
Call: 1-715-437-0477Patient Advocacy Foundation
Patient Advocacy General
www.patientadvocate.orgCall:1-800-532-5274
Abbott Medical Food Products http://www.abbottpatientassistancefoundation.org/medical_nutritionals.asp Applied Nutrition Medical Food Products Call: 1-800-605-0410 Email: [email protected]: www.medicalfood.com/coverage.php
Cambrooke Foods Medical Food Products Call 1-866-4-LOW-PROMead Johnson Nutrition Medical Food ProductsNutricia Medical Food Products Call: 1-800-356-7354, ext. 1200Vitaflo Medical Food Products Call: 1-888-VITAFLOBioMarin Pharmaceutical http://www.kuvan.com/patients/parent-caregiver
s-patient-support-a-assistance-programs.html Call: 1-877-MY-KUVAN
Resources
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Covered Benefit?Yes
Medically Necessary?Yes
Processed Correctly?Yes No - Deny
No - Deny
No - Deny
Coverage Process Roadmap
We want to help you get there!
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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We’ll Stop Here, But More in the Appendix
•The slides in the appendix provide a high level look at:oTypes of coverage• Government, Group, Individual• Insured and Self-funded
oState Mandated BenefitsoSelf-Insured Employers
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Questions?
Time For More Discussion
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Appendix
Why is insurance coverage
so complicated?
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Types of Coverage•GovernmentoMedicaid and Medicareo Title V: Children with Special
•Individual or family planso Includes “High Risk Pools”
•Group Coverage (Employer-based) o Insured Plans, regulated by the statesoSelf-Insured Employers • Also called “self-funded” or “ERISA plans”
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Government Insurance - Types•Low Income Help: Medicaid, WIC, Title 5oHealth coverage for lower-income individuals
and familiesoCoverage varies by state, can be very
complicated•MedicareoHealth coverage for people 65 or older, people
under 65 with certain conditions or disabilities •Federal/Military employees and retirees
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Government PKU Coverage•Medicare oMedical Food generally not covered
except in rare circumstances•Medicaid – rules vary state by state•Plans for federal employeesoRegulated by Congressional law or
administrative policies•It is very complicated and
mysterious!
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Private Insurance:Individual (or Family) Coverage
•Buy directly from an insurance company oCoverage for PKU may be required
•More limited benefitsoCompared to group coverage
•Currently, most people have to pass a health screen to get individual coverage
•An alternative: A state “high risk pool”oGuaranteed coverage but may be expensive!
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Employer-Based or Group Coverage•Many people have health insurance
coverage through their employer’s plan•Generally, two types of employer plans:oAn INSURED plan, subject to state
“insurance mandates”oA SELF-FUNDED plan, not subject to state
“insurance mandates”• Also called “Self-insured” or “ERISA plans”
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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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
lawo PKU medical food is an example in many states
•Some mandates come from federal lawoE.g., equal coverage for mental health oThere is no federal mandate for PKU
coverage
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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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
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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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”oAs a category, prescription drugs are
almost always covered(This is why Kuvan coverage is generally
available)
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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State Insurance Mandates for PKU
Blue: Formula and low-pro foodsPink: Low-pro foods only!
Yellow: Formula only : No Mandate
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Self-Insurance is Different•Some employers “self-insure.” They
don’t buy “insurance” from an insurance companyoDesign their own medical planoAssume the claims risk themselves oThey “self-insure”
•They are subject only to federal law•They are NOT subject to state mandates
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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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
foodsoSometime on purposeoSometimes they’ve never heard of PKU
Improving the lives of individuals with PKU and pursuing a curewww.npkua.o
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Which Employers Self-Insure?•Generally, it is the larger employers:o82.1% of employers with 500 + employeeso25.7% of employers with 100 to 499 employeeso13% 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