Transcript case studies - pbcc

*
Breast and Cervical Cancer Prevention and Treatment Program
Question:
* Sheila, a 49-year-old woman with no health insurance
pays to see her doctor for annual check-ups. During
her last exam a breast lump is detected and she pays
for a mammogram and needle aspiration.
Unfortunately, the test results come back positive and
Sheila is found to have breast cancer. She has used up
all her money.
* How do you advise her?
*
Answer:
* She is eligible for Free Treatment through the
Breast and Cervical Cancer Prevention and
Treatment (BCCPT) program as long as she meets
income, residency, and immigration requirements
and has a social security number.
* Sheila and her doctor should fill out the
HealthyWoman Enrollment form PA 600B.
*
Question:
* Maggie, a 28-year-old woman calls you because
she has pain and maybe a lump in her right
breast. She works as a waitress and has no
health insurance coverage.
* What would you tell her?
*
Answer:
* Because of her symptom and lack of health insurance,
she may be eligible for Free Treatment through the
BCCPT program.
* She should call the PA Department of Health’s
HealthyWoman program to see if she is eligible to get
a mammogram.
* Maggie should mention that she is symptomatic and
has a lump. If she is found to have breast cancer she
will be put directly into the BCCPT program.
*
Question:
* Dolores is a 52-year-old woman who has been diagnosed
with breast cancer and has been accepted into the
BCCPT program. Her physician would like her to go to
the hospital that he is affiliated with for her treatment,
but Dolores would like to go to another hospital.
* She calls you to find out what her options are. What do
you tell her?
*
Answer:
* Dolores can go to any Medicaid provider. As
long as the hospital accepts Medicaid, she can
go there.
* It is her choice.
*
Question:
* Linda is a 55-year-old woman who was
diagnosed with breast cancer two years ago.
She is currently on tamoxifen. Recently she lost
her insurance coverage.
* Is she eligible for Free Treatment through
BCCPT?
*
Answer:
* Yes, she is eligible for the BCCPT program.
Tamoxifen counts as current treatment as does
Arimidex.
* As long as she meets the other eligibility guidelines,
she is medically eligible and could receive up to
three months retroactive coverage.
*
Question:
* Nancy a 48-year-old woman is diagnosed with breast cancer and receives
medical assistance via BCCPT. In February 2011, Nancy has surgery,
reconstruction, and chemotherapy which is completed in November 2011.
* She is estrogen receptor negative and is NOT put on tamoxifen. Her doctor
tells her to come for a follow-up check-up in February 2012 at which time
she will also need a mammogram.
* Nancy receives a letter in December telling her that her that she is due for
renewal for the BCCPT program and that she has 30 days from receipt of the
letter to complete the PA600BR (renewal document). Her doctor must send
it and medical documentation to the Office of Medical Assistance Programs
for review.
* How do you advise her?
*
Answer:
* Tell Nancy to contact her doctor’s office immediately to make
sure that the renewal forms are sent in as required.
* If the Office of Medical Assistance Programs does not get the
documentation, or if the woman is no longer in active
treatment she is no longer eligible for the BCCPT program.
* You should encourage her to take care of any outstanding
medical needs before her coverage runs out if it is determined
she is no longer eligible for the BCCPT program.
*
Question:
* Marty, a 40-year-old woman with breast cancer has just
finished a course of chemotherapy. She requires medical
visits but is not currently receiving medication or
radiation. She receives a notice stating her coverage is
terminated because she is not in ongoing treatment.
* Is this correct?
*
Answer:
* Yes, follow-up medical visits, labs and x-ray studies are
not considered the same as ongoing treatment, therefore
Marty is no longer considered in treatment and her
coverage through BCCPT will be terminated.
* If her cancer reoccurs, the doctor can make a referral by
submitting the PA 600B form.
OR
* She can go through the HealthyWoman program directly
for a mammogram and exam.
*
Question:
* Meredith is 35 years old and has been diagnosed
with advanced metastatic cervical cancer and has
just finished a course of chemotherapy. She requires
medical visits, labs, and x-ray studies but is not
currently receiving medication or radiation. She
receives a notice stating her coverage is terminated
because she is not in ongoing treatment.
* Is this correct?
*
Answer:
* Terminating Meredith’s coverage is NOT correct.
* Being on remission is looked at differently from advanced stages
of cancer where it is considered persistent and incurable and the
person is in need of ongoing medical care.
* Because she Meredith has metastatic cancer, her doctor should
clearly document that the cancer is persistent and incurable and
that his patient needs ongoing medical services and treatment.
* The key words are “persistent and incurable.”
*
Question:
* Anna was diagnosed with breast cancer and her
insurance covered some but not all of her treatment.
She cannot afford reconstructive surgery because she
has reached the limit on her policy.
* Even though she has insurance, can Anna apply for the
BCCPT program?
*
Answer:
* Yes, Anna can apply because her insurance is not considered
“creditable” coverage. In other words, her insurance isn’t
equal to the coverage she can receive from the BCCPT
program.
* Anna is underinsured.
*
Question:
* Shirley has been treated for her breast cancer through BCCPT for
the last 13 months. She recently turned 65 years old and is now
enrolled in Medicare and is no longer eligible for BCCPT.
* She is having trouble paying her Medicare Part B premium that
covers her medical insurance for physician and outpatient care.
She also needs help paying her deductible.
* What can Shirley do? Is she eligible for help with Medicare
because she was on the BCCPT program?
*
Answer:
* The County Assistance Office reviews cases like Shirley’s for other medical
coverage before terminating a woman from the BCCPT program. Shirley
may qualify for Medicare Savings Programs that will help pay for:
* Medicare Part A, which covers hospital insurance
* Medicare Part B, which covers physicians’ visits and other outpatient
healthcare providers
* Help with deductibles, medi-gap policies and coinsurance
* Beyond the Medicare Savings Programs she may also be eligible for extra
health through the Medicare Part D prescription plan
* Shirley should contact her local County Assistance Office to see if she
qualifies for any of these programs. She can also call Medicare directly at
1-800-MEDICARE.
*
Question:
* Ruth has been diagnosed with cervical cancer and has
Medicare Part A. Ruth needs chemotherapy by IV infusion at
an outpatient clinic but Medicare will not cover Ruth because
she does not have Medicare Part B.
* Ruth applied for the BCCPT program but is told that she
doesn’t qualify because she has “credible coverage” through
Medicare.
* How do you advise her?
*
Answer:
* Encourage her to appeal this decision because without
Part B she must pay out-of-pocket for all physician visits
and outpatient care. If a woman can not afford this, she
will not have access to the treatment and care that she
needs.
* While Medicare A is considered creditable coverage by the
Office of Medical Assistance Programs, some women have
been able to get into the program by appealing the
decision.
*
* Always have the doctor send as much medical information as possible
when filling out the necessary forms.
* The PA Department of Welfare’s Office of Medical Assistance Programs
makes the final medical decisions regarding ongoing treatment.
* The woman and her doctor ALWAYS have the option to appeal a denial.
* Please share this information!
You can help save the lives of women
across the state by providing them with lifesaving free treatment
through the Breast and Cervical Cancer Prevention and Treatment
Program.