Transcript SAMPLE - Philadelphia Multiple Myeloma Networking Group

Overview of Co-Pay Assistance and Financial
Assistance Resources
Christina Bach, MBE, MSW, LCSW, OSW-C
Educational Content Specialist and Psychosocial Content Editor, OncoLink
[email protected]
Fact: Cancer is expensive
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68% of personal bankruptcies in the US are the result of medical debt.
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78% of those declaring personal bankruptcy due to medical debt were INSURED
(Woolhandler, et.al. American Journal of Medicine, 2009).
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One out of four cancer patients avoids filling prescriptions due to cost (The
Oncologist, 2013).
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42% of insured cancer patients express a significant or catastrophic financial
burden (The Oncologist, 2013).
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11 of the 12 cancer drugs approved by the FDA in 2012 cost over$100,000 per year.
Fact: Cancer is expensive
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55% of cancer patients surveyed said the stress of dealing with costs negatively
affects their ability to focus on their recovery (Association of Oncology Social
Work).
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36% of patients have discussed the cost of treatment with their oncologist
(Association of Oncology Social Work).
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16% of patients and caregivers report that they believe their oncologists give a lot
of thought to the financial implications of the treatment they prescribe
(Association of Oncology Social Work).
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About one half of patients surveyed feel comfortable speaking with health
professionals about financial issues (Association of Oncology Social Work).
Insurance doesn’t cover everything:
Do you know your potential costs?
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The patient is ALWAYS responsible for
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Premium-what your plan costs every month
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Deductible-a fixed dollar amount you pay BEFORE your insurance pays anything
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Co-pays-a fixed cost sharing amount assigned to a specific service
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Co-insurance- usually a percentage: plan is responsible for “x” %;
patient is responsible “y” %
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MOOP-maximum out of pocket the individual pays; usually assessed annually
Not to mention…
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Changes in work and income due to medical condition and treatment schedule
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Waiting periods for disability
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Cost of COBRA coverage if unable to work
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Non cancer related life needs---housing, transportation, food, utilities, phone
Why is increased access to copay/financial
assistance important?
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Improves access to care
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Improves adherence to treatment plan
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Improves patient outcomes
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Improves quality of life
Is there help out
there?????
What is Co-Pay Assistance?
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Co-pay assistance is financial assistance for co-pays/co-insurances (patient
responsibility) for patients WITH insurance—but whom we would consider to be
UNDERINSURED (commercial/private/Medicare)
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Patients must meet BOTH diagnostic & financial criteria
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Co-pay assistance covers costs of medication (oral and IV); some co-pay
foundations also cover insurance premiums as well as transportation/travel
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But again, this is dependent on diagnostic criteria
What is Co-Pay Assistance
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Co-pay assistance typically does not cover co-pays for diagnostic imaging, labs,
radiation, or office visits*
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*unless treatments are administered on the same day as the office visit
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Co-pay assistance is not available to the uninsured
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Co-pay assistance differs from co-pay cards
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Co-pay assistance can not be applied to treatments that are DENIED by the
insurance company or are experimental/off label uses of medications
Co-Pay Assistance Foundations
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Receive their funding from private donors and pharmaceutical companies
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Each foundation decides WHICH treatments are covered for each diagnosis by
their co-pay assistance foundation (a formulary)
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Will cover both oral and IV medications as indicated on their formulary
Name
Amount
Eligibility
Assistance covers
Leukemia and Lymphoma Society Copay
Assistance Program
www.lls.org
(877) 557-2672
$10000
Renewable
annually
based on
available
funding
500% FPL
•
Patient Access Network Foundation
https://www.panfoundation.org/
866-316-PANF
$10000
Renewable
annually
based on
available
funding
500%FPL
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Disease related and approved treatments
(oral/iv)
Patient Advocate Foundation
http://www.copays.org/
866-512-3861
$10000
Renewable
annually
based on
available
funding
400% FPL
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Disease related and approved treatments
(oral/iv)
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Disease related and approved treatments
(oral/iv)
MD office visit copays on same day as
treatment
Premium assistance
Name
Amount
Eligibility
Cancer Care Co-Pay
Assistance Foundation
cancercarecopay.org
866-552-6729
$7000
400% FPL
Renewable annually based
on available funding
• Disease related and
approved treatments
(oral/iv)
Chronic Disease Fund
http://www.cdfund.org
(877) 968-7233
No set cap across the
board; award is case by
case and takes into
account cost of living
• Disease related and
approved treatments
(oral/iv)
• Some transportation
and lodging costs
(separate application
process)
Based on cost of living,
outstanding medical bills
and income
Assistance Covers
Co-Pay Cards
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The co-pay card first appeared in 2005 as a means by which pharmaceutical providers
could offer instant ‘rebates’ or ‘discounts’ to patients.
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This helps to combat some of the challenges to prescription pharmaceuticals, including
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Generic competition
Lack of patient adherence and persistence due to out of pocket cost for the medication at the
commercial pharmacy
Co-pay cards are ONLY for patients who have employer based/private/commercial
insurance.
They are not available to patients with Medicare Part D sponsored RX plans or Medicaid
• You are eligible to use a co-pay card if you have an ACA (aka “Obamacare”)sponsored plan
•
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For eligible patients, these cards can be very helpful for privately insured patients receiving
some high dollar drugs.
How do I apply?
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Gather necessary documents
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Proof of income
Diagnosis and treatment information
Copies of insurance cards
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Identify and contact the fund/pharmaceutical company
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Be sure all documents are completed by your care provider ASAP
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Keep copies of your award letter and instructions on how to utilize funds
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Ask your care team for help!!!
I’m approved, now what?
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GET ORGANIZED!
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If you are using your award for oral medications, contact your pharmacy and
provide them with information about your funding source
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Most specialty pharmacies are very experienced with working with copay assistance
funds!
For chemotherapy (IV) related bills, collect explanation of benefits (EOB’s) from
the payer and bills from the provider.
•
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You must have matched EOB’s and bills to submit a payment request
It is POSSIBLE to have the foundation billed directly by your treatment site, but this is
very dependent on your treatment site’s billing policies and processes
USE IT OR LOSE IT!
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Apply when you need funds
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If you don’t submit claims to the foundation within a set period of time (varies
amongst each group) you will LOSE YOUR FUNDING
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With most funds, you cannot apply again if you lose your funding until a year has
passed from the initial application
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Stay on top of submitted claims and keep records of payments received
Other sources of prescription assistance
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Partnership for Prescription Assistance (PPA)
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Needymeds.org
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Rx Relief Pharmacy Discount Card
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RxAssist
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RxOutreach
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Xubex
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Generic Programs-Target, Wal-mart, Shoprite
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These programs do not often offer assistance for cancer drugs, but they do offer assistance
for many medications used for symptom management (depression, anxiety, nausea, diarrhea,
seizures) and can be accessed at significant savings
Other sources of prescription assistance
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Medicare Part D Recipients: Low Income Subsidy- “Extra Help”
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PA-PACE/PACENET
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NJ-PAAD
Other sources of financial assistance
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American Cancer Society (ACS)
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Cancer Care
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Has a specific program for transportation reimbursement for Myeloma patients
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Stomp the Monster
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Bringing Hope Home
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Sink or Swim Philadelphia
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Breathing Room Foundation
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South Jersey Cancer Fund
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National Marrow Donor Program
Crowd sourcing and fundraising
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Gofundme http://www.gofundme.com/medical-illness-healing/
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Indiegogo https://www.indiegogo.com/
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Youcaring http://www.youcaring.com/medical-fundraising
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Rally https://rally.org/
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Give Forward http://www.giveforward.com/
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Healthline http://www.healthline.com/health/online-medical-fundraising
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Causewish http://causewish.com/
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Host a local event: auctions, beef and beer, raffles---think outside the box!
Crowdsourcing Pros and Cons
Pros
Cons
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Helps gets the bills paid!
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Potential for your story to go viral
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Reaches large number of potential
donors quickly
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Fees involved with websites
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Potential tax liabilities for donor and
recipient
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Donations given through
crowdsourcing are not tax deductible
unless they are given to a non-profit
organization
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Potential for your story to go viral
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Fosters a sense of community and
solidarity
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Ease of use of websites for managing
donations
Fundraising tips: telling your story
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Who will the fundraiser support?
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Get the community involved and help
bring awareness to your cause.
• Think about community groups you
are involved in who can help rally
support (PTA, running club, dog park)
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How will the money be used if the goal is
met?
• Formulate a solid plan for giving back
and paying forward.
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Reiterate where is the money going.
This is your opportunity to tell (and sell)
your story.
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Where is the medical treatment taking place?
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Who is the doctor?
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What exactly are the medical expenses?
• Be as specific and detailed as you can be.
Your treatment center’s social workers,
navigator and financial counselor can help
you with this
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When is the money needed by?
• Provide a sense of urgency by stating a
target date for funds to be raised
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Ultimately donors are always going to
appreciate your honesty and being
transparency
SAY THANKS and show your
appreciation
Conclusions
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Help is out there, you must be willing to share your story, ask for help and receive
it.
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Get creative.
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Use fundraising and crowdsourcing to help achieve specific fundraising goals.
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Thank foundations and individuals for their help!
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Give back: pay forward.
QUESTIONS?
Contact information:
Christina Bach, MSW, MBE, LCSW, OSW-C
Educational Content Specialist & Psychosocial
Content Editor, OncoLink
www.oncolink.org
[email protected]
215-662-3221