improving the lives of individuals with pku and pursuing a cure insurance challenges and ways to...

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


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Introductions

•Raenette Franco, CBCS Certified Biller Coder Specialist/Reimbursement Consultant oNew Jersey

•Beth Rader, Independent Consultant oSan Francisco

•Sean Corry, Insurance Broker, PKU DadoSeattle


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Here’s What We’ll Talk About

•Today we’ll talk about insurance coverage: oDifferent types of coverage

oTips, skills, and strategies to address challenges

oWhere you might find some help


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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


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1. Covered Benefit?

2. Medically Necessary?


Paid!

Do You Have Coverage For Medical Foods?

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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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 pre-determination 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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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.


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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!

•NPKUA provides Reimbursement assistance. Please contact our Reimbursement Coaches Team.

Covered Benefit


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Types of Coverage•Government (i.e. Medicaid, Medicare,

Etc.)

•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


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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


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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


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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?oAny exclusions?

Covered Benefit


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Evaluating Potential Coverage•Find out what your cost-sharing will beoDeductibles – must pay out-of-pocket before

coverage.oBenefit maximum Caps or Limits (you pay

out-of-pocket after cap/limit is reached).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


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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


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Digging Deeper for Coverage Information

•The Benefits Booklet oSometimes called an “Insurance Certificate” or

“Evidence of Coverage” oALWAYS keep the benefits booklet for coverage

details in writing. 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


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Benefit Booklet Example

Covered Benefit

Page 21 of a “Benefits Booklet”


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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.

•Sign-up/Enroll on your insured plan online.

•Can you get a copy? From where?

Covered Benefit


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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


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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!

Covered Benefit



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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



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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


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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?


Paid!

Medical Necessity

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?


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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.


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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


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Coverage Process1. Covered Benefit?

2. Medically Necessary?


Paid!

Process Issues


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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?

Process Issues


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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


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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


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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

•Carefully read your Explanation of Benefits (EOB) for any descriptive errors.

Claims Denials


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Claims Denials

•Claims mistakes can be corrected!oSimply denied in erroroCoding problemsoMistaken for “Food Supplement”oMissing authorization numbers or

provider National provider numbers (NPI).

Claims Denials


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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” iso Not a “food supplement!”o It is “prescribed” by your doctor or clinico 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.

Claims Denials


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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

startedoAsk if your physician can contact the

medical review director.

Claims Denials


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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? • Letter of Medical Necessity• A treatment plan? • Other details?

Claims Denials


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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


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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.

•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!

Claims Denials


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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


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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 o Tools on the websiteoNew Insurance Coach

Claims Denials


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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

Resources


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Resources For PatientsOrganization Category Reimbursement Contact

NPKUA Patient Advocacy for PKU www.npkua.orgCall: 1-715-437-0477

Patient Advocacy Foundation

Patient Advocacy General

www.patientadvocate.orgCall:1-800-532-5274

Compassion*Works – MFRS

Patient Advocacy – Medical Food Reimbursement Specialists & Consultant

Call: 973.402.3984Email: [email protected]

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-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-patient-support-a-assistance-programs.html Call: 1-877-MY-KUVAN

Resources

http://www.npkua.org/

http://www.patientadvocate.org/

http://www.abbottpatientassistancefoundation.org/medical_nutritionals.asp

http://www.abbottpatientassistancefoundation.org/medical_nutritionals.asp

mailto:[email protected]

http://www.medicalfood.com/coverage.php

http://www.kuvan.com/patients/parent-caregivers-patient-support-a-assistance-programs.html

http://www.kuvan.com/patients/parent-caregivers-patient-support-a-assistance-programs.html


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Financial Assistance ProgramsOrganization 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-r-us/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.

mailto:[email protected]

http://genes-r-us.uthscsa.edu/sites/genes-r-us/files/state_contacts.pdf

http://genes-r-us.uthscsa.edu/sites/genes-r-us/files/state_contacts.pdf

http://www.medicaid.gov/


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Covered Benefit?

Yes

Medically Necessary?

YesProcessed Correctly?Yes

No - Deny

No - Deny

No - Deny

Coverage Process Roadmap

We want to help you get there!


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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 Benefits

oSelf-Insured Employers


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Questions?

Time For More Discussion


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Appendix

Why is insurance coverage

so complicated?


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Types of Coverage•GovernmentoMedicaid and Medicare

o Title V: Children with Special

•Individual or family planso Includes “High Risk Pools”

•Group Coverage (Employer-based) o Insured Plans, regulated by the states

oSelf-Insured Employers

• Also called “self-funded” or “ERISA plans”


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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

complicatedoMedical Needy Programs through Medicaid

•MedicareoHealth coverage for people 65 or older, people

under 65 with certain conditions or disabilities

•Federal/Military employees and retirees


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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!


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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!


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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: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”


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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


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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


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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)


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State Insurance Mandates for PKU

Blue: Formula and low-pro

foods

Pink: Low-pro foods only!

Yellow: Formula only

: No Mandate


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Self-Insurance is Different•Some employers “self-insure.” They

don’t buy “insurance” from an insurance companyoDesign their own medical plan

oAssume the claims risk themselves

oThey “self-insure”

•They are subject only to federal law

•They are NOT subject to state mandates


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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 purpose

oSometimes they’ve never heard of PKU


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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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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!

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