insurance challenges and ways to succeed

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•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 coverageoTips, skills, and strategies to address

challengesoWhere 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?

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?


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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


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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


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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?

Covered Benefit


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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


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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”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 ExampleCovered 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

•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. 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



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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?3. Processed Correctly?

Paid!

Medical Necessity

Key Questions:• Do you have a prescription?• What are your plan’s rules for assuring coverage?


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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?

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


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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

Claims Denials


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Claims Denials•Claims mistakes can be corrected!oSimply denied in erroroCoding problemsoMistaken for “Food Supplement”

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” 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


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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


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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


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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.

•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 oTools 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 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


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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

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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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!


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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


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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 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”


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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


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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•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 foodsPink: 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 planoAssume 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 purposeoSometimes they’ve never heard of PKU


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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

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