A PATIENT S GUIDE Understanding Your Healthcare Benefits

Transcription

1 A PATIENT S GUIDE Understanding Your Healthcare Benefits This guide includes useful information about how health insurance works and the reimbursement process used to pay for treatments.

2 TABLE OF CONTENTS What Is Health Insurance? 2 Common Types of Insurance 3 Understanding Insurance Coverage 4 What You May Pay 5 Treatment Approval Process 6 Insurance Checklist 7 Explanation of Benefits 8 Which Insurance Pays First? 9 State Medicaid Provides health insurance coverage to low-income people Insurance Public (Federal or State) Medicare Covers people Aged 65 and older Aged <65 years with certain disabilities With end-stage renal disease Veterans Health Administration/TRICARE/ Department of Defense Provide benefits to individuals, including Veterans Active-duty service members National Guard and Reserve members Retirees Families of retirees Introduction/Types of Insurance Insurance Appeals 10 Co-Pay Program 12 Financial Assistance 15 Medicare Part A Hospital insurance covers inpatient services Medicare Part B a Medical insurance covers medically necessary and preventive services, including doctor visits and drugs that must be given by a doctor Medicare Part C Medicare Advantage Plans allow Medicare benefits through managed care plans Medicare Part D Prescription drug coverage provides an outpatient prescription drug benefit Health Insurance: What Is It? Health insurance helps pay for medical and pharmacy costs. It is like other types of insurance, like car or homeowners insurance. You pay a certain amount of money on a regular basis a premium and your health plan pays for a portion of your medical bills. You may also have additional costs based on your medical needs. We will discuss these topics in this guide. Group Health Insurance Employer-sponsored plans Private (Commercial) Individually Purchased Insurance You buy health insurance directly from a health plan or association-sponsored health plan Who Pays for Health Insurance? In the United States, there are two types of health insurance: Public health insurance government-run programs, such as Medicare and Medicaid offered by Centers for Medicare & Medicaid Services (CMS), the Veterans Health Administration (VHA), TRICARE, and the Department of Defense (DoD) Private health insurance also called commercial insurance such as plans offered by employers This chart represents a summary of the most common insurance types and is not all-inclusive. As a patient, you are responsible for knowing what is covered by your health insurance. a Medicare-eligible patients must enroll in Part B to receive Part B benefits. Eligibility requirements vary based on the type of coverage (public or private) and the plan you have purchased. Check with your plan to confirm your eligibility. 2 3

3 Understanding Insurance Coverage What Will You Be Asked to Pay? It is important to know which medical and pharmacy services are covered under your health plan policy. Your policy coverage is usually explained in one of the following documents; however, it could vary depending on your health plan: Evidence of Coverage (EOC), which may also be called a Certificate of Insurance This is a legal document that summarizes which services and treatments are included or not included within your benefits Summary Plan Description If you receive your healthcare coverage through an employer-sponsored plan, you may only receive a summary of your benefits and plan features. This is not a legal document. You can request the EOC from your Human Resources department to obtain more details about your coverage Your health plan will provide you with a health insurance card as proof of insurance. The card contains important information about your coverage. Healthcare professionals use this information to process your healthcare claims. Some cards include the costs you may need to pay for different services or drugs. Sample Medicare Universal Identification Card You may be asked to pay for some of the cost of your treatment. The amount you pay will depend on your benefit coverage. Your Evidence of Coverage or Summary Plan Description will tell you what your annual deductible is, if any, and about other potential costs. Your annual deductible is the amount you pay out of pocket each year before your health plan pays your claims. You may also pay a monthly premium for your insurance. The amount that you are required to pay for your treatment may vary based on: Office visit Cost of drug and administration Deductible Co-pay Co-insurance Other costs, depending on your coverage Determining what you will be asked to pay can be complicated. Please work with your oncologist s office to understand how much you may have to pay. Here is an example of how these costs may be added up. Office visit and/or infusion cost Deductible The amount you pay out of pocket each year before your health plan pays claims Co-insurance A percentage of the costs you may pay for a drug or service Coverage/Costs Examples of a Medicare and commercial insurance card are included here. Your health plan can answer any questions about your card or coverage. Sample Commercial Insurance Card OR Co-pay or Co-payment A set amount you pay for a drug or service Amount You Pay 4 5

4 Treatment Approval Process Many health plans may require an approval process such as precertification or prior authorization before starting therapy. Your oncology team can help you secure this approval for treatment in two common ways. These steps may be necessary throughout your treatment. Precertification If required, your oncology team verifies your benefits and coverage before you start treatment. Prior authorization (PA) If required, your oncology team provides the health plan with your medical history, diagnosis, and treatment plan to show that the treatment they are seeking for you is medically necessary and will be used appropriately. You can use the checklist below to ensure that you give your oncologist all of the information he or she needs to have about your insurance coverage. Insurance Checklist Primary/Secondary Insurance Information Primary insurance carrier Plan name Subscriber number Group number Secondary insurance carrier Plan name Subscriber number Group number In this process, your oncologist s office or hospital may ask for the following basic information about you: First and last name Gender (male/female) Date of birth Daytime phone number Address US citizenship or legal residency (yes/no) Social Security Number If you have Medicare coverage: Check all that apply: Part A Part B Part D Medicare Part C (Medicare Advantage) Medicare policy number Effective date If you have Medicare Part D or Medicare Part C (Medicare Advantage), you may need to provide the following information: Insurance name Phone number ID/policy number Policy holder Primary/secondary insurance information State, veteran, or other plan Treatment Approval 6 7

5 Understanding Your Explanation of Benefits (EOB) and Medicare Summary Notice (MSN) What Is Coordination of Benefits? After you have received treatment, your health plan will send you an EOB or an MSN. They are records of the services you received. They are not bills. The EOB or MSN provides a statement of how much your plan covered for those services, the reason(s) services are not being covered, and how much you may be responsible for paying. The EOB or MSN is an important document to use if you disagree with your plan s decision on your claim. Sample EOB and MSN forms are shown here: Sample EOB Notice Coordination of Benefits is a program that determines which health plan or insurance policy will pay first if two health plans or insurance policies cover the same benefits. If one of the plans is a Medicare health plan, federal law may decide which plan pays first. The amount that each plan pays is based on your specific coverage. In a situation in which you have coverage from two or more health plans, the plans may coordinate reimbursement. The Coordination of Benefits form you receive from your health plan explains which plan is your primary health plan the one that pays first. The other plan is considered your secondary health plan the one that pays second. Your oncology team can work with your health plans to coordinate your benefits on your behalf. The table below explains how Medicare works with other health insurance plans. Know Who Pays First If you have retiree insurance (insurance from former employment)... If you re 65 or older, have group health plan coverage based on your or your spouse s current employment, and the employer has 20 or more employees... Medicare pays first. Your group health plan pays first. Sample MSN Notice If you re 65 or older, have group health plan coverage based on your or your spouse s current employment, and the employer has less than 20 employees... If you re under 65 and disabled, have group health plan coverage based on your or a family member s current employment, and the employer has 100 or more employees... If you re under 65 and disabled, have group health plan coverage based on your or a family member s current employment, and the employer has less than 100 employees... If you have Medicare because of End- Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant)... Medicare pays first. Your group health plan pays first. Medicare pays first. Your group health plan will pay first for the first 30 months after you become eligible to join Medicare. Medicare will pay first after this 30-month period. Important: In some cases, your employer may join with other employers or unions to form a multiple employer plan. If this happens, only one of the employers or unions in the multiple employer plan has to have the required number of employees for the group health plan to pay first. For more information, contact your employer or union benefits administrator. Benefits 8 9

6 Handling Disputes Related to Your Treatment What If Your Medicare Part D Drug Plan Will Not Cover Your Medication? There may be times when your health plan denies or limits coverage for a certain treatment. Your health plan should let you and your oncologist know in writing if it is denying or underpaying a claim. The plan must also describe the reason for the denial and inform you of the process for filing an appeal. Usually your oncology team will file the appeal for you. But there may be times when you need to get involved or you may want to file the appeal yourself. You have a right to do this. In fact, in 2010, new federal rules were put into place giving consumers in new health plans the right to appeal decisions made by their health plan. Most oncology practices and hospitals will work on your behalf to complete the reimbursement process. Bristol-Myers Squibb provides a service that can help your oncologist with the reimbursement process. Bristol-Myers Squibb provides a service that can help your oncologist with the reimbursement process. You can find out more about this service by visiting BMS Access Support at Medicare Part D is the federal government s voluntary prescription drug benefit program that helps pay the cost of prescription drugs and prescription drug insurance premiums Medicare Part D drug plans are run by private insurance companies. Each company has to follow Medicare s rules for drug coverage, but each has its own set of rules, restrictions, and co-payments However, you have the right to appeal if Medicare, your Medicare health plan, or your Medicare Prescription Drug Plan denies: Your request for a healthcare service, supply, item, or prescription drug Your request for payment of a healthcare service, supply, item, or prescription drug you already have received, or if Medicare stops providing or paying for all or part of a service, supply, item, or drug Your request to change the amount you must pay for a healthcare service, supply, item, or prescription drug You can ask for a coverage determination, which is a written explanation of your drug-coverage benefits You or the doctor who prescribed the medication can ask for an exception if: Y ou need a drug that is not on your plan s list of covered medications You contend that you should pay less for a more expensive drug because you can t take any of the less expensive drugs for the same condition Insurance Appeals REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: [Insert plan address(es)] Fax Number: [Insert plan fax number(s)] You may also ask us for a coverage determination by phone at [insert plan telephone number] or through our website at [insert plan web address]. Talk to your doctor if you have additional questions about drug coverage or want to know more about filing an appeal. Medicare also has information on how to file an appeal at Who May Make a Request: Your prescriber may ask us for a coverage determination on your behalf. If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative. Contact us to learn how to name a representative. Enrollee s Information Enrollee s Name Enrollee s Address Date of Birth City State Zip Code Phone Enrollee s Member ID # Complete the following section ONLY if the person making this request is not the enrollee or prescriber: Requestor s Name Requestor s Relationship to Enrollee Address City State Zip Code Phone Representation documentation for requests made by someone other than enrollee or the enrollee s prescriber: Attach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent). For more information on appointing a representative, contact your plan or Medicare. Name of prescription drug you are requesting (if known, include strength and quantity requested per month): 10 11

7 What Does the BMS Oncology Co-Pay Program Offer? Co-Pay Program Terms and Conditions Bristol-Myers Squibb supports access to certain BMS oncology products. The BMS Oncology Co-Pay Program is designed to assist eligible, commercially insured patients who have been prescribed certain BMS oncology products with out-of-pocket deductibles, co-pays, or co-insurance requirements. Here s what the program offers: YOU PAY THE FIRST $25 Bristol-Myers Squibb will cover the remaining amount, UP TO $25,000 of your co-pay per infusion PER YEAR Restrictions may apply. Final determination of Program eligibility is based upon review of a completed application. The Program will cover the out-ofpocket expenses of the BMS product only. It does not cover the costs of any other healthcare provider charges or any other treatment costs. You may be responsible for non drug-related out-of-pocket costs, depending on your specific healthcare benefits. This Program covers select BMS Oncology products. Please contact Access Support for a complete list of covered products Enrolled patients pay the first $25 of their co-pay per infusion. BMS will cover the remaining amount up to $25,000 per year This Program will cover the out-of-pocket costs of the BMS product only. It does not cover the cost of any other healthcare provider charges or any other treatment costs The Program may apply to retroactive out-of-pocket expenses that occurred within 120 days prior to the date of enrollment, subject to the annual Program maximum of $25,000 This offer is not valid for patients whose infusions are covered by a federal healthcare program (such as Medicare, Medicaid, TRICARE, or VA programs), that pays, in whole or in part, for prescription drugs, or where the entire cost of the infusion or monthly prescription is covered by commercial insurance. Patients may not submit a claim for reimbursement under any of these programs. Patients who move from commercial insurance to insurance through a federal healthcare program will no longer be eligible for the Program. Patients who accept this offer confirm that the offer is consistent with his/her insurance and that he/she will report the value of the co-pay assistance as required by his/her insurance provider. Patients must not seek reimbursement from any healthcare reimbursement accounts or flexible spending accounts Patients must enroll by December 31, 2015 Explanation of Benefits (EOB) must be submitted within 180 days post-infusion/ prescription to receive co-pay assistance Proof required for payment must be a valid Explanation of Benefits (EOB) with product code-specific information. An EOB must be submitted regardless of assigned J-code This offer is valid only in the United States and Puerto Rico This offer is not an insurance benefit This offer is void where prohibited by law, taxed, or restricted This offer may not be combined with any other offer, rebate, coupon, or free trial This offer is non-transferable Bristol-Myers Squibb reserves the right to rescind, revoke, amend, or terminate this offer or the Program in its entirety at any time Absent a change in Massachusetts law, effective July 1, 2015, Massachusetts residents will no longer be eligible to participate in the program Co-Pay Program 12 13

8 How Does the Co-Pay Program Work? Bristol-Myers Squibb Helping You Manage Your Treatment Costs Your doctor s office will need your name, address, insurance carrier, and member identification number. Your doctor s office completes the application and enrolls you through BMS Access Support. BMS Access Support determines your eligibility, including the amount of your benefit, and notifies you and your doctor. For more information or to apply for assistance, call BMS Access Support at , 8 AM to 8 PM ET, Monday Friday, or visit BMS Access Support from Bristol-Myers Squibb can help identify programs that may be able to help you manage the cost of your treatment. BMS Access Support provides these opportunities based on your insurance coverage. For patients with commercial (private) insurance BMS product co-pay programs may be available For patients with insurance through Federal Healthcare Programs They are not eligible for co-pay assistance programs sponsored by Bristol-Myers Squibb However, BMS Access Support can help refer patients to an independent foundation that offers the best support for their individual needs For patients without prescription drug coverage Access Support can refer you to independent charitable foundations that may be able to provide financial support, including the Bristol-Myers Squibb Patient Assistance Foundation (PAF), a charitable organization that provides medicine, free of charge, to eligible, uninsured patients who have an established financial hardship. The Bristol-Myers Squibb Patient Assistance Foundation accepts the Access Support application. For more information, you can visit Patients may be eligible for BMS PAF if they: Do not have insurance coverage, or have been denied coverage for a requested medicine Are enrolled in a Medicare Part D plan that covers the medication and have spent at least 3% of their yearly income on out-of-pocket expenses for prescription medication in the current year Are being treated on an outpatient basis Live in the United States, Puerto Rico, or the US Virgin Islands Meet the income limits for the requested medicine Other eligibility criteria apply. BMS Access Support cannot guarantee acceptance by BMS PAF It is important to note that charitable foundations are independent from Bristol-Myers Squibb Company. Each foundation, including the BMS PAF, has its own eligibility criteria and evaluation process. Bristol-Myers Squibb cannot guarantee that a patient will receive assistance Financial Assistance 14 15

9 Do you have questions about affordability options? If you are not sure what programs are available to you, please contact BMS Access Support for a person-toperson conversation about your insurance coverage and your options AM to 8 PM ET, Monday Friday OR VISIT Bristol-Myers Squibb Company. All rights reserved. Access Support and Access Support logo are registered trademarks of Bristol-Myers Squibb Company. ONCUS14UB /14