First Steps

1. First Steps Health Insurance 101 Lauren Dunn, MSW Hemophilia Social Worker Central VA Center for Coagulation Disorders VCU Medical Center

2. Hemophilia and Health Insurance Having health insurance is important for everyone. It�s especially important for people with chronic health issues, like hemophilia. Health insurance provides payments for visits to the doctor and clotting factor medicine.

3. What are the options? There are many different types of health insurance. It�s important to understand the differences before you make a decision about which plan is the best for you. The most common kinds of health insurance are: Employer sponsored group health insurance (HMO, PPO, etc.) Individual �open enrollment� insurance Medicaid/FAMIS Medicare

4. Employer Sponsored Group Health Insurance With this type of coverage, the employer offers a policy to all employees. Employers and employees share the cost of monthly premiums and all employees are offered the same coverage, at the same rate, regardless of health status.

5. Types of Group Health Insurance HMO- HMO stands for �Health Maintenance Organization�. HMO�s often have lower monthly premiums, but are more restrictive in choice of providers HMO�s also typically require patients to obtain a referral from a primary care doctor before they can see a specialist. PPO- PPO stands for �Preferred Provider Organization�. PPO�s typically have higher premium cost but allow more choice of providers and do not require referrals for specialty care.

6. Individual Health Policies In the state of Virginia, persons with chronic illnesses can access personal health coverage through the Anthem Virginia Standard plan. While this coverage is available to everyone, regardless of health status, it is usually very expensive for people with chronic health issues.

7. Medicaid/FAMIS Medicaid and FAMIS are programs that provide health coverage to children and certain individuals and families who fit into eligibility groups recognized by federal and state law. Medicaid and FAMIS provide comprehensive coverage through age 19 to eligible children. Medicaid also covers some adults who are disabled.

8. Medicare Medicare is federal health insurance available to persons over the age of 65 or who have been determined disabled.

9. Frequently used terms in health insurance Premium- The monthly amount the policy holder (patient) pays for the health insurance policy. Deductible- The amount the patient pays before the policy will pay for medical care. Co-Pay- A flat payment amount (usually $25-$40) the patient is responsible for paying for doctor�s visits or other medical services, regardless of the total cost of the care provided. Co-Insurance- A percentage of the total cost (usually 10-20%) that the patient pays for medical services.

10. Frequently used terms in health insurance Major medical benefit- This part of your policy covers things like doctors visits and hospital admissions. Many policies provide coverage for factor through major medical benefits. Prescription benefit- This part of you policy provides coverage for your prescription medicines. Some insurance policies have started moving coverage for factor from the major medical benefit to the prescription benefit. Specialty Injectable- This is a term frequently used by insurers to describe factor concentrate.

11. Frequently used terms in health insurance Lifetime max or cap- The maximum amount a policy will pay for a policy holder. Some policies have no lifetime cap. Others have caps anywhere from 1 million to 5 million. Once the maximum limit is paid by the insurer they will not make additional payments for healthcare. Explanation of Benefits (EOB)- A statement sent to the patient from the insurance company showing the total medical bill, the amount the insurer paid, and the amount the patient owes to the provider. An EOB is not a bill. Out of pocket limit- The is the total amount per year that the patient will pay out of pocket for healthcare.

12. What should I ask before choosing a policy? What is the monthly premium cost? How much is the deductible? Will this policy allow me to receive care from a hemophilia treatment center? Will I need a referral to see a hematologist? Does this policy provide coverage for factor concentrate (sometimes referred to as �specialty injectables�)? Is factor covered as a prescription benefit or a major medical benefit? Is there a lifetime cap on the medical or prescription benefits? Do I have a choice of factor providers or am I required to use a specialty pharmacy? What is my co-pay or co-insurance responsibility for factor? Is there a maximum out of pocket limit that I have to pay per year?

13. Obstacles to Obtaining Health Insurance Cost Aging out of Medicaid/ FAMIS or parent�s group policy Loss or change of jobs Fewer employer�s offering group coverage

14. Addressing the Obstacles There are 2 programs the help people with without health insurance access the care they need: The Virginia Bleeding Disorders Program Patient Services, Incorporated (PSI)

15. Virginia Bleeding Disorders Program The VBDP is a �safety net� program offered through the VA Department of Health. The VBDP is not health insurance, however it does provide medical services for bleeding disorders through two levels of enrollment: Basic Program Enrollment Full Program Enrollment

16. Basic Program Enrollment Patients who have a third party payor (private insurance, Medicaid, Medicare) are enrolled in the Basic program The VBDP services as a secondary payor, meaning it pays any remaining co-insurance after the primary payor makes payment. The VBDP does not pay co-pays or deductibles

17. Full Program Enrollment Patients who do not have a third part payor enroll at the �Full Program� level The VBDP serves as the primary payor for all bleeding-related medial care Eligibility for Full Program Enrollment is based on income, however families above income for full program enrollment can �spenddown� to become eligible. Once a family has paid 5% of their total income toward medical costs, they can receive full program enrollment in the VBDP

18. How do I enroll in the VBDP Persons with bleeding disorders can enroll in the VBDP during an HTC visit or by calling 1-866-228-2516. Enrollment is open to any resident of Virginia with Hemophilia A or B, or von Willebrand�s Disease. There is no enrollment fee or premium for participation in the VBDP

19. Patient Services, Incorporated (PSI) PSI is a national non-profit company that helps people with high cost chronic illnesses access and pay for health insurance premiums. PSI works closely with HTCs and the VBDP to assist people with hemophilia and other inherited bleeding disorders. If you have access to a health insurance policy, but cannot afford to pay for it, PSI might be able to help.

20. How can apply for help from PSI? Eligibility for PSI assistance is based income and severity of illness. HTC social workers can help determine if you are eligible for PSI assistance and can help you complete the application for PSI.

21. Why is Health Insurance so Important? Health insurance is important for all people due to the high cost of medical care. For the average person with hemophilia, the cost per year for clotting factor alone is between $60,000 to $120,000!

22. What other help is available? Homecare co-pay waiver programs- these programs provide assistance to families who cannot afford to pay co-pays for factor. Manufacturer Assistance Programs- Programs that allow patients to earn credits (based on factor usage that can be redeemed for free factor in the event of a loss of insurance. Manufacturer Compassionate Use Programs- Provide a limited amount of �compassionate use� factor to those with low income and no insurance.

23. How do I enroll? Homecare waiver programs- Contact you homecare company for information Manufacturer assistance programs: Baxter (Advate, Recombinate)- 1-800-888-4502 Bayer (Kogenate)- 1-800-288-8374 Wyeth (Benefix, ReFacto)- 1-888-999-2349 ZLB Behring (Helixate, Humate-P, Mononine)- 1-866-415-2164 Novo Nordisk (NovoSeven)- 1-877-NOVO-777 Manufacturer Compassionate Use Programs- Contact your HTC for information.

24. Your HTC is here to help! Understanding health insurance can be overwhelming. HTC social workers have expertise in helping you navigate the insurance maze. Contact your HTC social worker any time you need assistance related to your health insurance.