Understanding Health Insurance Options and Obstacles

Learn how to choose commercial health insurance or a Medicare plan, who qualifies for Medicaid, and managing claims disputes.

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Understanding Health Insurance Options and Obstacles

Thursday, April 22, 2021

Presenter: Gary Goldstein, Stanford Health Care.

Presentation is 46 minutes plus 10 minutes of Q & A

Summary: There are many kinds of insurance plans and coverages available in the United States.  This presentation describes different plans in both the private market and government sector to guide patients through the maze of options. It also describes how different plans may complement one another and provide fuller coverage than any single plan on its own.


  • Private insurance includes a range of options and organizations that are available through an employer or the private marketplace. Careful comparison of these options before deciding on a plan is highly recommended.
  • All insurance plans still have significant expenses for patients. These should be scrutinized closely to choose the best overall combination of costs and coverage for each patient’s specific needs.
  • Medicare and Medicaid programs are important resources for those who meet their eligibility requirements. They can often be combined with Advantage plans or other private insurance to maximize your coverage for diverse medical conditions.

Key Points:

(01:50)   In the U.S. there are four types of  commercial insurance:  large employer group health plans eg. Blue Cross/Blue Shield, Aetna, United Healthcare, Cigna; small employer group plans; self-funded plans, where the insurance company administers the plan but the employer actually pays the benefits; and individual plans, such as those purchased through the Affordable Care Act.

(05:02)    Commercial insurers offer with different policy types, including Preferred Provider Organizations, Health Maintenance Organizations, and Point of Service Plans.

(09:37)     Expenses not covered by insurance that are paid by the patient may include premiums, deductibles, and copays. Some of these expenses may be offset by coinsurance and out-of-pocket maximums.

(13:01)      Prescription drug coverage may or may not be offered as part of a healthcare plan.

(15:20)       COBRA plans are available for eligible employees whose employment ends and who want to pay a premium to continue insurance coverage for a period of time.

(20:24)       Medicare is a government plan for people over 65 years of age and selected other populations. It includes Parts A, B, C, and D that cover different aspects of medical care. Since Medicare does not cover all medical costs, choosing a Medicare supplement plan adds significant protection against those remaining costs.

(30:10)       Insurance approval for transplants can be a complex matter and may depend on the specific diagnosis. Many transplants may not require authorization for Medicare coverage but will need authorization from Advantage plans. [Also see time stamp (54:56) in the Q & A section].

(33:27)       Clinical trials may be eligible for coverage with Medicare, Medicare Advantage or supplemental plans, depending on coverage restrictions and type of trial.

(39:38)       It is critical that patients inform providers of all their insurance coverages from all the plans you have. This will maximize your overall benefits and minimize your individual costs. Also know that cancer policies may be available but must be purchased prior to a diagnosis and are not intended to replace full insurance.

(42:55)       Appeals may be possible after a denial of coverage. You should work closely with your provider if an anticipated service is denied or a claim for prior service is denied.

(Note: When the speaker refers to BMT or bone marrow transplant in this presentation, those terms are meant to include stem cell and cord blood transplants as well.)

Transcript of Presentation:

(00:01) [Marcia Seligman] Introduction. Hello, everyone. My name is Marcia Seligman. Welcome to the workshop Understanding Health Insurance Options and Obstacles. I'd like to introduce our speaker, Mr. Gary Goldstein.

Mr. Goldstein is the director of transplant services operations for blood and marrow transplant patient, cancer cell therapy, and solid organ transplantation at Stanford Healthcare. He has over 30 years of experience in healthcare finance for stem cell transplantation and cellular therapies. Mr. Goldstein often participates in advocacy efforts on Capitol Hill to obtain Medicare for stem cell transplantation and other cellular therapies. Join me in welcoming Mr. Goldstein.

(00:49) [Gary Goldstein] Overview of talk: Understanding health insurance options and obstacles. Thank you so much for the introduction and thank you to BMT InfoNet for the opportunity to speak. Today I'm going to be speaking about understanding health insurance options and obstacles, in particular in the US healthcare system. I want to confirm I have no conflict of interest to disclose.

The overview of our goals, today I hope that you can develop a better understanding of commercial insurance, of COBRA rules, Medicare and understanding Medicare Part D drug coverage, Medicaid plans and we'll also talk about clinical trial coverage, in particular for cancer clinical trials. Coordination of benefits regarding how plans work together for patients who have more than one insurance. And we will touch briefly on some alternative coverage plans.

(01:50)                 Commercial insurance and large group health plans. When we talk about commercial insurance, we're referring to the for-profit and not-for-profit insurance companies. Many of you have heard of the big players, typically the Blues, Aetna, Cigna, United Healthcare, and there are some smaller players as well.

There are different plan types, and those typically start with the employer large group health plans. The US healthcare system is still built very strongly around people getting insurance coverage through their employment or through a family member's employment.

 (02:32)                 Small group insurance plans. Next step we have small group plans. There are some small groups where it may not be a large employer, but rather a small company that seeks to insure a dozen or so of their own employees.

(02:48)                  What is a self-funded insurance plan? There are also self-funded plans. Many patients are on self-funded plans nowadays and they have no idea. So let's take a minute to talk about what a self-funded plan is and how it differs from a tradition employer large group health plan.

When an employer purchases a large group health plan for their employees, what they're doing is paying the industry company both to administer claims, to in some cases provide an authorization review as well as to pay the medical bills and manage that risk. But now a lot of large employers are willing to manage the risk and pay the bills themselves.

So, with a self-funded plan, that insurance company is really only acting as an administrator there to create ID cards, issue authorizations and process claims. The claims are actually paid with money from the employer.

Why does that make a difference? Well, the laws can be different, as well as who is making the decision as to what benefits are going to be covered and what will not be covered. In the case of a self-funded plan, it is the employer, or it could be a labor trust fund for example.

(04:12)                  Ways to purchase individual health insurance. Lastly, there are individual plans. If you lose your group coverage, or perhaps you didn't qualify for that in the first place, you may go to directly purchase an individual plan. How do you do that? Well, nowadays there's a couple different pathways.

The Affordable Care Act - hsd been called Obamacare or the ACA - is a way that states or the federal government have created a marketplace where you can purchase plans, or in some cases get subsidies from your taxes. In addition to this, you can also still purchase off the exchange either through an industry broker or sometimes directly from an insurance company.

(05:02)                  Preferred Provider Organization (PPO) and Exclusive Provider Organization (EPO) health insurance. When we talk about commercial insurance, there are also different policy types. One of the most common types is a PPO plan, which stands for preferred provider organization. It’s a very classic kind of plan that has two tiers of benefits.

There are providers who have contracted with the insurance companies to be preferred providers. They've agreed on a discounted rate that applies both to the insurance company and to the patient. So it is financially to the patient's best interest to receive care through that preferred provider.

However, there is still the ability to get coverage at a lower level, but still some coverage, at a non-contracted non-preferred provider. So there's a benefit in that regard, if you really want to seek a second opinion outside of the preferred network, you can do so and still have some coverage in place.

There's also an exclusive provider organization plan, or EPO. Very, very similar to PPO plan. Typically the exclusive provider network is smaller, so your options for in-network discounts are less, but it's still the same general idea.

(06:28)                  Health Maintenance Organizations (HMO). Next, we have a health maintenance organization, or HMOs. Kaiser is certainly one of the most recognized, but nowadays in many states there are numerous HMOs.

When you sign up for an HMO, you normally pick or are assigned a primary care physician who is affiliated with a medical group or individual physician association or IPA. They are responsible for providing, in many cases, all of your medical care. If you want to go outside of that medical group, say, for blood and marrow transplantation, that is often not available within the group, they need to authorize every service outside of that group area.

In some cases they may refer you out for a BMT, but individual components of the treatment, such as a chest x-ray or daily labs, they may say, "We still want to do that." So it's definitely a more complex kind of plan, requires a lot more authorization coordination in order to ensure appropriate coverage.

(07:43)                  Point of Service health insurance (POS). Lastly, there is a three-tier point of service plan, or POS plan. This plan was designed to get the best of all worlds when we look at an HMO and a PPO.

The tier one level, if you use your PCP or your medical group, or you get authorization from them, you get your full HMO level benefits, the highest benefit level possible. But say you want to go to that transplant center without a direct referral from your medical group. If that transplant center is contracted as an in-network provider with your insurance carrier, then you can get tier two level PPO in-network benefits without having to get authorization from your medical group.

Lastly, if that specialty center does not have a contract with your insurance, you can still go there, but you will be getting PPO level out-of-network benefits. So a higher cost, but at least some coverage.

This is a great plan as far as flexibility, although it does lead to some difficulties in bill and claim submission and payments, and we do find some patients having to get a lot of fixes made because they may have an HMO level authorization to go to their transplant center, but if that authorization isn't put on the appropriate bill, then the claims are paid at the tier two PPO level. We do see a lot of patients have to fight to get that tier two payment upgraded to a tier one level. So definitely a good kind of plan, but you need to really make sure that every claim is managed appropriately.

Even the best insurance has significant expenses for a patient. Let's go through what those expenses can be.

(09:45)                   Health insurance premiums are the monthly cost of having an insurance policy. First of all, there's premiums. Premiums are normally the monthly cost of having an insurance policy. You're responsible for a premium whether or not you get medical services during that month. If you have an employer plan, the employer may pay all or the majority of the premium, but the employee may pay an additional amount. In some cases, especially for things like COBRA, the patient themselves has to pay the full premium.

(10:17)                  Health insurance deductibles are the first bills that the patient pays before insurance kicks in. There's a deductible. Now deductibles are normally the first bills in that medical period that the patient is fully responsible for before insurance benefits kicked in. Deductibles are typically annual deductibles, but they're not always a calendar year deductible. The majority of plans, come January 1st, that deductible renews and people are aware to think about having some money set aside. But sometimes an employer plan may have a policy year that renews every June 1st, for example, in which case the deductible also renews that June 1st. So it's important to understand not only what your deductible is, but when will it renew.

(11:04)                  Health insurance co-pays are flat dollar amounts paid for each doctor or hospital visit. There are co-pays. Co-pays and coinsurance are two different things. Typically when we'll refer to the co-pays, we're talking about flat dollar amounts, often in an HMO plan. For instance, $25 MD visit copay, that's the patient responsibility, or a $200 emergency room visit responsibility for the patient, whereas the insurance then pays the rest of the contracted rate to the provider.

 (11:34)                 Coinsurance is the percentage of a healthcare bill a patient is required to pay after meeting the deductible. Coinsurance is a little bit different. It's normally a percentage what the patient will owe. So after a deductible is met, a typical PPO plan is often designed as an 80/20 plan. The insurance pays 80% of the agreed upon contractual rate, the patient pays the other 20%.

(11:56)                  The definition of maximum out-of-pocket co-pays varies. Find out from the insurance company what your maximum out-of-pocket payment for healthcare includes.  What happens if you have a million dollars’ worth of medical care or more? Are you going to owe 20% of that? Obviously that could be a huge financial toxicity. But the good news is that in almost every plan, if you're seeing an in-network provider, you will have an out-of-pocket maximum. And this is designed to limit your liability to a maximum amount during that plan year.

Now, your out-of-pocket maximum may be quoted to you as say 5 or $10,000, but it's important to understand what is included in that. Sometimes it's everything that you're going to pay out of your pocket, including the deductible. But some insurances quote you deductible, and then separate out-of-pocket maximum where they're referring, say, to that 20% portion of the coinsurance. So, important to understand is the deductible included or in addition to the out-of-pocket maximum.

(13:01):                 Prescription co-pays may or may not count toward your maximum out-of-pocket expenses. Another difference with plans is whether or not prescription co-pays are included. Some plans have prescriptions built into them, and the out-of-pocket maximum prescription co-pays go against that. That's an ideal situation because whenever an out-of-pocket maximum is quoted, you really know that truly should be your maximum medical expense assuming you go to an in-network provider.

If you have a prescription card though with coverage from a different company, then your prescription co-pays typically do not go towards your out-of-pocket maximum. And when you're trying to figure out how much money you're going to spend on medical care, it could be much higher because of that.

(13:50)                  What are contractual discounts and “reasonable and customary rates” in health insurance? Now, I've mentioned several times about PPOs, HMOs having contractual discounts. If you have a PPO plan and you go to a non-preferred provider, your plan will still look at the bills and determine a reasonable and customary rate for that bill. They often base it on what their contractual agreements were with the in-network providers. The different is the in-network provider has agreed to that discount and will write that off. It's not your responsibility.

But if you go to a non-preferred provider, you can, and normally will, owe that reasonable and customary amount. So if your doctor bills for $1,000, and they're not a contracted doctor, the insurance may say, "We think $500 is reasonable and customary. We're going to pay 80% of that." The patient will owe the 20% of that $500, plus the second $500 to bring it up to the billed amount. So a huge liability.

If you are going to a non-contracted physician or medical provider, talk to them about it. See if they will accept the reasonable and customary rates, or in some cases negotiate a letter of agreement with your insurance company so that you don't have to worry about that unknown and possibly very large cost.

 (15:20)                 How COBRA health insurance plans work. Now, if you have your insurance through your employer or your spouse’s employer and that employment is ending, you may be eligible for COBRA. COBRA stands for the Consolidated Omnibus Budget Reconciliation Act. Congress passed the act many, many years ago with the idea of trying to ensure people have a way of keeping coverage, at least short term.

 (15:47)                  So who qualifies for COBRA? Well, the plan needs to be a group health plan with 20 or more employees. There needs to be a termination of the covered employee's employment for any reason other than gross misconduct. The employer must notify the plan within 30 days of termination. And then the plan must provide the employee an election notice within 14 days of receiving the termination notice from the employer.

(16:18)                 Ask your employer to tell the COBRA administrator as soon as possible that you are unemployed and have elected to have COBRA coverage.  Now, the employee then has 60 days to elect COBRA or decline. We have some patients who their coverage has ended, they've received their COBRA paperwork, they know they have 60 days to elect the coverage, and so they sit on it. While that is fine from a legal standpoint, what will happen is you're going to show as terminated in the insurance company's system. Your physician or hospital may start wanting you to pay up front, even if they're willing to wait because you tell them, "Don't worry, I'm signing up for COBRA. I'm going to get that coverage back in place," I guarantee you that retail pharmacies are going to make you pay up front for all those prescriptions.

Now, once COBRA's in place, it will go cover retroactively. There will not be a gap in coverage. But in the meantime, you could have put a lot of charges for prescriptions on your credit card, run a big balance, it may take you a while to get those funds back. So if you are going to elect COBRA, I ask and suggest that you speak to your employer to say, "Please notify my plan and my coverage termination, my employment termination as soon as possible. Speak to that COBRA administrator, have them send me that coverage paperwork as soon as possible. I want to pick it up."

When you complete that paperwork, it typically says you don't have to send in a payment along with the paperwork. "We'll send you a bill later on." You should know that until you do send in payment, you still won't show as eligible on the plan. So, if you are told you don't need to send a payment, that's true, but I suggest that you ask them, "I'd like to get coverage in place as soon as possible. How much do I owe? Who do I make the check out to?" And send that payment in along with the election notice. That way your coverage will be back in place as soon as possible.

(18:29)                  The Affordable Care Act tax credit. I spoke earlier about the Affordable Care Act or the ACA. Now, to qualify for ACA tax credit, you need to currently live in the United States, you need to be a US citizen or legal resident. You need to not currently be incarcerated. And you need to have income no more than 400% of the federal poverty level.

Now if you do qualify, then you can apply through a state run or federal marketplace. They are referred to as ACA exchanges. Some states like my state, California, has Coverage California, our state ACA exchange. Some states opted not to create an exchange of their own. If you reside in those states, you can go to the federal marketplace to apply.

(19:26)                  Who qualifies for Medicare? Now let's switch gears and talk about Medicare. Who qualifies for Medicare? Well we all, or at least most of us, think of patients 65 and older as being the Medicare population, and that is the great majority of people on Medicare. But there are also those under 65 who have received Social Security disability benefits for 24 months or longer that can then become Medicare-eligible.

People with end-stage renal disease generally can qualify for Medicare after three months of regular dialysis, or after a kidney transplant. Since this is a BMT talk, I'm not going to get into ESRD [end stage renal disease] rules for Medicare. They're a little bit different than other disability rules. Patients with ALS, Lou Gehrig's disease, can qualify as well.

(20:24)                  Medicare Part A covers in-patient hospital costs. When it comes to Medicare, there are multiple parts and pieces. So to help you understand them, we've got Medicare Part A. Part A is what the majority of working people in the United States are paying in to the Medicare system, you're paying into the Part A system in coverage. If you qualify for Medicare and you've paid in enough, then Part A is provided to you at no cost. That covers in-patient hospital stays.

(20:59)                  Medicare Part B covers out-patient hospital costs and physician charges.  Part B is separate. Part B covers outpatient hospital stays, for instance, in a cancer center or ambulatory treatment center. It also covers the physician's charges, what we refer to as professional fees. So these are covered at 80% of the Medicare allowable rate, meaning that the patients who don't have any other coverage owes that other 20%, which could be quite expensive. So Part B is normally not considered a drug coverage plan, but it does cover some medications. One of the most important for our group is immune suppression after a Medicare-covered BMT.

(21:58)                  There may be a penalty if you delay purchasing Part B when you are eligible.  Now, Part B can be purchased when you are eligible for Part A, but if you delay, say I don't want it now, there can be penalty for purchasing it at a later date.

In addition, there only may be certain periods of the year that allow you to pick up Part B with or without a penalty. So it's important to understand those rules, and if you qualify for Part B, but you don't want to pick it up right away, understand whether you are going to get a penalty that will apply to you for the rest of your coverage life on Medicare Part B. If you have an active large group health plan, because you or your spouse are still employed, that may be one reason why that penalty is waived. But it's important for you to understand if you qualify for that or not.

(22:39)                  Medicare Part C is Medicare Advantage Plans.  Medicare Part C is normally not referred to as Medicare Part C. A lot of people don't even know there is a Part C, but they will understand if you refer to it by its name as the Medicare Advantage Plan. So the Medicare Advantage Plan is where patients assign their Medicare Part A and B over to a commercial plan. So technically you still have Medicare coverage, but Medicare A and B no longer are responsible for paying your medical bills. The advantage plan is responsible.

(23:15)                  Medicare Part D is the prescription drug coverage. And then lastly, there's a Medicare Part D, that's the prescription coverage plan. So if you are going through cancer care, BMT, and you opt to pick up Part A and Part B, but don't get a drug plan, you may find that you have significant expenses. So most Medicare patients do pick up the Part D plan, in addition, since Part B only covers at 80% of the allowable rate, and there are some other deductibles even for Part A, most Medicare patients will also pick up a Medicare supplement plan.

(23:54)                  How to choose a Medicare supplement plan . Once again, when you pick up Medicare A and B, you should normally pick up a supplement plan right at that time as a window for picking it up, in which case, depending upon your age and how you became eligible, the companies may be obligated to sell you a policy. If you wait later on, they may be able to look at your medical history and say, "No, we don't want you." So if and when you're becoming Medicare eligible, if you think you want a supplement instead of an Advantage plan, then definitely consider purchasing one right away.

Now, when it comes to purchasing a supplement plan, there's a lot of them, and they're given letters to define the benefit level. Here is a list or a grid of the different Medigap or Medicare supplement plans. As you can see from this, plans F and G have some of the best coverage across the board. They may however have more expensive premiums. These plans will all cover some of the Medicare Part B coinsurance at 20%, but not all of them cover that in full.

There's also the Medicare Part A coinsurance. If you're in the hospital for a long time, you could owe daily amounts, and these plans won't pick those up. There's Part A and B deductible coverage for some plans. Part B excess charge coverage, you see that under F and G, that is just like what we were talking about with reasonable and customary on a commercial plan, if you see a non-Medicare contracting doctor who is going to charge extra, if you have these kind of plans, the supplement will pick that up rather than having it be your responsibility.

Now the great thing about this grid is that if you decide you want a Medicare Plan G, every company that offers a Plan G, the benefits are the same. So assuming that they're all reputable companies, you can just price shop the different plans you use and make your decision on who to pick up that way. Some patients ask, "Does your hospital accept this particular supplement or not? Are you contracted?" It's not like we would be for a commercial payer because Medicare sets the rate. So basically Medicare is the contract. We'll take any Medicare supplement and it doesn't matter. What matters is it a plan C or G or L, et cetera.

(26:34)                  Medicare Part D: How prescription drug plans work. Medicare Part D, that's the prescription drug plan. It's difficult to understand. They can be expensive, but they are typically less expensive than having no prescription coverage at all.

Now what expenses are there? Like other insurance plans, there's going to be premiums. There's an annual deductible. The deductible can vary based upon plan, but in 2021, Medicare set a maximum of $445. After that is met, then the coverage kicks in.

Now, coverage varies from plan to plan. There are different co-pays and different coinsurance. There's often different tiers of medication for generic versus brand name versus specialty medication. If you know what medications you're currently on and you're shopping for Part D plan, many of these plans have online calculators. You could input your prescription and it will show what the coverage rates would be. If you don't know what medications you're going to need in the future, it's very difficult to shop for a Part D plan.

(27:43)                  Medicare Part D prescription drug coverage gap or “doughnut hole”:  Now, these plans, after the deductible kicks in with coverage, but once you and your plan spend $4,130 combined on drugs, which includes the deductible, then you reach a coverage gap or doughnut hole. During that time, you have to pay for all your medication. The supplement Part D plan does not. It's an extremely complicated formula to figure out when you're going to get out of that doughnut hole.

I wanted to put some slides together, but they were coming out to 10, 20, 30 slides just on that formula itself. I am not Einstein, so it's a little bit difficult to go through them. I encourage you, if you're going to get a Part D plan to do some research and speak to advocacy groups and try to get some more information regarding that. We just don't have the time today. Once you get out of the doughnut hole, then your coverage kicks back in until the next calendar year or plan year starts.

(28:51)                  How Medicare part C Advantage plans work. Now let's go back to Medicare Part C, the Advantage plans. So in this case, as I mentioned, Medicare fee-for-service, A and B benefits are signed over to a commercial carrier, an HMO, or a PPO plan. And there are pros and cons to this.

Now, the pros, typically you will see lower premiums. You still have to purchase your Part B plan, but you don't have to pay just a supplement. Sometimes these include drug plans, so you don't have to purchase the Part D plan. The premiums, Medicare themselves helps offset some of the cost since they're getting out of paying your medical bills. That's the pros.

The cons may be that there are restricted networks. Almost every hospital in the US accepts Medicare rates. The great majority of physicians and academic medical centers are all Medicare-contracting. If you sign up for Medicare Advantage plan, you are limited to that PPO plan or even more restrictive, an HMO plan. You can't go to any center you want to anymore. So besides restricted networks, there are more authorization requirements.

Medicare has a rule book, very few items actually require prior authorization. Stem cell transplants, for instance, where you look up what diagnoses Medicare covers in autologous or allogeneic transplant for, we don't have to request authorization for Medicare. But if you sign up for the Advantage plan, then we do need to get their approval for that service and many others.

As we saw from the Medicare supplement grid, many of the supplement plans, when combined with A and B, you may have 100% coverage for all your doctor and hospital bills, but that will not be the case under most Advantage plans. You may have lower premiums, but you often have higher co-pays.

 (30:54)                 Medicaid has asset and income requirements you must meet to qualify for coverage. I briefly wanted to talk about Medicaid. It needs to be brief because there are different rules for each state, so I can't talk about specifics for any one state. However, one of the things they have in common are typically that there are asset and income requirements that need to be met. Medicaid is designed for people with low assets and low income, otherwise you may not qualify.

Folks who do qualify may get 100% coverage for all of their medical care, or they may have in some states what's referred to as a share-of-cost, where they owe the first X amount of medical bills that come in the door. Now, the good news about share-of-cost different from a premium is if you don't get medical care in a given month, then you don't owe any premiums, so you only owe if you get services. But again share-of-costs [inaudible 00:31:53] every Medicaid patient.

(31:56)                  Managed Medicaid plans. Managed Medicaid plans have become more and more popular in most states. Similar to a Medicare Advantage plan, the idea is that the coverage is shifted over to a commercial company. Unlike Medicare though, with the Medicare Advantage, you choose what company you want, and if you want an Advantage plan at all. With Managed Medicaid, you don't get a choice. The Medicaid plan will stick you in a managed plan, and sometimes you get out of it for the actual transplant. That's not always the case.

 (32:31)                 What happens if you need medical care but can’t afford insurance?. So, actually, what happens if you need medical care, but you can't afford insurance? You don't have any options for insurance through your employer, you don't qualify for Medicare, and you can't qualify for Medicaid.

Depending on the state that you live in, in many cases, the county that you reside in is responsible for providing you medical care. If you go to your local county hospital, they may have you sign up for the billing and pay program. In some cases, they provide uncompensated care, basically free medical care, sometimes free prescription medications for low-income, low-assets county residents who otherwise don't have coverage.

(33:27)                  Medicare coverage of clinical trials.  I'd like to talk about clinical trials and insurance coverage. Many of you have gone through stem cell transplant, and certainly some of you may still be going through that treatment now. Some of these treatments are on clinical trials. If you need future treatment, it might be on a clinical trial.

Medicare created a clinical trials policy back in 2000 because they wanted Medicare patients to get the benefit if they were able to participate in clinical trials. Now, they did specify that it needs to be a qualifying clinical trial, and those rules are pretty broad. So most academic medical centers, the trials that they're doing are qualifying, but if you're going to participate, it's worth asking the investigator who's discussing the trial with you is this a Medicaid qualifying trial.

What wouldn't be, is if a trial is just a data collection trial, it's not really a treatment for curative or treatment intent, it might not be qualifying, but most cancer trials are qualifying.

[If] Medicare says that there are investigational services on the trial, these would be, for instance, if the trial is to study the efficacy of a medication or cell therapy that has not be approved by the FDA for commercial use, then that drug or cell product is investigational, experimental. It needs to be provided or covered by the trial itself. If that particular drug or treatment is been given in combination with the stem cell transplant, but the transplant itself, say for leukemia, is a standard-of-care service, even though it's part of the trial, Medicare says with the clinical trials policy that Medicare will cover the standard-of-care services on the trial.

(35:32):               Medicare Advantage plan coverage of clinical trials.  Now, if you have a Medicare Advantage plan, clinical trials are kind of a unique area of coverage because as we said, you've assigned over your Medicare Part A and B, but under a clinical trial, all of a sudden, Medicare A and B are going to come back into play and be the primary player for the standard-of-care services once you're on trial. The Advantage plan then picks up as secondary, and they cover the difference between Medicare's A and B co-payments, which are typically higher than the Advantage plan, and what the Advantage plan would pay.

Now if you got a supplement, they're going to pay that difference anyway, but the Advantage plan, if only Medicare A and B pay, you'd be out significant out-of-pocket, so this particular rule allow outside Advantage plans to ensure that you're no worse off by going on a clinical trial rather than getting treatment through standard-of-care.

(36:33)                  Affordable Care Act clinical trial coverage. The Affordable Care Act came out with their own clinical trial policy to apply to commercial insurance plans, both those purchased through the Affordable Care Act and most employer group health plans as well. And it closely mirrored Medicare's policy of saying the standard-of-care services on qualifying trial need to be covered by these insurance plans.

That's usually the case, but there are some plans that are referred to as grandfathered plans. Plans that excluded coverage for clinical trial standard-of-care services prior to the Affordable Care Act that are still in place have been grandfathered, and those rules and requirements don't apply to them.

Though we still have some patients unable to participate or unable to get coverage to participate in a clinical trial, it's important to understand what coverage you have. And if your insurance, if they don't want to pay for standard-of-care service on trial, you need to ask them are they a grandfathered plan, how can they have the right to do this?

 (37:40)                 How Coordination of benefits (COB) works with multiple health insurance plans. Coordination of benefits or COB is the term that we use to talk about how patients with multiple insurance plans, who pays first, and how do they work together.

So, an employee's own group plan is almost always primary over a spouse's plan. Group plans almost always pay primary before an individual plan.

For children covered by two policies, one from each parent, then those plans normally use the parent's birthday rule. The birthday rule states that whichever parent's birthday comes first in a calendar year, that plan is primary. That doesn't mean which plan is older, it means if one parent has a birthday in February, and the other June, then the plan from the parent whose birthday is in February is the primary one.

Medicaid has its own rules regarding coordination of benefits, especially in relationship to commercial plans. Of course Medicare plans play primary to supplements, but if you have Medicare and employee group health plan where it's 20 or more employees, and you have that coverage through your active work or say it's for your spouse, their active work, that employee group plan is primary over Medicare. If you stop working or they stop working, if it's a COBRA plan or retirement plan, then Medicare is primary.

 (39:38)                 Inform your health care provider about all of your insurance plans. Please, please, please be sure to inform your medical providers of all of your insurance coverages. We have some patients who come to us, they have one plan that they really like, perhaps they don't like the other plan as much, and they only tell us about one of their plans. But if that's really the secondary plan, based upon coordination of benefit rules, when we submit claims, they often get kicked back out saying, "No, no, no, you need to bill this other plan first." We as providers say, "Holy mackerel, we didn't know about that other plan."

What's bad is we didn't get a transplant or other treatment authorized through them, we may now get denials and that second plan may not want to pay. So it's extremely important that we know about all of the plans that you have.

(40:27)                  Cancer policies. I'm going to touch briefly on other types of policies including cancer policies and cost-sharing ministries. So, cancer policies are plans that are not intended to replace full insurance. That's an important distinction. Some people understand that and some people, that's their only coverage, that's not going to be sufficient. So it may help cover deductibles, copays, lost income, that's one of the primary purposes. It normally has to be purchased prior to a cancer diagnosis in order to have a payout. In some cases, a lump sum plan may provide a fixed dollar payout based upon a particular diagnosis under the plan.

 (41:23)                 Health insurance cost-sharing ministries are not health insurance.  Health insurance cost-sharing ministries aren't insurance. So what are they?

They are typically pooled funds, often through a church or religious institution, sometimes through a social group, where people voluntarily pay into this fund, and then those dollars are used to offset or pay medical bills for people in the group. The problem with this type of plan is that there are no guaranteed coverage benefits. There are no legal protections.

If you have a traditional insurance plan, in California, we have the Department of Managed Care that oversees HMOs. We have the California Insurance Commission that oversees regular commercial insurance. But there aren't the same legal protections for these cost-sharing ministries. You can pay in. You then have to submit your bills to them and they will decide what and if they will pay. There's no guarantees of that.

Because of that lack of guarantee, most providers consider patients with these plans to be self-pay. In that case, they may require significant deposits up front. You have to pay for your medical care as you get it. And if you're lucky you'll get some reimbursement through the cost-sharing ministry, but again, no guarantees for that. We're getting near the end of my talk.

 (42:55)                 How to appeal a denial of coverage by health insurance. I did want to talk quickly about appeals if you get a denial. There's two different types of denials, authorization denials prior to treatment, and then claims denials where treatment was given and then the bill gets kicked back.

So, if it's an authorization denial, one of the questions to understand is, is the service denied or was it that the provider was denied, and that the plan is redirecting the care. For instance, you have an HMO and you want to get transplanted at one center, they're saying, "No, our center of excellence is a different center." They didn't deny a BMT, but they did reroute you.

So, if a service is denied, it's important to work with the requesting provider and ask them are they sure that these are the right diagnosis codes and procedure codes. If they weren't accurate, denials can occur. If it's a redirection, and you're not happy about it, does the provider that they're trying to direct you to have the same skill set as the denied provider? If not, that may be a reason for an appeal. Do partner with your medical provider for this appeal.

Now a claims denial means that service is already provided, a bill went in. Was prior authorization required and obtained? If it was required and not obtained, that's a clear reason for a claims denial. The question is can it be requested retroactively. Once again, are the diagnosis codes and procedure codes applicable and accurate? So work with your provider to see if that was the problem. In some cases, claims can be resubmitted.

(44:38)                  Practical tips to minimize your healthcare costs. Lastly, a few odds and ends.

Check provider billing statements against insurance explanation of benefits. Every time your insurance pays, you should get either in the mail or electronically an EOB [explanation of benefits] explaining what they paid, what you owe, and why you owe what you owe. Was it put towards the deductible, a copayment, a coinsurance? Was something denied and therefore your responsibility?

Know when open enrollment periods begin and end. If you're going to be changing plans, it's important to understand those windows. You don't want to be caught finding out that you didn't turn in paperwork in time. Now you may have to wait another year to get the coverage you want.

Understand potential penalties for delaying Medicare coverage. We talked about that earlier.

Apply for financial assistance if needed. Many providers do have financial assistance plans for lower income patients. In many cases, we're able to waive copayments or deductibles, and accept insurance's payment in full. But if you have difficulty making those kind of payments, talk to your provider to see if they have any sort of assistance.

In addition, if you have expensive medications, especially ones that are not covered by your insurance, there's often brand-specific medication assistance. Speak to the manufacturer of your brand, see if they have anything. The social worker or other person at your doctor's office or the transplant center may be able to assist. Prograf is one expensive drug that a lot of patients do get assistance from the manufacturer, so that can certainly be of help.

(46:30)                  Websites with useful information about health insurance. And lastly, in closing I just want to show you some of the websites for additional information and resources on COBRA, the Affordable Care Act, Medicare, and how to choose a Medigap or Medicare supplement policy. I encourage you to take a screen shot of this or take a photo with your camera. If you don't remember these links, you can of course google. I recommend that when you do google for information on these areas, look for a .gov official government website to make sure you're getting the most accurate information.

So, thank you very much for your time, and I look forward to answering the questions whenever possible.

Question and Answer Session

(47:14) [Marcia Seligman]  Thank you, Mr. Goldstein for this excellent presentation. We will now take questions. As a reminder, if you have a question, please type it into the chat box on the lower left hand corner of your screen.

(47:26)  The first question is, "I am still on disability and have insurance under that umbrella. I am concerned I won't be able to get coverage if I work part time. Will I always be able to have coverage regardless of my condition as a transplant patient?"

(47:45) [Gary Goldstein] So I can't speak to specifics, what I will say is that the answer is no, you're not always guaranteed that coverage. Some of the coverage is only during time of short-term disability. Once you go on long-term disability, it may not kick in, or it may for those first two years after which you may qualify for Medicare if you are still disabled.

So, it is important to talk to your plan, whether that's through your former employer's HR or current employer's HR, and find out specifically for them what your plan allows or doesn't allow, especially when it comes to working to part time. In some cases if you don't work enough hours, you may be able to keep your coverage, but have to pay a greater percentage or the entire premium yourself.

(48:40) [Marcia Seligman] The next question is, "I am paying high amounts of coinsurance on my eye care due to a PPO plan with Mayo. Is there a suggestion? I'm working with my insurance company for the tier plan."

(48:57) [Gary Goldstein] So eye care is very tricky because a lot of medical plans say, "We don't want to cover things that should be covered under a vision insurance plan." And vision insurance plans typically only have a few thousand dollars’ worth of coverage per year. They're really designed for an eye exam and glasses or contacts. So if you have a medical problem, like ocular GVHD, then you really need to look at what the benefit is and why is it that you're having problems.

Now, there can be a difference, for instance, in number of visits authorized. Typically, there's not a benefit maximum for an ocular GVHD specialist visit, but it may be authorization-wise, they only want to approve X number of visits. If you still need more, have your provider give a letter of justification why you still need that.

One of the problems we find is some of our patients benefit from eye drops that are made from their own serum. Most insurances do not cover that. We have not been able to find a way to get that covered by any insurance. And in some cases, there are transplant groups that nonprofits that work with fundraising, so sometimes our patients fundraise to cover some of these kind of expenses. But there's not a lot of great options out there unfortunately.

(50:28) [Marcia Seligman] Okay, thank you. The next question is, "Will signing up for Medicare cancel the retirement medical plan for my husband? His employee insurance approved his BMT, and we pay the premiums to keep it. Can we have both?"

(50:44) [Gary Goldstein] So, there are different rules based upon that particular employer. I will say this, the great majority plans say that once a patient becomes Medicare-eligible, they are required to accept Medicare Part A and purchase Medicare Part B. That retirement plan may then convert to the equivalent of a supplement plan where benefits say, "We cover 20% of the Part B. We cover 20% of the doctors' bills."

If you don't elect Medicare A and B, those plan benefits may still switch over to that supplement. In other words, now you're only getting 20% coverage. So it's extremely important to find out from them, "Do I have the option to just keep this plan?"

The other thing that would be that even if you do that, will that disqualify you for a Medicare Part B penalty later on? So, in most cases, you're going to be needing to take on that Medicare, and that plan will either convert, or in some cases end. Some employers actually have their own supplement plan that they will switch you over to.

(51:59) [Marcia Seligman] Can you use Medicare and personal insurance combined for expenses?

(52:05) [Gary Goldstein] The answer is yes, but if you have an individual plan that's not a Medicare supplement, the only rule for coordination of benefits that is clear is that Medicare pays first. But how that secondary coordinates with Medicare, or if they coordinate, is very unclear.

So, what will happen is, say you have a Medicare Part B, you outpatient chemotherapy, Medicare applies a deductible, Medicare applies a 20% copay. If you send that to a Medicare supplement, they're typically going to say, "Okay, well we're picking up that deductible. We're picking up that 20% copay, or majority."

Your individual plan may say, "Oh, wait, you've got an $8,000 deductible, so that's kicking in. You still owe all of that money." So they don't coordinate very well. They're not made to work together as well as a supplement plan. Like I said, some of these plans to convert to a supplement, especially if it's one through an employer. So those work a lot better, and you need to understand the rules or talk to the plan or to your employer.

(53:19) [Marcia Seligman] Okay. The next question is, "What is the most effective way to research individual private pay insurance plans in order to determine if a specific hospital will accept them?"

(53:33) [Gary Goldstein] So first, when you're comparing plans, one of the things that I like to do, many of our patients maybe have an employer that's offering, say, three plans. Other times, you're shopping individually, so it's a little bit more difficult.

First of all, I like making an Excel spreadsheet that lists, "Okay, here's the annual premium total. Here's the annual deductibles for the different plans. Here's the out-of-pocket maximum," and again, try to figure out if that includes the deductible or not.

Try to figure out what the total expected expense is, especially if you were to meet that out-of-pocket maximum, say you get a lot of bills. And then you can say, "Boy, if I choose this plan, I've got higher deductible, but my premiums are so much lower, it's going to be a better plan financially."

Once you understand which plans seem to be the best for you out-of-pocket, then you can go to your preferred center and say, "These are the plans that I'm interested in. My first choice is Company A. Are you in network with them?" Again, be sure to say, "I'm buying it on the exchange," or not, because that could make a difference-

That's really the best way to go about it. What you may find is that one doctor you go to says, "I'm preferred." The other doctor say, "I'm not." So once again, it's not cut and dry. You'll just have to decide who you want to go with.

(54:56) [Marcia Seligman] Okay, thank you. This will have to be our last question. We are running out of time. But the question is, "In 2013, there were only a small number of transplant facilities who accepted insurance Medicare coverage for allo transplants. Has this changed?"

(55:14) [Gary Goldstein] Well, there were a lot of centers that accepted Medicare coverage for allogeneic transplants. The trick is what diagnosis you had. So if you have acute leukemia, or any leukemia, you were okay. If you had MDS or myelofibrosis or lymphoma, and you needed allogeneic transplant, those diagnoses weren't on the covered list.

What has happened is there is now a coverage with evidence determination, or CED, for people with MDS and myelofibrosis, as well as multiple myeloma and sickle cell, saying allogeneic transplant will be covered by Medicare as long as you agree to participate in a particular clinical trial that is a data enrollment trial that shows or will show long-term whether that treatment is effective or not.

If you have lymphoma, you are still in the dark. Medicare may or may not cover that. They're silent on whether allo transplant is covered for a lymphoma diagnosis. That's still a problem. The transplant community is working on trying to get Medicare to make a determination on that, but we're not there yet. So you have to work with your individual center as to whether they're going to provide that treatment or not.

(56:37) [Marcia Seligman] Closing. On behalf of BMT InfoNet and our partners, thank you, Mr. Goldstein for your very helpful remarks. And thank you, the audience, for your excellent questions.




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