1. Common Insurance Challenges & Access Strategies for people with CF
Yamini Saxena, MHSA Senior Case Manager, CFF Compass Bethesda Office, MD

2. Presenter Disclosure
Yamini Saxena, MHSA There are no relationships to disclose related to this presentation.

3. Common Insurance Challenges & Access Strategies for people with CF
Find plans where medical deductible is integrated with prescriptions
Copay cards may off-set deductible
Health Savings Accounts (HSAs)
Hospital financial assistance programs
Supplemental coverage
State-sponsored premium assistance or special health needs program
Medicaid through waiver programs
Disease-specific non-profits
COST BARRIERS
Rising marketplace premiums and don’t qualify for subsidies or Medicaid
High Deductible Health Plans (HDHP) = ↑ out-of-pocket costs
What are the strategies for the first two bullets?

4. Common Insurance Challenges & Access Strategies for people with CF
COST BARRIERS
Newly eligible to Medicare
Home IV not covered
ACCESS STRATEGIES
Supplemental coverage
Medicare Savings Programs
Medicare Extra Help
Medicare Supplemental Plans
Medicaid through spend-down or waiver programs
State-sponsored special health needs program
Medicare Advantage plans
Dual eligible coverage
State-sponsored chronic needs program
Outpatient infusion Dept.

5. Common Insurance Challenges & Access Strategies for people with CF
Other options: employer plans, dependent coverage, COBRA
Transition of Care or Continuity of Care
Apply for network gap exception, peer-to-peer review usually better than written appeal
Utilize in-network facilities, at least for diagnostic procedures or lab work
ACCESS BARRIERS
Coverage for further away or out-of-state care centers
Limited plans available
Going outside the exchange – losing subsidies to cover care center

6. Common Insurance Challenges & Access Strategies for people with CF
Consider formulary alternative or generic substitute
Proactively request formulary exceptions or prior authorizations
CoverMyMeds can help facilitate
If PA is denied, doctor may submit additional documentation without appeal, or ask for a peer-to-peer review over the phone
72-hour emergency fill
If you identify any unreasonable coverage restrictions for CF drugs, communicate to Compass
ACCESS BARRIERS
Prior authorizations

7. Common Insurance Challenges & Access Strategies for people with CF
ACCESS BARRIERS
Requirement to fill enzymes through mail order pharmacies that do not bill copay cards
ACCESS STRATEGIES
Manual reimbursement with enzyme copay cards
Fill through specialty pharmacies

8. Open Enrollment – Key Dates
MEDICARE
Oct 15 – Dec 7
MARKETPLACE/INDIVIDUAL PLANS
Nov 1- Dec 15 on healthcare.gov
Some states have extended the deadline
Compass can help people navigate their insurance options; recorded webinar on Port CF

9. International CF Patients Issues & Access Routes
Access to medications and devices such as vests, outside USA
US manufacturers do not offer patient assistance outside USA; however, some will allow if patient is being treated by a US physician
Manufacturers with global distributors can connect with family
Non-profits may provide financial grants, both domestically and globally (e.g., First Hand Foundation)
Access to specialized care with physicians who can deliver care for cystic fibrosis
Cystic Fibrosis Worldwide has CF clinics listed globally
Connect with established CF organizations in neighboring countries that have care models (e.g., UK Trust Fund)
Few CF pulmonologists in US willing to provide phone consultation
International physicians can join LLC listserv for clinical advice

10. International CF Patients & Access Issues
Assistance in coordinating travel to the United States for treatment
Help connect with CFCC who accept international patients
Hospital “international coordinator”
Must show financial capability
Manufacturer patient assistance programs
Health insurance marketplace
State-sponsored children with special healthcare needs program

11. Questions?
Yamini Saxena, MHSA Senior Case Manager, CFF Compass Bethesda Office, MD