Medical debt is a persistent source of stress for a growing number of people living in the United States, especially people with significant medical needs.
According to a recent report from the Kaiser Family Foundation (KFF), more than 16 million people owe more than $1,000 in medical debt, and 3 million owe more than $10,000. And the crisis may get worse, since drug prices are on the rise.
Fortunately, a number of resources exist to help people gain access to the medications and treatments they need without sending them spiraling into debt. However, many people can get overwhelmed when trying to determine which resources are available to them and how to pursue them.
Enter the financial navigator. Financial navigators are uniquely positioned within hospitals and health systems to help patients identify the various resources available to them and apply for the ones that best meet their needs. Aided by technology solutions that streamline the process of finding appropriate resources and applying for them, financial navigators can steer patients toward the right assistance at the right time.
Understanding the Various Options for Financial Assistance
It’s stressful enough to cope with a medical condition that requires expensive treatment. Many patients are unprepared to navigate a complicated network of financial assistance resources for which they may or may not be eligible. As financial navigators help patients find and secure these resources, they should should explore all potential cost-saving opportunities, including:
Copay Assistance Programs
For many people who need ongoing access to medications but can’t afford the cost, copay assistance programs are a lifeline.
“These programs help with paying deductibles, copays, and coinsurance for patients with cancer or other chronic diseases with high-cost treatment,” explains Lambert.
Manufacturer Copay Assistance: How it works: pharmaceutical manufacturers offer discount programs to patients who need help paying for their prescription drugs. They provide coupons that patients can take to their pharmacy when filling their prescriptions, or patients can apply the coupon toward their insurance company’s annual cost-sharing requirement. Patients must have private insurance, not government-funded insurance, to qualify for these programs, notes Lambert.
Foundation Copay Assistance: Meanwhile, other organizations, including nonprofit foundations, provide copay assistance but also include patients who have government-funded insurance such as Medicare, Medicaid, or military benefits. The grants are typically disease-specific, with assistance available for people with a variety of conditions, such as multiple sclerosis, arthritis, sickle cell disease, and various forms of cancer. A few examples of nonprofit foundations that provide this type of assistance include The PAN Foundation, the Healthwell Foundation, Needy Meds, CancerCare, and the Leukemia & Lymphoma Society.
Free Drug Programs
Through free and replacement drug programs, pharmaceutical companies provide medications at no cost to patients in need. They’re typically most appropriate for uninsured patients who would otherwise be unable to pay for their medications, according to Clara Lambert, Director of Financial Navigation at TailorMed.
However, there can be situations when a patient with insurance coverage may be eligible for a free drug program because their insurance doesn’t cover the cost of prescription medications. For example, someone might have Medicare but they also have a high out-of-pocket limit, or they have Medicare Part D with a high copay.
In a hospital or health system setting, specialty and infusion pharmacies are often responsible for managing free drug orders. However, if the hospital pharmacy is not in-network with a patient’s insurance, financial navigators can help them find other resources–such as drug savings programs at pharmacies in their area.
A financial navigator can also investigate the possibility of government assistance for some patients.
In some circumstances, people with Medicare may be able to turn to State Health Insurance Assistance Programs (SHIPs) and the Social Security Administration’s Extra Help program, which is designed for Medicare beneficiaries who need help paying their monthly premiums, annual deductibles, and copayments related to Medicare prescription drug coverage. Also, some states have State Pharmaceutical Assistance Programs that can help people with certain medical conditions who need assistance.
Hospital Charity Programs
Charity care is also a possible source of financial relief for some patients.
The Patient Protection and Affordable Care Act (the ACA), which became law in 2010, included a requirement that nonprofit hospital organizations offer financial assistance to people who can’t afford care. As a result, the IRS requires nonprofit hospital organizations to offer charitable care to low-income patients. They have to spell out all the specifics, including how patients can apply for help through these Financial Assistance Programs, or FAPs.
However, patients may find it hard to navigate the process of applying for assistance, in part because the eligibility requirements vary from state to state, according to the Consumer Financial Protection Bureau. For example, the threshold for eligibility for free care is a household income below 100% of the federal poverty level (FPL) in Washington state but 200% in New Jersey and Massachusetts. Some people whose annual income exceeds that threshold may be eligible for reduced-cost assistance—if they know about the assistance and can navigate the application process, that is.
Also, patients don’t always find out from their provider what’s available in terms of charitable dollars. The result: many people may not get financial assistance that could help them. In fact, a study in The New England Journal of Medicine found that many hospitals didn’t notify patients about their eligibility for financial assistance before the hospitals began the process of debt collection.
Harnessing the Power of Technology
With so many different forms of patient financial assistance–and different eligibility requirements and application processes for each program–there are a lot of details to grasp.
Fortunately, technology solutions can expedite and streamline the process. Platforms like TailorMed enable navigators to flag patients who may be at risk of financial distress. These solutions produce a tailored list of resources for which the patient may be eligible, based on their diagnosis, treatment plan, insurance, income, and other details. The technology then automates the enrollment process, so that navigators can save time on manual tasks and focus on what really matters: helping the patient afford care.
Stopping Medical Debt Before It Starts
With healthcare costs, including medication costs, on the rise, patients are diligently searching for ways to pay for treatment. Many aren’t aware of the financial assistance that may be available to them. And those who are can be easily frustrated by the prospect of culling through such a wide variety of options, including free drug programs, copay assistance programs, hospital charity programs, and government assistance–all of which have different rules and requirements.
That’s when a financial navigator can step in and lead them through the process. And technology solutions can make it so much easier to access and enroll patients in resources to help them pay for the care they need—without racking up debt.