Case Scenarios

Case Scenarios PowerPoint PPT Presentation


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Case Scenarios

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1. Case Scenarios

2. “I don’t have health insurance.” Sheila, a 49-year-old woman with no health insurance pays to see her doctor for annual check-ups. During her last exam a breast lump is detected and she pays for a mammogram and needle aspiration. Unfortunately, the test results come back positive and Sheila is found to have breast cancer. She has used up all her money. How do you advise her?

3. “I don’t have health insurance.” She is eligible for Free Treatment through the Breast and Cervical Cancer Prevention and Treatment (BCCPT) program as long as she meets income, residency, and immigration requirements and has a social security number. Sheila and her doctor should fill out the HealthyWoman Enrollment form PA 600B.

4. The worried young woman Maggie, a 28-year-old woman calls you because she has pain and maybe a lump in her right breast. She works as a waitress and has no health insurance coverage. What would you tell her?

5. The worried young woman Because of her symptom and lack of health insurance, she may be eligible for Free Treatment through the BCCPT program. She should call the PA Department of Health’s HealthyWoman program to see if she is eligible to get a mammogram. Maggie should mention that she is symptomatic and has a lump. If she is found to have breast cancer she will be put directly into the BCCPT program.  

6. “I want the best hospital.” Dolores is a 52-year-old woman who has been diagnosed with breast cancer and has been accepted into the BCCPT program. Her physician would like her to go to the hospital that he is affiliated with for her treatment, but Dolores would like to go to another hospital. She calls you to find out what her options are. What do you tell her?

7. “I want the best hospital.” Dolores can go to any Medicaid provider. As long as the hospital accepts Medicaid, she can go there. It is her choice.

8. 2 years into tamoxifen treatment Linda is a 55-year-old woman who was diagnosed with breast cancer two years ago. She is currently on tamoxifen. Recently she lost her insurance coverage. Is she eligible for Free Treatment through BCCPT?

9. 2 years into tamoxifen treatment Yes, she is eligible for the BCCPT program. Tamoxifen counts as current treatment as does Arimidex. As long as she meets the other eligibility guidelines, she is medically eligible and could receive up to three months retroactive coverage.

10. Coverage for medical follow-up Nancy a 48-year-old woman is diagnosed with breast cancer and receives medical assistance via BCCPT. In February 2011, Nancy has surgery, reconstruction, and chemotherapy which is completed in November 2011. She is estrogen receptor negative and is NOT put on tamoxifen. Her doctor tells her to come for a follow-up check-up in February 2012 at which time she will also need a mammogram. Nancy receives a letter in December telling her that her that she is due for renewal for the BCCPT program and that she has 30 days from receipt of the letter to complete the PA600BR (renewal document). Her doctor must send it and medical documentation to the Office of Medical Assistance Programs for review. How do you advise her?

11. Coverage for medical follow-up Tell Nancy to contact her doctor’s office immediately to make sure that the renewal forms are sent in as required. If the Office of Medical Assistance Programs does not get the documentation, or if the woman is no longer in active treatment she is no longer eligible for the BCCPT program. You should encourage her to take care of any outstanding medical needs before her coverage runs out if it is determined she is no longer eligible for the BCCPT program.

12. Marty, a 40-year-old woman with breast cancer has just finished a course of chemotherapy. She requires medical visits but is not currently receiving medication or radiation. She receives a notice stating her coverage is terminated because she is not in ongoing treatment. Is this correct?

13. Yes, follow-up medical visits, labs and x-ray studies are not considered the same as ongoing treatment, therefore Marty is no longer considered in treatment and her coverage through BCCPT will be terminated. If her cancer reoccurs, the doctor can make a referral by submitting the PA 600B form. OR She can go through the HealthyWoman program directly for a mammogram and exam.

14. Meredith is 35 years old and has been diagnosed with advanced metastatic cervical cancer and has just finished a course of chemotherapy. She requires medical visits, labs, and x-ray studies but is not currently receiving medication or radiation. She receives a notice stating her coverage is terminated because she is not in ongoing treatment. Is this correct?

15. Terminating Meredith’s coverage is NOT correct. Being on remission is looked at differently from advanced stages of cancer where it is considered persistent and incurable and the person is in need of ongoing medical care. Because she Meredith has metastatic cancer, her doctor should clearly document that the cancer is persistent and incurable and that his patient needs ongoing medical services and treatment. The key words are “persistent and incurable.”

16. Underinsured Anna was diagnosed with breast cancer and her insurance covered some but not all of her treatment. She cannot afford reconstructive surgery because she has reached the limit on her policy. Even though she has insurance, can Anna apply for the BCCPT program?

17. Underinsured Yes, Anna can apply because her insurance is not considered “creditable” coverage. In other words, her insurance isn’t equal to the coverage she can receive from the BCCPT program. Anna is underinsured.

18. Eligibility: Transition from BCCPT to Medicare Shirley has been treated for her breast cancer through BCCPT for the last 13 months. She recently turned 65 years old and is now enrolled in Medicare and is no longer eligible for BCCPT. She is having trouble paying her Medicare Part B premium that covers her medical insurance for physician and outpatient care. She also needs help paying her deductible. What can Shirley do? Is she eligible for help with Medicare because she was on the BCCPT program?

19. Eligibility: Transition from BCCPT to Medicare The County Assistance Office reviews cases like Shirley’s for other medical coverage before terminating a woman from the BCCPT program. Shirley may qualify for Medicare Savings Programs that will help pay for: Medicare Part A, which covers hospital insurance Medicare Part B, which covers physicians’ visits and other outpatient healthcare providers Help with deductibles, medi-gap policies and coinsurance Beyond the Medicare Savings Programs she may also be eligible for extra health through the Medicare Part D prescription plan Shirley should contact her local County Assistance Office to see if she qualifies for any of these programs. She can also call Medicare directly at 1-800-MEDICARE.

20. Medicare A Ruth has been diagnosed with cervical cancer and has Medicare Part A. Ruth needs chemotherapy by IV infusion at an outpatient clinic but Medicare will not cover Ruth because she does not have Medicare Part B. Ruth applied for the BCCPT program but is told that she doesn’t qualify because she has “credible coverage” through Medicare. How do you advise her?

21. Medicare A Encourage her to appeal this decision because without Part B she must pay out-of-pocket for all physician visits and outpatient care. If a woman can not afford this, she will not have access to the treatment and care that she needs. While Medicare A is considered creditable coverage by the Office of Medical Assistance Programs, some women have been able to get into the program by appealing the decision.

22. Final Notes: Always have the doctor send as much medical information as possible when filling out the necessary forms. The PA Department of Welfare’s Office of Medical Assistance Programs makes the final medical decisions regarding ongoing treatment. The woman and her doctor ALWAYS have the option to appeal a denial. Please share this information! You can help save the lives of women across the state by providing them with lifesaving free treatment through the Breast and Cervical Cancer Prevention and Treatment Program.

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