Virginia Bleeding Disorders Program

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Virginia Bleeding Disorders Program

• September 2007

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Goals of VBDP

• To assess the current state of health of
  Virginians with inherited bleeding disorders
• To develop and support systems of comprehensive
  care
• To assure access to care by acting as a safety
  net and providing care coordination
• To promote healthy policy development

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1 Assessing the current state of health for
Virginians with BD

• Data, data, data
• Numbers served by clinic, diagnosis, severity of
  disease, insurance
• Ex Southwest Needs Assessment
• Adult Study

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2 To develop and support systems of
comprehensive care

• Supplementing salaries of core team
• Negotiating payments to promote preventative and
  comprehensive care
• Providing insurance case management
• Promoting joint programming
• Sharing and networking across centers

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3 To assure access to care by acting as a
safety net and providing care coordination

• Pool of funds
• Financial basis
• Bleeding disorder-related care only
• Contracted hospitals
• Limited in scope
• State pharmacy based
• Contract with Patient Services, Inc

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4 To promote healthy policy development

• Hemophilia Advisory Board
• Advises VBDP in management of programs
• Considers relevant legislation
• Reviews impact of other policies on BD community
• Studies trends and future of BD care
• Transition Subcommittee

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Transition Milestones Insurance concerns

• What do I do when I age out of my parents
  insurance?
• How can I obtain COBRA? How can I afford COBRA?
• What happens if I am no longer eligible for
  Medicaid on my 19th birthday?
• What if I have a lapse in insurance coverage of
  more than 63 days?
• Do I HAVE to pick a career that offers employment
  with health insurance?

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Options for coverage during transition

• Analysis of all insurance options
• School insurance
• Other parents policy
• Full-time and part-time employment options
• PSI and open-enrollment
• Guarantee issue vs. high risk insurance pools
• Pool of funds for pre-existing conditions
• Factor assistance programs
• Financial screening through hospitals

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Overview of VBDP Pool of Funds

• Limited amount of money to assist uninsured,
  underinsured and those on a preexisting condition
  clause
• Not an entitlement program
• Funds from Title V (MCHB) and state general fund
  match

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Covered Conditions

• Persons with inherited bleeding disorders are
  those who have hemophilia, von Willebrand Disease
  or other congenital bleeding disorder
• Based on COV 32.1-8932.3418.3
• Care and treatment of persons suffering from
  hemophilia and other congenital bleeding diseases

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Covered Services

• Comprehensive clinic services
• Medications related to the treatment of bleeding
  disorders
• Hospitalization for severe, emergent bleeding
  episodes preauthorized hospitalizations related
  to the bleeding disorder. Required orthopedic
  surgery is limited to individuals up to 21 years
  of age.
• Ancillary services such as orthopedic appliances
  (up to age 21 years), imaging studies, physical
  therapy and laboratory tests related to the
  bleeding disorder.

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Noncovered Services

• Insurance deductibles and/or copayments
• Experimental or investigative medical and
  surgical treatment or procedures
• Dental services
• Ambulance or other transportation services
• Wheelchairs and their repairs
• Genetic services

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Restricted Services Covered Only If Preauthorized
by Review Panel

• Immune tolerance therapy
• Primary prophylactic treatment
• Secondary prophylactic treatment of more than one
  months duration
• Elective surgery or factor used for elective
  surgery

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Eligibility Requirements

• Residency
• Financial
• Less than 200 FPL (233 in Northern VA)
• Must meet spenddown if above
• Health Insurance
• Screened for FAMIS, FAMIS Plus, and SSI if
  indicated
• Screened for PSI services

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Limitations of Pool of Funds

• Replenished annually
• Not an entitlement program

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Policies and Procedures

• Application
• Financial and insurance eligibility
• Preauthorization, unless emergency care
• No retrospective payments
• Emergent services can be initiated without full
  application at the Managers discretion. If not
  found eligible, emergent service alone will be
  paid.

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Policies and Procedures

• Services from credentialed vendor
• Verification of services
• Rembursment at FFS medicaid rate.
• Payor of last resort
• Limited to 50,000 annually, unless appealed

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Policies and Procedures

• Spenddown
• Incomes above fiscal limit
• May access funds only after meet 5 of their
  gross family income in out-of-pocket or
  spenddown
• --Period 6 mos prior to re/enrollment to 6 mos
  into enrollment
• --May make monthly installments

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Policies and Procedures

• Spenddown includes
• Insurance co-pays and deductibles
• Costs of treatment exceeding insurance benefits
• Dental services, meds, supplies, equipment,
  therapies, labs, imaging, surgery,
  hospitalizations
• Does not includes meals, transportation

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Policies and Procedures

• Reviewed by HAB annually

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VBDP Review Panel

• Requested by patient/family or HTC
• MD, RN, SW from HTC not currently providing care

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Appeal Process

• Written appeal to Director of the Children with
  Special Health Care Needs Program
• May seek advice from Adjudication Officer
• Decision is final and binding