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Assistance programs

Assistance programs allow treatments to be more financially accessible to patients. Some assistance programs may provide patients with temporary free access to treatment while their coverage investigation is ongoing and others may reduce the out-of-pocket costs for patients. Assistance programs are managed in the Assistance Program (mvn__PJN_Assistance_Program__c) custom object, where each record type represents an enrollment into a different type of assistance program. Users can create Assistance Program records via the Assistance Program (PJN_Assistance_Program) button on a Coverage Investigation (mvn__PJN_Coverage_Investigation__c) record.

Bridge assistance program

Bridge assistance programs are managed by the PJN_Bridge record type. These are assistance programs for patients who are already undergoing treatment but experience a gap in their commercial insurance coverage. Bridge programs usually offer several weeks of treatment at no cost to the patient while their new insurance is assessed for therapy access.

Copay savings program

Copay savings programs are managed by the PJN_Copay record type. They are assistance programs for patients who have commercial insurance coverage but have to make a copay contribution. Copay savings programs reduce the copay amount that these patients have to pay, typically down to no cost at all.

Patient Assistance Program (PAP)

Patient Assistance Programs (PAP) are managed by the PJN_Patient_Assistance_Program record type. They are assistance programs granting patients free treatment as long as the patients meet specific criteria, such as, but not necessarily, the following:

  • the patient's household income must not exceed a certain percentage of the federal poverty level, as defined in the Care Program (CareProgram) Health Cloud object;

  • the patient must either be uninsured or have insurance that doesn't cover the desired therapy;

  • the patient must have on-label diagnosis; and

  • the patient must have U.S. residency.

Komodo Care Connect has a Financial Clearing House layer that enables integrations with external vendors such as Experian. The layer is called via the Assistance Program Eligibility Config (mvn__PJN_Assistance_Prog_Eligibility_Config__mdt) custom metadata type and is used to help users determine a patient's PAP eligibility. Once the external integration is configured, users can use the Evaluate PAP Eligibility (PJN_Evaluate_PAP_Eligibility) quick action in the Assistance Program (mvn__PJN_Assistance_Program__c) record to compile the most up-to-date data on the patient to send to the vendor. The data may be sourced from multiple records, such as the patient's Account record if it is a new enrollment and no information exists in the current Assistance Program record or the current Assistance Program record if it is an existing enrollment. For example, if the mvn__PJN_Address__c and mvn__PJN_Phone__c fields on the Assistance Program record are empty, then the Contact Information (mvn__PJN_Contact_Information__c) records on the mvn__PJN_Address_Lookup__c and mvn__PJN_Phone_Lookup__c fields take precedence. However, the name and address must match the data in the external vendor. The vendor will return its evaluation to Komodo Care Connect so that the Assistance Program record can be updated accordingly, such as by populating the mvn__PJN_Estimated_Household_Income__c, mvn__PJN_Estimated_Household_Size__c, mvn__PJN_Federal_Poverty_Level_Percentage__c, mvn__PJN_Program_Federal_Poverty_Threshold__c, and mvn__PJN_PAP_Eligibility__c fields. Once finished, the Evaluate PAP Eligibility button will disappear and the Assistance Program record will be marked as "Locked."

Note

If Experian is unable to return an estimated household income, then the federal poverty level percentage will be set to 0 and the outcome will be set to Unknown.

Note

The mvn__PJN_Program_Federal_Poverty_Threshold__c field contains static data and is stamped at the time of the patient's initial enrollment into a Patient Assistance Program. This ensures that patients who were previously eligible for PAP remain eligible even if the program's threshold against the federal poverty level defined in the Care Program (CareProgram) Health Cloud object changes.

Quick Start program

Quick Start programs are managed by the PJN_Quick_Start record type. They are assistance programs for patients who need treatment before their insurance can begin coverage. For example, if a prior authorization is delayed for more than five days, a free month of medication may be shipped to the patient to let the patient start treatment while coverage is still pending. However, because it is not guaranteed that insurance will provide coverage, if the prior authorization is denied, the patient may have to later be enrolled into PAP instead.

Quick Start programs differ from Bridge programs in the timing of their coverage; while the former covers costs at the beginning of treatment, the latter covers costs in the middle of treatment.