PAYING FOR BLEEDING DISORDER MEDICATION

In California

State-level regulations are a critical factor in determining access to treatment and shaping advocacy efforts. These policies can either support patients or limit their ability to receive necessary care. Read on to learn more about the regulatory landscape in California and how advocacy is affected.

See more California-specific topics:

  • Paying for Bleeding Disorder Medication

  • Medical Complexity

  • Access to Bleeding Disorder Medication

  • Denials Based on a Bleeding Disorder Diagnosis

  • Patient Competency to Self-Infuse

  • Identifying Someone to Administer Infusion

Medi-Cal Members

  • Medi-Cal members: For members with physical health conditions, including bleeding disorders, medications are covered through the Medi-Cal Rx program.

  • Step 1: Ask About Using Medication from Home

    • “Does your facility have a home-medication policy? If so, I already have my prescribed medication at home and can bring it with me at admission, so payment wouldn’t be an issue.”

    • “If your facility doesn’t currently have a home-medication policy, we can share a sample policy that makes this process easy and ensures safety and cost transparency.

    Step 2: If Home Medication Isn’t Allowed

    • “We understand your concerns about the cost of bleeding-disorder medications. In some cases, your facility can bill insurance directly for the medication, even if you’re paid through a per-diem or risk-based model.”

    • “We’d be happy to contact the insurer or join a call with you to confirm how reimbursement will work. This helps avoid confusion or delay.”

    • “Based on our understanding of how these products are covered for Medi-Cal members, you are typically able to bill for this medication separately and you will not be responsible for the cost of this medication.”

    Talking Points for Insurer Calls

    • “We’re calling to confirm how [my / my family member’s] bleeding-disorder medication will be reimbursed if given during a behavioral-health admission.”

    • “Can you confirm whether the medication is carved out and reimbursed separately from the facility’s per-diem rate?”

    • “If not, can the facility bill directly for the medication, or would a specialty pharmacy handle billing and shipment?”

    • “Are there any prior-authorization requirements or documentation we should send to avoid delays?”

      After the call, write down the name of the insurance representative, date, and what was agreed upon. This record can prevent confusion later.

  • Send the following to the facility:

    • Medi-Cal Coverage for Bleeding Disorder Medication: Personalize this email template to inform facilities of the agreed-upon reimbursement approach from your insurer.

Commercial Insurance

  • Depends on the insurance, but in some cases, facilities can bill insurance directly for injection/infusion medications, even if the facility is paid through a risk-based arrangement or gets a “per diem” rate.

    This happens most often when:

    • The person has Medicaid managed-care coverage with risk-based payment models, or

    • Private insurance pays facilities under bundled payments, case rates, or global budgets.

    When facilities aren’t sure whether they’ll be reimbursed for the medication, they may delay or deny admission.

    Fortunately, there are simple solutions:

    1. Bring your medication from home.
       If the facility allows patients to bring their own prescribed medication, cost isn’t an issue—this is often the fastest and easiest solution.

    2. Clarify payment with the insurer.
       If home medication isn’t allowed, the insurer can explain exactly how the facility will be reimbursed or how a specialty pharmacy can ship the medication directly.

    Your bleeding-disorder treatment team can help with both of these steps and provide sample policies, insurer contacts, and documentation.

  • Commercial Insurance:

    • Step 1: Ask About Using Medication from Home

      “Does your facility have a home-medication policy? If so, I already have my prescribed medication at home and can bring it with me at admission, so payment wouldn’t be an issue.” “If your facility doesn’t currently have a home-medication policy, we can share a sample policythat makes this process easy and ensures safety and cost transparency.”

    • Step 2: If Home Medication Isn’t Allowed

      “We understand your concerns about the cost of bleeding-disorder medications. In some cases, your facility can bill insurance directly for the medication, even if you’re paid through a per-diem or risk-based model.” “We’d be happy to contact the insurer or join a call with you to confirm how reimbursement will work. This helps avoid confusion or delay.”

    • Talking Points for Insurer Calls

      “We’re calling to confirm how [my / my family member’s] bleeding-disorder medication will be reimbursed if given during a behavioral-health admission.” “Can you confirm whether the medication is carved out and reimbursed separately from the facility’s per-diem rate?” “If not, can the facility bill directly for the medication, or would a specialty pharmacy handle billing and shipment?” “Are there any prior-authorization requirements or documentation we should send to avoid delays?”

      After the call, write down the name of the insurance representative, date, and what was agreed upon. This record can prevent confusion later.

  • Send the following to the facility:

    • Commercial Insurance- Coverage for Bleeding Disorder Medication: Personalize this email template to inform facilities of the agreed-upon reimbursement approach from your insurer.