Breast Cancer Treatment Grant Fund

I. MISSION

A. The Mission statement of the Susan G. Komen Breast Cancer Foundation is to eradicate breast cancer as a life threatening disease by advancing research, education, screening, and treatment.

II. OBJECTIVES

A. To improve the accessibility and affordability of breast cancer treatment by providing grant funds for breast cancer treatment, diagnosis, and critical support services for Orange County residents who are medically underserved, under-insured, or uninsured in accordance with the Komen Mission Statement and the laws, which are governed by the State of California.
B. The Komen Breast Cancer Treatment Grant Fund is established to remove financial obstacles when these individuals are diagnosed with breast cancer from receiving expeditious life-saving breast cancer treatment.  The diagnostic component is established to remove financial obstacles for individuals to receive life-saving diagnostic procedures required to obtain an expeditious cancer diagnosis.
C. Breast Cancer Treatment is defined as surgery, post-surgical wound care, prescribed medication, radiation therapy, chemotherapy, and hormone therapy.
D. Breast Cancer Diagnosis is defined as diagnostic mammograms, ultrasound, FNA's, stereotactic or core biopsies, incisional biopsies, pathology, cytology, and other procedures to obtain a diagnosis.
E. Critical Support Services are defined as other obstacles not specifically defined as treatment or diagnosis that would inhibit the onset of treatment. 
F. HCF acknowledges that the Komen Breast Cancer Treatment Fund is not an insurance company.  If the patient is qualified, the Fund will provide a grant for certain breast cancer treatment, diagnostic procedures, and critical support services within the limits established by Komen.

III. HEALTHCARE FACILITY/HEALTHCARE FACILITATORS CRITERIA FOR PARTICIPATION

A. Healthcare Facilitators must provide extended case management and coordinate treatment through a Komen approved participating HCF meeting the required HCF criteria.
B. HCF must provide board certified care for breast cancer diagnosis and treatment by a qualified healthcare team.
C. Komen does not assume the legal and medical responsibility for the patient.
D. HCF must not discriminate based upon financial status, race, or sexual orientation.
E. HCF must assist the patient in obtaining treatment funds through other funding sources before applying to the Komen Treatment Grant Pool:
1. BCCCP
2. Medical/Medicare
3. MSI
4. California Health Collaborative/CBCTFP
5. Private Insurance
6. Underwriting by HCF and Physician Team
7. Other
F. HCF can use Komen grant funds to supplement outlined costs not covered by other plans.  Treatment Grant funding is limited to a maximum of $7,500 for Breast Cancer Treatment, $2,500 for Breast Cancer Diagnostic Procedures, and $1,000 for Critical Care Services, per patient annually (12-month period). Komen reserves the right to establish grant limits for all procedures. HCF will be advised in writing of any grant limits established.
G. HCF must designate a single Program Administrator to coordinate all patient-funding requests with Komen.
H. Upon approval, HCF will provide patient services in a timely manner.
I. HCF will administer Komen funding on behalf of the patient.
J. HCF will file a written report with supporting documentation within 60 days of funding to account for the use of the funds.
K. HCF may file additional Patient Grant Applications for a patient providing that all previous Grant funding has been exhausted and accounted for and the total does not exceed the established limits per patient.
L. HCF must be a non-profit corporation.
M. HCF must provide Komen with a certificate of insurance with the Komen Foundation named as an additional insured.
N. HCF will execute all negotiations with medical providers.
O. HCF should receive all bills.  The Komen Foundation should not receive any bills from medical providers.  The Komen Foundation is a third party funding source and should be not be listed as or treated as an insurance company.

IV. PATIENT APPLICATION

A. HCF Program Administrator will verify that the patient meets the Komen Treatment Grant criteria and submit an Individual Treatment Grant Request (ITGR)
B. Application must include:
1. Patient information as outlined on the ITGR
2. Patient diagnosis summary to include histology and stage for treatment
3. Patient needs for diagnostic procedures or critical support services
4. Summary of other funding available
5. Requested amount of grant funds
6. Summary of what grant funds are requested for:
a. Meet insurance deductible
b. Assist with MSI share of costs
c. Treatment procedures not covered by other sources (medication, post-surgical home healthcare, hospice, etc.)
d. Diagnostic procedures not covered by other sources
e. Initiate life-saving breast cancer treatment as defined when no other funding is available
f. Other
7. HCF must attach supporting documentation to the ITGR (Approval/Denial of other funding sources, proof of insurance deductible, etc.).
8. Grant applications for funds must be requested before treatment is initiated and may not be applied for retroactively.
9. Treatment/services not covered by the Komen Breast Cancer Treatment Grant Fund:
a. Social Worker Services
b. Psychotherapy
c. Breast reconstruction
d. Wigs
e. Mileage
f. Post-surgical home health care is limited to $85.00 per day not to exceed 10 days.
g. Other

V. KOMEN TREATMENT GRANT FUNDING

A. Komen will designate a Breast Cancer Treatment Grant Pool.
B. Funding will be made available to all Orange County Healthcare facilities and Healthcare Facilitators that meet the Treatment Grant criteria.
C. Komen funding will supplement other available funding as outlined in Section II F.
D. The maximum funding per patient is $11,000 per calendar year as outlined in Section II F.
E. Komen will process patient Grant applications in a timely manner to expedite the required services.
F. HCF pool participants may draw no more that 33% of the pool without the waiver of all HCF pool participants.
G. Komen will not pay for procedures that have not been approved before the date of service.

VI. QUALITY ASSURANCE

A. The Orange County Affiliate of the Susan G. Komen Breast Cancer Foundation as grantor, reserves the right to review the Healthcare Facilities or the Healthcare Facilitators records regarding qualification procedures and expenditure of grant funding.  Should any improprieties be discovered the provider would be suspended from the grant pool until such time as the infraction is remedied to the satisfaction of the Grant Review Committee and the Board of Directors.

VII. TREATMENT GRANT PROCESS

A. Completed Individual Treatment Grant Requests (ITGRs) should be faxed to the Programs and Grants Manager at 714.957.9155.
B. Approvals and denials will be faxed to HCF within 1 - 3 days unless longer consideration is required.
C.  A check made payable to HCF will be mailed to cover the approved treatment grants.