Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
128 Cards in this Set
- Front
- Back
Private Health Insurance
a)invented by whom? b)and when for who? (2) |
a)accident insurance firms first offered "health insurance"
b1)1849 for California gold rush workers b2)1860 railroad workers |
|
Most early plans
a)covered... b)GOAL |
a)INCOME LOSS, not health costs from illness/accidents
b)protect loss of income |
|
____ was first to offer prepaid hospital care (and when to who) and problem w/ this?
|
1929 Baylor University Hospital; offered care to dallas teachers
ONLY worked @ the BU hospital |
|
American Hospital Association early insurance plan (3)
|
1)established statewide Blue Cross hospital insurance
2)patient pays bill 3)Blue Cross reimburses pt |
|
____ created Blue SHIELD for...
|
California Medical Assn
for medical (physician) payments |
|
Blue Cross fxn
Blue Shield fxn |
BC) hospital reimbursement
BS) medical reimbursement (physician) |
|
Insured rates pre and post WW2
|
Pre- 5%
Post- over 50% |
|
What caused mass incr in insured post WW2
|
Manufacturing jobs giving health insurance to attract workers so the companies could meet quota's
|
|
Post WW2 BC/BS controlled by hospitals/physicians and their GOAL was...
|
PROTECT providers from financial loss
|
|
Indemnity insurance def
|
guaranteed reimbursement that was generous and little attention to costs
|
|
By 1950s Blue Cross & Blue Shield merged result (1) and goal (1)
|
1)most health insurance plans now offered MAJOR MEDICAL INSURANCE
2)offset expenses incurred by catastrophic illness/injury |
|
Why did early indemnity insurance need to change?
|
due to little attention to controlling costs the system would implode
|
|
Rx outpatient coverage was rare until...
|
the 1970s
|
|
Reasons for scarcity of Rx coverage b4 1970s (4)
|
1)hospital-medical services largest portion of costs
2)small $ amounts for Rx's w/ a large # of claims 3)different from original principles of health insurance 4)antitrust laws prohobited pharmacists from cooperatively negotiating fees w/ insurance co's |
|
Health insurance is ____ to most
|
financial security
|
|
How does Rx coverage violate principles of health insurance (3)
|
1)not substantial loss
2)may not represent accidental/unpredictable hazard 3)administrative costs high |
|
Why include Rx drug coverage? (2)
|
1)often preventive in nature
2)less expensive than alternatives |
|
Indemnity insurance
a)def. b)problems (3) |
a)reimbursement to patient for cost of medical expenses (pt pays provider)
b1)pt must collect/keep receipts for claim forms b2)company must process thousands of pt claims b3)NO incentive to control costs |
|
Service Benefit program (2)
|
1)healthcare provider submits claims to insurer and pays them directly
2)standardized, automated claims, contracts involved |
|
Fee-for-Service?
|
fee paid to provider for each service provided
|
|
Managed Health Care (2)
|
1)payment utilizes cost controls
2)utilization controls using pt and claims databases to improved quality of care |
|
Third Party
a)what are the 3 party's b)can be.... c)ex... |
a)patient, provider, payer (payer is the 3rd party)
b)multiple participants, segments c)medicare beneficiary |
|
Insurance Premium def
|
amt paid monthly to insurer to purchase the insurance policy
|
|
Cost-sharing mechanisms (4)
|
1)deductible
2)copayment 3)coinsurance 4)tiered co-payment |
|
Deductible? (3)
|
1)patient pays ALL expenses until specified out-of-pocket amount reached
2)applies to first dollar of each period (annually) 3)discourages hog wild use |
|
Copayment?
|
pt pays set specified fee for each service
|
|
Coinsurance?
|
pt pays specified PERCENTAGE of cost
|
|
Tiered co-payment (3 and ex)
|
Tier 1- preferred generics
Tier 2- preferred brand products Tier 3- non-preferred brand products OU AETNA plan |
|
Viscious Cycle of insurance (4)
|
Comprehensive Coverage --> stimulates demand --> increases prices --> more insistence on comprehensive coverage LEADS back to comprehensive coverage
|
|
Patients want what out of insurance (viewpoints)
|
convenient access to providers, quality services, low out-of-pocket costs
|
|
Employers want what out of insurance (viewpoints)
|
balance b/w healthy, satisfied employees and controlling amount spent on health benefits
|
|
Administrators want what out of insurance (viewpoints)
|
satisfy employer groups
|
|
Providers want what out of insurance (viewpoints)
|
control of their practice, adequate payment
|
|
Who got healthcare included in social security?
|
LBJ
|
|
Medicare is the principal social health insurance program for...(3)
|
1)persons 65 & older
2)some ppl w/ disabilities under age 65 3)ppl w/ end stage renal disease |
|
What put Medicare/caid into social security
|
Title 18 of the SSA in 1965
|
|
Medicare was originally designed to..
|
compliment SS retirees, survivors, and disabled
|
|
Medicare Parts (4)
|
1)Part A- hospital insurance
2)Part B- physician insurance 3)Part C- Medicare Advantage 4)Part D- Rx drug coverage |
|
Medicare Advantage? (2)
|
1)done thru the private sector
2)only for those elgible for medicare A&B |
|
Medicare is controlled by who?
Medicaid is controlled by who? |
CARE) federal govt
CAID) state govt |
|
Where do $ for Part A come from (2)
|
1)hospital insurance trust fund
2)payroll tax 1.45% on employers and employees |
|
Cost sharing mechanisms used by Part A (3)
|
1)premiums
2)deductibles 3)coinsurance |
|
Part A elgibility (2)
|
1)atleast 65yo (can get as early as 62, but will only get 70% of benefits for rest of life)
2)entitled to SS benefits |
|
Automatic elgibility to Part A @ no cost if...
|
made 40 or more quarters of SS payments
|
|
For 65 yo non-SS beneficiaries...(2)
|
Monthly premium of:
a)$215 for 30-39 quarters of SS payments b)$400 for less than 30 quarters of SS payments |
|
Part A coverage/cost
a)# of days covered and where b)deductible c)coinsurance (3) |
a)150 days annually @ hospital and skilled nursing facility
b)For days 1-60 around $900-$1000 c1)For days 61-90, 25% per day c2)For days 91-150, 50% per day c3)Over 150 days you pay all costs |
|
Lifetime reserve of Part A
|
60 days
|
|
Part A coinsurance @ SNF's
|
12.5% for days 21-100
|
|
Part B
a)aka... b)enrollment type |
a)Supplemental Medical Insurance (SMI)
b)VOLUNTARY |
|
Part B funding sources (5)
|
a)deductibles ($125)
b)monthly premiums ($90) c)deducted from SS check d)co-insurance is 20% of approved charges e)federal treasury (taxes) |
|
Part B pays for...(4)
|
1)medicare elgible physician services
2)outpatient hospital services 3)home health visits for persons w/o part A 4)DME |
|
Medicare Reform could include (4)
|
1)only Part A @ risk of bankrupting
2)higher cost sharing 3)increase payroll tax 4)decreased benefits |
|
Restructing for medicare reform could include... (4)
|
1)increase age requirement
2)defined contribution 3)individual savings account 4)managed care |
|
Why are legal immigrants good for SS?
|
add workers to add to the SS fund
|
|
General Info about Medicare claims made... (3)
|
1)20% make no claims
2)30% make claims less than $500 3)10% of users consume 70% of program payments |
|
Medi-gap?
|
covers 75% of deductibles and coinsurances that medicare doesn't cover
|
|
Medicare Advantage fxn?
|
to help manage costs?
|
|
1st attempt by medicare for Rx drugs and why didn't it work?
|
1988 Catastrophic Coverage- provided broad coverage of outpatient medications
Organized groups of old ppl objected to taxes and incr in premiums (so got repealed) |
|
Pre-part D Rx coverage of medicare included only...(3)
|
1)diabetic supplies (CMS form 1500)
2)immunosuppressives (organ transplant) 3)cancer meds |
|
Before Part-D
a)% of ppl that pay more than $1000/year for Rx's b)% of ppl w/o any Rx coverage |
a)20%
b)30% |
|
Issues in Rx coverage? (questions that needed to be answered) (5)
|
1)who to cover?
2)how should CMS admin it? (public or private) 3)how comprehensive of coverage? 4)how do you controls costs if gov't becomes primary purchaser of drugs for the elderly? 5)How do you finance it? |
|
Part D was gently phased in by... (2)
|
1)Medicare Modernization Act of 2003 (MMA)
2)phased in by giving drug discount cards @ first |
|
MMA impact on pharmacy (3)
|
1)drug discount cards
2)addition of part D plans 3)payment for MTM |
|
First Phase-Drug discount cards
a)how provided b)who elgible c)provisions for... |
a)private plans (not Medicare) pharmacists expected to proved them, gov't not involved
b)VOLUNTARY participation for all medicare elgible pts excluding those w/ medicaid elgibility c)for low income beneficiaries |
|
Part D
a)who elgible b)dual elgibility? c)Why limited opportunity to enroll w/o penalty? |
a)VOLUNTARY, if you get part A you are elgible for part D
b)If dual elgible for medicare and medicaid you must enroll in part D to keep gettin Rx benefits (no more medicaid Rx benefits) c)want ppl to sign up early to avoid adverse selection |
|
Adverse selection?
|
person signs up for insurance right when they get sick
|
|
What is Part D's LOW INCOME assistance?
|
if greater than 150% FPL you are elgible for more extensive coverage
|
|
How is CMS administering Part D?
|
Thru PRIVATE SECTOR, medicare recipients must select and sign up for a plan in their area
|
|
Basically 2 types of coverage for Part D
|
a)plans that are Part D only using PDP's
b)plans that are integrated w/ medicare a,b,c (medicare advantage) |
|
Regarding insurance programs what is it illegal for a DPh to do?
|
help pt select a plan, but can make 2-3 recommendations
|
|
Part D requirements when offering plans? (2) and what if requirements not met?
|
1)at least 2 qualifying plans must be available
2)at least one must be a part D plan only If 2 plans not available, beneficiary given opportunity to enroll in fallback plan arranged by the federal govt |
|
CMS Standard Benefit structure for Part D (5)
|
1)monthly premium of about 35$
2)Deductible is the first $250 you spend (you pay 100% of your first 250$) 3)Pay 25% co-pay until your total health care costs are up to 2400$ 4)Gap in coverage until $3850 spent (you pay 100% b/w 2400 and 3850$) 5)Catastrophic coverage after $3850 (you pay 5% after this) |
|
Catastrophic coverage? (3)
|
$2 for generic
$5 for brand or 5% of price of the med |
|
Why do benefit thresholds change every year?
|
to grow @ same rate as growth of drug expenditures
|
|
Low income coverage in Part D (2)
|
1)if <135% FPL, no premiums, deductible, gap coverage, nominal copays
2)if 136-150% FPL, plan benefits on a sliding scale |
|
MTM
a)requires... b)gives pharmacists... c)pays pharmacist for... d)DPh's must get... |
a)payments for pharmacists pt care services
b)provider status c)for non-dispensing activity d)must get PROVIDER # |
|
To qualify for Part D coverage of MTM pt must...(3)
|
1)have multiple chronic diseases
2)taking multiple meds covered by part D 3)identified as likely to incur high annual med costs |
|
New administrative part of Part D (3)
|
1)requires electronic prescribing
2)requires use of counterfeit proof Rx pads on part D Rx's 3)standard benefit ID card |
|
Part D formularies
a)determined by... |
a)individual PDP
|
|
Individual PDP formularies
a)must be developed and reviewed by... b)must include... c)must be.. |
a)by a P&T committee
b)include atleast 1 physician and pharmacist w/ expertise in care of elderly/disabled c)be based on scientific evidence (but often based on economic evidence) |
|
Bottom line on insurace for pts (2)
|
1)maximize benefits
2)minimize personal expenditures |
|
Bottom line on insurace for providers
|
maximize reimbursement
|
|
Bottom line on insurance for supplier
|
induced demand (ppl abusing insurance)
|
|
Blue Cross created by...
Blue Shield created by... Goal of each |
BC- hospitals
BS- physicians ENSURE PAYMENT |
|
Carve-out?
|
When a TP insurance separates the Rx coverage from other health benefits
|
|
Contractor of Rx drug coverage in an insurance program?
|
PBM (pharmacy benefit manager)
|
|
PBM fxns (9)
|
1)MANAGER OF RX BENEFITS
2)PROGRAM ADMINISTRATOR 3)PROCESSES CLAIMS 4)contracts w/ providers 5)tracts elgible beneficiaries 6)develops formulary system 7)conducts DUR 8)reimburses providers 9)audits providers |
|
Reimbursement from an insurance co =
|
dispensing fee plus ingredient cost
|
|
Methods of determining cost of "ingredient" (4) (which does no one use and which is used most frequently)
|
1)AWP (average wholesale price) (NOT USED)
2)EAC (estimated acquistion cost)**** 3)WAC (wholesaler acquistion cost) 4)MAC (maximum allowable cost) |
|
Impact of health insurance on pharmacy (2)
|
1)steady decreasing dispensing fee (so pharmacies need to be efficient w/ computers and techs)
2)low reimbursement b/c of anti-trust laws |
|
Reimbursement and anti-trust laws?
|
the laws dont let pharmacists get together and reject contracts
|
|
How to avoid anti-trust laws and try to incr reimbursement?
|
use pharmacy organizations like PPOK to gather large # of pharmacies together to act as a chain for buying purposes
|
|
Medicare Part D is run by...
|
individual PDP's not the govt!!!
|
|
When Medicaid was originally created as part of LBJ's "Great Society" it was to be...
|
a short-term stop gap to be replaced by national health care
|
|
Medicaid was est by... (2)
|
1)1965 Amendments to social security act
2)Title XIX of SSA |
|
Medicaid...
a)____ program b)provides medical benefits to... c)guarantees coverage for... |
a)federal and state entitlement program
b)medical benefits to poor or who have no health insurance c)basic health and long-term care services |
|
Medicaid is ____ run
|
STATE
|
|
States have flexibility to determine certain aspects of medicaid like... (3)
|
1)setting reimbursement rates
2)broadening of elgibility requirements 3)benefits offered |
|
Medicaid is offered where?
|
each state, u.s. territory, and DC
|
|
Medicaid and its eligibility vary...
|
state-to-state
|
|
Are states reqd to have Medicaid?
|
NO, but all participate
|
|
For a state to recieve matching federal funds for medicaid...(5)(but which are optional) (3)
|
Must offer:
1)inpatient hospital 2)outpatient hospital 3)physician services 4)home health services 5)prenatal care 1)outpatient Rx drugs 2)physical therapy 3)optometrist/glasses |
|
Federal share of cost of Medicaid is determined by...(4)
|
1)FMAP
2)which is based on state per capita income compared to nat'l average 3)no greater than 83% 4)no less than 50% |
|
OK's FMAP is ___ indicating...
|
decreasing
state is doing better economically |
|
Medicaid accounted for what % of federal funds to OK?
|
40%
|
|
Limit on amt federal govt spends on Medicaid (3)
|
1)NONE
2)Must match state spending per set % 3)as state spending increases federal spending must incr accordingly |
|
Who makes the medicaid payments to providers?
|
oklahoma health care authority (OHCA)
|
|
Medicaid does not provide health care for all poor unless... (5)
|
1)kids
2)pregnant 3)aged 4)blind 5)disabled |
|
3 broad groups for basis of elgibility to Medicaid and what is special about these...
|
1)mandated categorically needy (you are reqd to give these ppl funds if you want federal funds)
2)optionally categorically needy 3)medically needy Each group varies state-to-state |
|
Mandated Categorically needy (7)
|
1)ppl who get federally assisted income maintenance programs (like welfare)
2)Temporary Assistance for Needy Families (TANF) 3)ppl getting Social Security Income (SSI) (who are aged, poor, blind or disabled) 4)Eligibility based on income and asset level 5)pregnancy related services 6)children under 6 7)Families up to 133% FPL |
|
Optional categorically needy? (3)
|
1)do not meet requirements for mandated coverage
2)but share many characteristics of mandated 3)usually kids/pregnant w/ income below 185% FPL |
|
SCHIP (State children's insurance program)
a)purpose b)result |
a)help states cover uninsured low income kids
b)less than 10% of kids uninsured |
|
SCHIP eligibility (5)
|
1)less than 19yo
2)family income less than 185% FPL 3)not eligible for medicaid 4)no credible insurance 5)pregnant women less than 185% FPL (in OK) |
|
Medically needy? (3)
|
1)persons that would be eligible for categorically needy groups but their income is above the limit allowed by the state
2)ppl who "spend down" to get medicaid eligiblity (by having high medical expenses) 3)typical medically needy individual: Old in nursing home |
|
Majority of Oklahoma Medicaid recipients were...
|
kids 18 and under
|
|
Average monthly total Rx costs per pt (how much incr since 2000 in %) (and how much are they incr per year)
|
a)40%
b)10% |
|
Drug Rebate Program?
|
Pharmaceutical Manufacturers gave $100million to states
|
|
OHCA Pharmacy Program before 2004 (2)
|
1)3 Rx limit/month
2)resulted in incr hospital costs |
|
OHCA Pharmacy Program after 1-1-2004 (2)
|
1)6 Rx/month
2)Rx may be greater than 100 units or 34 days supply |
|
Medicaid Reimbursement formula
|
Ingredient cost:
a)for brand EAC = AWP-12% b)for generic SMAC PLUS DISPENSING FEE $4.15 |
|
Why do states like medicaid?
|
2x better reimbursement than TP so putting more $ into state pharmacies
|
|
Advantage Waiver Program? (3)
|
1)for ppl on verge of being in nursing home
2)house & community based waiver clients 2)get 7 additional Rx's w/o prior auth |
|
In Advantage Waiver Program what do they have to do to be monitored BY MTM WITH A PRIOR AUTH PROGRAM? (2)
|
1)greater than 3 brand drugs/month
2)and 13 generic Rx/month |
|
OHCA Drug Management Programs
|
1)Prior Auth
2)by COP 3)via pharmacy management consultants |
|
prior auth form is filled out by...
|
pharmacy and dr.
|
|
Prior Auth categories (4)
|
1)arthritis/NSAIDS
2)anti-ulcer meds 3)BP meds 4)meds for ADHD |
|
Medicare
a)philosophy b)funding c)eligibility d)administered by... |
a)social insurance entitlement concept
b)cost sharing using social security taxes, monthly premiums c)65 or older/disabled d)federal admin |
|
Medicaid
a)philosophy b)funding c)eligibility d)administered by... |
a)medical assistance welfare concept
b)federal & state funding (general taxes)--nominal pt cost c)low income and needy d)state admin |