Transcript Medicaid

Medicaid, TRICARE,
CHAMPVA,
Workers’
Compensation, and
Discount Card
Programs
Chapter 5
1
© 2010 The McGraw-Hill Companies, Inc. All rights reserved.
Learning Outcomes
After studying this chapter, you should
be able to:
5-1 Identify two ways Medicaid programs
vary from state to state.
5-2 Discuss Medicaid prescription coverage.
5-3 Explain who is eligible for TRICARE and
CHAMPVA and how to verify eligibility.
5-4 Discuss the prescription benefit programs
offered to TRICARE and CHAMPVA
beneficiaries.
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Learning Outcomes (Continued)
5-5 Describe the coverage that employees have
under workers’ compensation insurance and
the possible drug benefits.
5-6 Briefly discuss discount programs that
assist individuals in paying for prescriptions.
Chapter 5
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Key Terms
• Catastrophic cap
• Categorically needy
• CHAMPVA
• Defense Enrollment
Eligibility Reporting
System (DEERS)
• Discount card
• Early and Periodic
Screening, Diagnosis,
and Treatment
(EPSDT)
• Federal Medicaid
Assistance Percentage
(FMAP)
• Fiscal agent
• Medicaid
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Key Terms (Continued)
• Medically
indigent/needy
• Military Treatment
Facility (MTF)
• Payer of last resort
• Sponsors
• State Children’s
Health Insurance
Program (SCHIP)
• Temporary
Assistance for Needy
Families (TANF)
• TRICARE
• TRICARE Extra
• TRICARE for Life
• TRICARE Prime
• TRICARE Reserve
Select (TRS)
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Key Terms (Continued)
• TRICARE Standard
• Welfare Reform Act
• Workers’
compensation
insurance
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Medicaid
•
•
•
•
Medicaid is an assistance program, not an
insurance program
Pays health care services for people with
incomes below the national poverty level
Both the federal and state governments
pay for Medicaid
Administered by a fiscal agent, an
organization that processes claims for a
government program
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Medicaid (Cont.)
•
The first Medicaid programs were
required by federal law as part of the
Social Security Act of 1965
• States participate in their Medicaid
programs in two ways:
1. Authorizing additional kinds of services
or making additional groups eligible
2. Determining eligibility within federal
guidelines
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Medicaid Coverage
•
According to federal guidelines, Medicaid
pays for the following types of health care:
• Many types of services – physician,
laboratory, x-ray, inpatient and
outpatient hospital, rural health clinic,
family planning, federally qualified
health-center, prenatal and nursemidwife, EPSDT
• Home health care and emergency care,
and care at a public nursing facility
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Medicaid Coverage (Cont.)
•
States may include additional Medicaid
coverage, including:
• Many types of services – clinic,
ambulance, chiropractic, mental-health,
allergy, dermatology, podiatry
• Many types of care – emergency room,
dental, private-duty nursing
• Various other drugs, devices, and
services
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Medicaid Coverage (Cont.)
•
•
Early and Periodic Screening, Diagnosis,
and Treatment (EPSDT) is a prevention,
early-detection, and treatment program
for children under the age of twenty-one
who are enrolled in Medicaid
The State Children's Health Insurance
Program (SCHIP), part of the Balanced
Budget Act of 1997, requires states to
develop and implement plans for health
insurance coverage for uninsured children
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Medicaid Eligibility
•
Generally, Medicaid recipients are people
who:
• Have low incomes and who have
children
• Are over the age of sixty-five
• Are blind
• Have permanent disabilities
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Medicaid Eligibility (Cont.)
•
One group of Medicaid recipients is known
as categorically needy
• Needs of these beneficiaries are
addressed under the Welfare Reform
Act
• Temporary Assistance for Needy
Families (TANF) was created by the
Welfare Reform Act and helps with
program helps with living expenses
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Medicaid Eligibility (Cont.)
•
Some states extend Medicaid eligibility to
include another group of people classified
as medically needy or medically indigent
• Includes individuals who earn enough
money to pay for basic living expenses,
but cannot afford high medical bills
• Once Medicaid eligibility is determined,
the recipient gets an identification card or
coupon explaining effective dates and any
additional information
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Medicaid Eligibility (Cont.)
•
Pharmacy technician insurance specialists
are alert to checking these three points:
• Eligibility
• Preauthorization
• Other insurance coverage
• Medicaid is referred to as the payer of last
resort, because it is the secondary payer,
and claims are filed elsewhere first
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Medicaid Drug Programs
•
States offer unique Medicaid prescription
drug plans
• The following factors vary by state:
• Covered and noncovered drugs
• Steps required for beneficiaries to
receive drugs
• Options for obtaining information and
registering for a program
• Expected reimbursement practices for
pharmacies
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TRICARE
•
•
•
TRICARE is the Department of Defense
health insurance plan for military
personnel and their families, and
insurance is automatically provided for or
paid by their branch of service
Benefits spouses and children of activeduty service members, called sponsors
A TRICARE beneficiary must be listed in
the Department of Defense Enrollment
Eligibility Reporting System (DEERS)
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TRICARE Standard
•
•
•
•
A fee-for-service program
Covers medically necessary services
provided by a civilian physician when an
individual cannot obtain treatment from a
military treatment facility (MTF)
Individuals must first seek care at a MTF
Patient cost-share payments are subject to
an annual catastrophic cap, a limit on the
total medical expenses that the patient
must pay in one year
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TRICARE Prime
•
•
•
•
A managed care plan similar to an HMO
Each individual is assigned a primary care
manager (PCM) who coordinates and
manages that patient's medical care
Active-duty service members are
automatically enrolled in TRICARE Prime
An annual enrollment fee is paid to join,
and copayments may apply to some
beneficiaries
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TRICARE Extra
•
•
•
An alternative managed care plan for
individuals who want to receive services
primarily from civilian facilities and
physicians rather than from military
facilities
Members must receive health care services
from a select network of health care
professionals
There is no enrollment fee, but there is an
annual deductible
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TRICARE Reserve Select (TRS)
•
•
A premium-based health plan available for
purchase by certain members of the
National Guard and Reserve activated on
or after September 11, 2001
Provides members and their covered
family members with comprehensive
health care coverage similar to TRICARE
Standard and TRICARE Extra
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TRICARE for Life (TFL)
•
•
•
Initiated in October 2001 to fulfill a
promise made to many military personnel
at the time of enrollment that they would
receive lifelong health care
TFL provides military health care
coverage to TRICARE beneficiaries who
are sixty-five years of age or older
TFL pays after Medicare and any other
health insurance
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CHAMPVA
•
The Civilian Health and Medical Program
of the Veterans Administration
• Helps pay health care costs for families of
veterans who are totally and permanently
disabled because of service-related injuries
• Also covers the surviving spouse and
children of a veteran who died from a
service-related disability
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Beneficiary Identification
•
•
•
People who qualify for TRICARE or
CHAMPVA are called beneficiaries
Beneficiaries get identification cards that
contain information needed for claims
Pharmacy technician insurance specialist
familiarize themselves with the processes
followed to verify the eligibility of
beneficiaries
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TRICARE Drug Programs
•
•
•
This pharmacy benefit is available to all
eligible U.S. uniformed service members
The amount a beneficiary pays toward the
cost of medication is based on whether the
prescription is a generic, formulary, or
non-formulary pharmaceutical
Copayments are equal for all beneficiaries
(except active-duty service members, who
receive free medications), depending on
where the prescription is filled
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TRICARE Drug Programs (Cont.)
•
TRICARE beneficiaries can fill
prescriptions by four methods:
1. At military treatment facility
pharmacies
2. Through the TRICARE Mail Order
Pharmacy
3. Using TRICARE Retail Network
Pharmacies
4. At Non-network pharmacies for a
higher cost
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Military Treatment Facility
Pharmacies
•
•
•
Convenient and inexpensive option to
beneficiaries
Prescriptions that are on the MTF
formulary may be filled (usually up to a
ninety-day supply) at no cost to the
beneficiary
TRICARE has a basic core formulary
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TRICARE Mail Order Pharmacy
•
•
•
Administered by Express Scripts, Inc.
(ESI), is available for prescriptions that
beneficiaries take on a regular basis
Often a more cost-effective method of
receiving prescriptions
Prescription refills may be requested by
mail, phone, or online
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TRICARE Retail Network
Pharmacies
•
•
Nationwide network of over fifty-four
thousand retail pharmacies
Beneficiaries who use pharmacies in the
ESI network do not have to file claims for
reimbursement if the pharmacies are
outside their primary region
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Non-network Pharmacies
•
Retail pharmacies that are not part of the
TRICARE network
• Beneficiaries can fill prescriptions at nonnetwork pharmacies, but doing so is the
most expensive option
• They have to pay for the entire amount
initially and then file a claim to receive
partial reimbursement
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Workers’ Compensation
•
Medical care for work-related injuries or
illnesses is covered by this federal or state
plan
• Such a plan also provides benefits for lost
wages and permanent disabilities
• Two kinds of situations that require medical
care are covered:
1. Traumatic injury
2. Occupational disease or illness (also
known as a nontraumatic injury)
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Workers’ Compensation (Cont.)
•
Compensation for work-related illnesses
and injuries may be one of five types:
1. Medical treatment
2. Lost wages (temporary disability)
3. Permanent disability payments
4. Compensation for dependents of
employees who are fatally injured
5. Vocational rehabilitation
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Workers’ Compensation Drug
Programs
•
•
Individuals who receive prescription
coverage as a result of workers’
compensation may be provided with thirdparty prescription cards to pay for their
prescriptions
Patients’ coverage should be verified by
contacting their employer, asking for the
name of the insurance carrier, and then
contacting that carrier
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Discount Card Programs
•
A number of states offer a discount card
for people who cannot afford prescription
drugs
• Discount cards offer savings that depend
on the drugs
• Average savings for commonly
prescribed drugs are from 5 percent to
more than 40 percent
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