Block 4 (2) Flashcards
(66 cards)
What are the types of cost sharing?
copay
coinsurance
corridor deductibel
What is a flexible compensation plan (cafeteria plan)?
approach that allows employee to customize his insurance coverage
What is a 1-25 plan?
plan that allows you to take pretax income from your paycheck and apply it to healthcare expenses
What is any willing provider legislation?
state legislation
if any provider is willing to work on the same terms as the preferred provider, they can’t be excluded from 3rd party plans
What does PPO stand for?
preferred provider organization
What is freedom of choice legislation?
similar to any willing provider, but from the consumer’s point of view
if consumer is willing to meet the terms of the provider, the provider can’t exclude them from treatment
What is stop loss coverage?
employer covers out of pocket expenses up to a set point, then insurance kicks in
What authorized medicare?
Title XVIII of the social security act
a federally administered program
What is Medicare Part A, B, and D?
A: compulsory hospitalization insurance
B: voluntary supplementary medical insurance
D: outpatient pharmaceuticals
What is Medicare Part C?
medicare managed care option (medicare advantage)
private plan, slightly different coverages / extra coverage of A and B
How does one become eligible for Medicare?
1) 65+ (85%)
2) under 65, but receiving cash benefits under the Social Security or Railroad programs due to disability
3) under 65, but a chronic kidney patient
Why does a plan use cost-sharing?
1) makes patient reconsider whether they really need the treatment
2) shifts some costs to the patient
3) reduces administrative burdens (fewer claims processed)
How is medicare financed?
Part A: FICA employer (6.2%) + employee (6.2% of paycheck) up to $118,500 of income, and a corridor deductible
Part B: premium ($104.90, 25%) and govt (75%)
How are Parts C/D financed?
premium
FICA stands for:
federal insurance contributions act
What does Medicare Part B cover?
non-physician coverage (podiatrist, lab, xray), 20% coinsurance
medical devices
some home health services (up to 100 visits/yr)
drugs given in the doctors office
physicians charges
What are DRGs?
Diagnosis-related groups
- 468 disease state categories
- provides incentive to discharge pt earlier
Describe wholesaler registration.
not with federal govt
- KYBOP + CHFS
- if using CS, CHFS and DEA
PDMA stand for:
Prescription Drug Marketing Act of 1987
Define pedigree
a detailed history of where a drug has been
paper or electronic supply chain record
3 components to a pedigree
traceability, licensure, pre-emption
transaction history, information, statement
What were the effects of PDMA 87?
pedigree
banned reimportation of pharmaceuticals
banned sale of drug samples
banned re-sale of products purchased at preferential prices
Describe wholesaler recordkeeping
everything received, processed, sold, destroyed
– keep 2 years, unless tied to specific rx (5 years)
When do pharmacy pedigree requirements go into effect?
march 2016
