Farley Flashcards
a monthly payment to the insurance plan to obtain coverage for prescription medications
premiums
the amount a patient pays out-of-pocket before their insurance coverage starts and the insurance begins to pay
deductible
Patients pay a fixed amount each time they fill a medication that falls into a specific formulary tier
Copayment
patients pay a percentage of the cost of their medication. the percent payment changes depending on what tier the medication is listed in the formulary
Coinsurance
What are the mandatory services for medicaid
physician services, lab/xray, inpatient hosp, outpatient hosp, EPSDT, family planning, rural & FQHCs, nurse midwife, nursing facilities
What are the optional services for medicaid
PRESCRIPTION DRUGS, clinic services, dentl, PT/rehab, case mangement, prosthetics/glasses, inpatient psych, home healthcare, personal care, and hospice
What did the Affordable Care Act (obamacare) do
it expanded medicaid coveraged to all adults with incomes up to 138% of the federal poverty level beginning in 2014 (~20k)
Who does medicaid cover
pregnant women and children age < 5yo with <133% of FPL, children 6-19 <100% of FPL, medicare recipients < 100% FPL, and patients with chronic illness (physical, severe mental or other functional)
What are the protected classes of formulary inclusions
antipsych, antidepressants, ASMs, cancer meds, immunosuppressants and HIV-AIDS
who does medicare cover
65+, and <65 with long term disability or ESRD
What is a 340B program
established in 1990 in response to medicaid drug rebate program. required to sell drugs at discounts to “covered entities”
what is a covered entity
hospitals and federal grantee health centers for underserved populations (low income, children, uninsured, rural, HIV/AIDs, and native american)
what is charity care (aka uncompensated care)
free or discounted health services provided to those who meet an organizations eligibility criteria for $ assistance and unable to pay for part or the full amount of the services
hospitals set own thresholds
What did the 2010 Affordable Care Act Provision do
permitted covered entities to contract with any number of pharmacies to provide 340B services to covered patients
What are FQHCs
federally qualified health centers aka nonprofit outpatient clinics that manage underserved populations.
MUST PROVIDE
comprehensive/culturually competent primary and preventive health care services. emergency services and services to help access care
advantage of FQHCs
eligible to receive federal grants, enhanced reimbursement under medicare and medicaid, eligibility for 340b status.
what is prospective paymeny system
used by FQHCs and they get a single per visit payment rate from medicaid and medicare to provide all services needed during a visit. the rate varies and is adjusted at each clinic
