Module 2 Other Healthcare Benefits

Question 1

In addition to medical benefits, what other healthcare benefits are equally as important for companies to offer?

Seven types

Answer 1

Behavioral health
Well being
Prescription drugs
Dental
Vision
Tax advantage accounts
Long-term care

Question 2

To evaluate a specific employee benefit, what things should be considered

Answer 2

Who is eligible
When is the employee eligible?
What benefits coverages included?
Is it voluntary or automatic?
Is it legally required or discretionary?

Who pays for it employee or company?

How was the plan funded?
How was the benefit valued by the workforce?

Question 3

What laws require that mental health be covered by medical plans at the same level as other health conditions?

Answer 3

Mental health parity laws

Question 4

What are some additional benefits aimed at supporting workplace mental health?

Answer 4

Positive culture
Work life integration
Employee assistance programs

Question 5

List the nine behavioral health conditions

Answer 5

Addictions
Anxiety and depression
Family dynamics
Difficult child behaviors
Mood disorders
Abuse recovery
Post traumatic stress disorder,
ADD


Question 6

List the four mental health conditions

Answer 6

Eating disorder
Trauma related disorders
Substance abuse disorders
Anxiety and depression disorders

Question 7

What programs are workforce intervention programs designed to assist employees and resolving personal problems that may be adversely affecting the employees performance or life?

Answer 7

Employee assistance programs
EAP

Question 8

How prevalent is EAP in most organizations large and small

Answer 8

Most larger employers and about half of small employers, Inc., EAP

Question 9

What type of programs focus more on the absence of physical or mental disease, including a holistic view, physical emotional, financial, social and or spiritual well-being

Answer 9

Wellness programs

Question 10

What are the goals of wellness programs?

Answer 10

Lower healthcare cost

Reduce absentee

Achieve higher employee productivity

Improve employee, engagement and life quality

Question 11

What types of information is collected through a health risk assessment?

Answer 11

Cholesterol BMI blood sugar, blood pressure….

Question 12

Wellness programs typically work to improve healthy habits- list examples of healthy habits

Answer 12

Weight control programs
Nutrition, counseling
Health and lifestyle coaching

Stress management programs, including yoga, and massage therapy

Exercise and fitness programs
Flu shots on site
Tobacco cessation programs

Question 13

What is the correlation between a health risk assessment and healthy habits initiatives?

Answer 13

Health risk assessments, identify risk factors

Healthy habits initiatives target proactive measures a member can take to reduce risk

Question 14

What legislation should be considered when evaluating wellness programs?

Answer 14

HIPAA and the affordable care act

Question 15

What incentives are typically used as a means of motivating employees to participate in health and wellness programs

Answer 15

Discounted health premiums

Rewards programs

Monetary bonuses

Health savings account contributions

Attendance awards

Cost sharing approaches

Question 16

What are the two categories of wellness programs established by the affordable care act?

Answer 16

Participatory wellness programs

Health contingent wellness programs

Question 17

Provide examples of participatory wellness programs

Answer 17

Generally available without regard to an individuals health status examples include

Fitness center cost reimbursement

Reward for attending no cost health education seminar

Reward for health risk assessment

Question 18

Provide examples of health contingent wellness programs

Answer 18

They generally require individuals to meet a specific standard related to their health to obtain the reward examples include

Reduce or end tobacco use

Achieve specific cholesterol target

Question 19

Most medical plans have coverage for prescription drugs, why would an organization carve out the prescription drug coverage from other aspects of the health program?

Answer 19

Cost-effectiveness

Question 20

What’s the fastest growing component of health benefits cost?

Answer 20

Prescription drugs

Question 21

What is a biotechnology drug?

Answer 21

A drug produced using natural sources which are less stable than synthetic drugs

Question 22

How long is the patent for new drugs with no generic equivalent?

Answer 22

Seven years

Question 23

What is the trending cost for generic drugs and why?

Answer 23

Generic drug cost A relatively less expensive than brand-name drugs, but generics are increasing because pharmaceutical companies are charging more as their profit margin is increased.

Question 24

What is a pharmacy benefit manager PBM?

Answer 24

PBM is a specialized firm that designs and manages a total drug program or selective management services

They include network development, fraud, and abuse detection prior authorization for some drugs, utilization review and analysis

Question 25

Why are Pharmacy benefit managers, under scrutiny of some employers?

Answer 25

Lawyers on the general public may scrutinize PMs because they receive rebates and incentives from pharmaceutical manufacturers. In many cases the incentives are more than the PBM receives from the client.

Question 26

What are the three types of prescription drug plan?

Answer 26

Plans that have co-pays Plants that have deductibles Plans with separate prescription drug deductibles

Question 27

How does a prescription drug plan that utilizes co-pays work?

Answer 27

There’s no deductible that has to be met and co-pays are typically required Co-pay is usually dependent on the classification of the prescription drug (generic lowest/ specialty drugs, highest

Question 28

How does a prescription drug plan that utilizes deductibles work?

Answer 28

An out-of-pocket deductible has to be met before insurance pays at that point there may be co-pays Usually associated with a HDHP

Question 29

How does a prescription drug plan that utilizes separate prescription drug deductibles work?

Answer 29

The prescription drug deductible has to be met separate from any medical plan deductibles Once the deductible is met there may be co-pays

Question 30

How does the cost management approach work utilizing tiers of drug coverage?

Answer 30

Attempts to shift cost to the consumer and steers them towards generic and preferred drugs 1 generic substitutions 2 formulary, or brand-name preferred 3 non-formulary or brand-name 4 specialty drugs

Question 31

To encourage generic use what does the term dispense as written mean to the pharmacy?

Answer 31

Dispense written 1 pharmacy fill at generic level if there is one even if the doctor request a brand-name Dispenses as written 2 Pharmacy. Phil is written, but the consumer has to pay the difference in cost between the brand cost and the generic cost plus the generic co-pay

Question 32

In regard to drug cost containment, what is the term step therapy Mean

Answer 32

The pharmacist will issue a generic equivalent to the consumer for a certain amount of time to try it With the generic is ineffective, the pharmacy, and then step up to the next formulary level and try again

Question 33

What are some key strategies and setting prescription co-pays to drive generic use?

Answer 33

Lower co-pays for generic, use higher co-pays for brand or specialty drugs Intended to drive the consumer to the generic drug

Question 34

What is a prescription drug cost containment strategy specifically targeting specialty or biotech drugs

Answer 34

Using specific pharmacies for the specialized drug Enables negotiating, incentives, or rebates, maybe an agreement directly with the pharmaceutical company

Question 35

In regard to dental plans, what are the four expense groupings for plan design

Answer 35

Preventive or diagnostic - clean/ X-ray Basic or minor restorative— fillings Major restorative - crowns bridges dentures Orthodontics

Question 36

In regard to dental plans, what is coinsurance?

Answer 36

The employee covers a percentage of cost for certain services Preventive may be free Other groupings may require a percent paid by the employee

Question 37

Define a dental health, maintenance organization, HMO

Answer 37

HMO are responsible for dental care Emphasize preventive care The member pre-pay fixed periodic fee usually monthly and receive services for that fee Restricted to Dentist contracted with the HMO

Question 38

Define a dental PPO - preferred provider organization

Answer 38

A contractual arrangement between a dental provider and employer or insurance company Operate on a fee for service basis Usually provide services on a discounted rate Dentist resent PPO’s when their usual customary fees are not honored

Question 39

What are advantages of dental HMO’s and PPOs

Answer 39

Cost control

Question 40

What are disadvantages of HMO’s and PPO’s?

Answer 40

Network difficulty Generally small networks Covered services are usually limited

Question 41

What are advantages of an indemnity dental plan? What are disadvantages of indemnity dental plans?

Answer 41

Has the largest offering of providers Participant pays percentages for Services (coinsurance) Disadvantages Provider reimbursement is lower from the insurance provider as compared to a PPO employees may end up paying more

Question 42

What are the advantages and disadvantages of a dental PPO

Answer 42

Advantages Can go in or out of network Pay percentage of services, coinsurance and provider agrees to contracted amount from insurance plan Disadvantages Have to meet a deductible There’s an annual maximum for coverage amount

Question 43

What are the advantages and disadvantages of a dental HMO

Answer 43

Advantages No deductibles or maximum Co-pays for treatments and services, but preventative or diagnostic services require no co-pay Disadvantages Requires choosing one provider or facility for all dental needs Need referral to see a specialist Outside network may have to pay the entire bill

Question 44

When comparing dental plan design to health plan design, why is dental plan design easier?

Answer 44

There’s an annual benefit cap per participant and less variability in pricing and usage

Question 45

In regard to dental plan design, what is the term alternate treatment provisions mean?

Answer 45

Dental problems can be treated in multiple ways. A dental plan will pay for the less expensive treatment. If the patient chooses a more expensive treatment, they pay the difference.

Question 46

In regard to dental plan design, what does the term predetermination mean?

Answer 46

All allows the dentist and the patient both to know how much will be paid under the plan

Question 47

In regard to dental plan design, what is the term coordination of benefits mean?

Answer 47

When a member is covered under more than one plan, both plans work together to ensure there is no overbilling or duplication for the member

Question 48

In regard to dental plan design, what’s the term coinsurance mean?

Answer 48

The plan participant, and the plan share the cost usually a percentage

Question 49

What percentage of adults over the age of 18 wear glasses or contacts?

Answer 49

2 thirds

Question 50

What percentage of vision plans allow coverage for PRK or Lasik surgery?

Answer 50

30 %

Question 51

What are complementary and alternative benefits?

Answer 51

Complementary and alternative medicines are used to treat chronic conditions usually side-by-side with traditional methods of treatment

Question 52

Three general characteristics of complementary and alternative benefits

Answer 52

Typically not used by US US physicians or hospitals Side-by-side or integrated use Alternatives to conventional drugs or surgeries

Question 53

What are the most common complementary and alternative modalities?

Answer 53

Chiropractic services Acupuncture Massage therapy Herbal therapies Comfort animal Immersion experience

Question 54

Long-term care insurance is a supplemental voluntary program. What is the purpose of long-term care insurance?

Answer 54

Provides a stream of payments to provide assistance with daily living, when insurable event occurs A qualifying, insurable event occur when an individual cannot perform a given number (Example 2 of five activities )of activities of daily living, such as bathing dressing, eating and moving from bed to chair

Question 55

What are the typical features of a long-term care policy?

Answer 55

Reimburse only non-medically necessary expenses Have a benefits waiting period. 30 to 180 days. Have a maximum daily allowance Have a maximum aggregate, payout 3 to 5 years Some cost-of-living adjustment features are very expensive

Question 56

What are restrictions associated with long-term care policy?

Answer 56

Must be organic in nature (no benefits for mental health or substance abuse) Subject to pre-existing condition, limitations Coordinate with Medicare

Question 57

What are tax implications and provisions of a long-term care policy

Answer 57

Governed by the internal revenue code, section 213D Paid after taxes Deductible and other medical expenses can be taken when they exceeded 7 1/2% of one’s adjusted gross income Employer contributions are excludable Policies are fully portable

Question 58

How does critical care insurance work?

Answer 58

An employee makes an election amount typically between 5000 and $30,000. If diagnosed with a covered condition, they receive a cash payment. Some plans allow employees to cover dependants Policy may be portable If employee premiums are pretax, the payment amounts would be taxable income Beneficial to employees enrolled in a high deductible health plan - cash payments made by this policy can help offset cost of care

Question 59

In regard to supplemental benefits, what is the hospital indemnity insurance plan?

Answer 59

Similar to AFLAC Cash payments Payments are typically a flat dollar amount Policy may be portable Maybe beneficial to employees in a high deductible health plan

Question 60

Which of the following statements is most accurate regarding behavioral health plans? Limits for the number of visits, and stays as an inpatient, must be the same as medical care limits Maximum annual and lifetime dollar amount, maybe no less for mental health than for medical care Does not utilize copayments, deductibles or coinsurance Coverage typically does not include chemical dependency

Answer 60

Maximum annual lifetime, dollar amount maybe no less for mental health than for Medical care

Question 61

Which of the following is an approach to managing prescription drug cost? Up-tiering Requiring consumers to use PBMs Covering specialty, or biotech drugs Encouraging, direct to consumer advertising

Answer 61

Up-tiering

Question 62

Which program develops customized content, and personalized communication to help employees manage their self-care Disease management CDHP Behavioral health Long-term care

Answer 62

Disease management

Question 63

What is one disadvantage of indemnity dental plans? Covered services are usually limited Employees have difficulty acquiring services within a specified network Reimbursement levels very due to unequal percentage rates Specific payments for a particular service are not clear in advance

Answer 63

Specific payments for particular service are not clear in advance

Question 64

Which statement best describes the purpose of long-term care insurance To provide employers with favorable tax treatment To provide universal reimbursement packages for parents of active employees To aid with daily living activities when an insurable event occurs To provide coverage for mental health and substance abuse conditions

Answer 64

To aid with daily living activities, when an insurable event occurs