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Certified Benefits Professional - Health And Welfare Plans And Types > Module 2 Other Healthcare Benefits > Flashcards

Module 2 Other Healthcare Benefits Flashcards

1
Q

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

Seven types

A

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

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2
Q

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

A

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?

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3
Q

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

A

Mental health parity laws

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4
Q

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

A

Positive culture
Work life integration
Employee assistance programs

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5
Q

List the nine behavioral health conditions

A

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


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6
Q

List the four mental health conditions

A

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

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7
Q

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

A

Employee assistance programs
EAP

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8
Q

How prevalent is EAP in most organizations large and small

A

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

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9
Q

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

A

Wellness programs

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10
Q

What are the goals of wellness programs?

A

Lower healthcare cost

Reduce absentee

Achieve higher employee productivity

Improve employee, engagement and life quality

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11
Q

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

A

Cholesterol BMI blood sugar, blood pressure….

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12
Q

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

A

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

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13
Q

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

A

Health risk assessments, identify risk factors

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

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14
Q

What legislation should be considered when evaluating wellness programs?

A

HIPAA and the affordable care act

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15
Q

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

A

Discounted health premiums

Rewards programs

Monetary bonuses

Health savings account contributions

Attendance awards

Cost sharing approaches

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16
Q

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

A

Participatory wellness programs

Health contingent wellness programs

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17
Q

Provide examples of participatory wellness programs

A

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

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18
Q

Provide examples of health contingent wellness programs

A

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

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19
Q

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?

A

Cost-effectiveness

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20
Q

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

A

Prescription drugs

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21
Q

What is a biotechnology drug?

A

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

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22
Q

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

A

Seven years

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23
Q

What is the trending cost for generic drugs and why?

A

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.

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24
Q

What is a pharmacy benefit manager PBM?

A

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

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25
Q

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

A

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.

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26
Q

What are the three types of prescription drug plan?

A

Plans that have co-pays

Plants that have deductibles

Plans with separate prescription drug deductibles

27
Q

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

A

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

28
Q

How does a prescription drug plan that utilizes deductibles work?

A

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

29
Q

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

A

The prescription drug deductible has to be met separate from any medical plan deductibles

Once the deductible is met there may be co-pays

30
Q

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

A

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

31
Q

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

A

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

32
Q

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

A

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

33
Q

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

A

Lower co-pays for generic, use higher co-pays for brand or specialty drugs

Intended to drive the consumer to the generic drug

34
Q

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

A

Using specific pharmacies for the specialized drug

Enables negotiating, incentives, or rebates, maybe an agreement directly with the pharmaceutical company

35
Q

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

A

Preventive or diagnostic - clean/ X-ray

Basic or minor restorative— fillings

Major restorative - crowns bridges dentures

Orthodontics

36
Q

In regard to dental plans, what is coinsurance?

A

The employee covers a percentage of cost for certain services

Preventive may be free
Other groupings may require a percent paid by the employee

37
Q

Define a dental health, maintenance organization, HMO

A

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

38
Q

Define a dental PPO - preferred provider organization

A

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

39
Q

What are advantages of dental HMO’s and PPOs

A

Cost control

40
Q

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

A

Network difficulty

Generally small networks

Covered services are usually limited

41
Q

What are advantages of an indemnity dental plan?

What are disadvantages of indemnity dental plans?

A

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

42
Q

What are the advantages and disadvantages of a dental PPO

A

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

43
Q

What are the advantages and disadvantages of a dental HMO

A

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

44
Q

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

A

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

45
Q

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

A

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.

46
Q

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

A

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

47
Q

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

A

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

48
Q

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

A

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

49
Q

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

A

2 thirds

50
Q

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

A

30 %

51
Q

What are complementary and alternative benefits?

A

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

52
Q

Three general characteristics of complementary and alternative benefits

A

Typically not used by US US physicians or hospitals

Side-by-side or integrated use

Alternatives to conventional drugs or surgeries

53
Q

What are the most common complementary and alternative modalities?

A

Chiropractic services

Acupuncture

Massage therapy

Herbal therapies

Comfort animal

Immersion experience

54
Q

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

A

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

55
Q

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

A

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

56
Q

What are restrictions associated with long-term care policy?

A

Must be organic in nature (no benefits for mental health or substance abuse)

Subject to pre-existing condition, limitations

Coordinate with Medicare

57
Q

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

A

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

58
Q

How does critical care insurance work?

A

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

59
Q

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

A

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

60
Q

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

A

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

61
Q

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

A

Up-tiering

62
Q

Which program develops customized content, and personalized communication to help employees manage their self-care

Disease management

CDHP

Behavioral health

Long-term care

A

Disease management

63
Q

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

A

Specific payments for particular service are not clear in advance

64
Q

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

A

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

Certified Benefits Professional - Health And Welfare Plans And Types (4 decks)

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