Module 2 Other Healthcare Benefits Flashcards
In addition to medical benefits, what other healthcare benefits are equally as important for companies to offer?
Seven types
Behavioral health
Well being
Prescription drugs
Dental
Vision
Tax advantage accounts
Long-term care
To evaluate a specific employee benefit, what things should be considered
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?
What laws require that mental health be covered by medical plans at the same level as other health conditions?
Mental health parity laws
What are some additional benefits aimed at supporting workplace mental health?
Positive culture
Work life integration
Employee assistance programs
List the nine behavioral health conditions
Addictions
Anxiety and depression
Family dynamics
Difficult child behaviors
Mood disorders
Abuse recovery
Post traumatic stress disorder,
ADD

List the four mental health conditions
Eating disorder
Trauma related disorders
Substance abuse disorders
Anxiety and depression disorders
What programs are workforce intervention programs designed to assist employees and resolving personal problems that may be adversely affecting the employees performance or life?
Employee assistance programs
EAP
How prevalent is EAP in most organizations large and small
Most larger employers and about half of small employers, Inc., EAP
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
Wellness programs
What are the goals of wellness programs?
Lower healthcare cost
Reduce absentee
Achieve higher employee productivity
Improve employee, engagement and life quality
What types of information is collected through a health risk assessment?
Cholesterol BMI blood sugar, blood pressure….
Wellness programs typically work to improve healthy habits- list examples of healthy habits
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
What is the correlation between a health risk assessment and healthy habits initiatives?
Health risk assessments, identify risk factors
Healthy habits initiatives target proactive measures a member can take to reduce risk
What legislation should be considered when evaluating wellness programs?
HIPAA and the affordable care act
What incentives are typically used as a means of motivating employees to participate in health and wellness programs
Discounted health premiums
Rewards programs
Monetary bonuses
Health savings account contributions
Attendance awards
Cost sharing approaches
What are the two categories of wellness programs established by the affordable care act?
Participatory wellness programs
Health contingent wellness programs
Provide examples of participatory wellness programs
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
Provide examples of health contingent wellness programs
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
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?
Cost-effectiveness
What’s the fastest growing component of health benefits cost?
Prescription drugs
What is a biotechnology drug?
A drug produced using natural sources which are less stable than synthetic drugs
How long is the patent for new drugs with no generic equivalent?
Seven years
What is the trending cost for generic drugs and why?
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.
What is a pharmacy benefit manager PBM?
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
Why are Pharmacy benefit managers, under scrutiny of some employers?
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.
What are the three types of prescription drug plan?
Plans that have co-pays
Plants that have deductibles
Plans with separate prescription drug deductibles
How does a prescription drug plan that utilizes co-pays work?
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
How does a prescription drug plan that utilizes deductibles work?
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
How does a prescription drug plan that utilizes separate prescription drug deductibles work?
The prescription drug deductible has to be met separate from any medical plan deductibles
Once the deductible is met there may be co-pays
How does the cost management approach work utilizing tiers of drug coverage?
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
To encourage generic use what does the term dispense as written mean to the pharmacy?
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
In regard to drug cost containment, what is the term step therapy Mean
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
What are some key strategies and setting prescription co-pays to drive generic use?
Lower co-pays for generic, use higher co-pays for brand or specialty drugs
Intended to drive the consumer to the generic drug
What is a prescription drug cost containment strategy specifically targeting specialty or biotech drugs
Using specific pharmacies for the specialized drug
Enables negotiating, incentives, or rebates, maybe an agreement directly with the pharmaceutical company
In regard to dental plans, what are the four expense groupings for plan design
Preventive or diagnostic - clean/ X-ray
Basic or minor restorative— fillings
Major restorative - crowns bridges dentures
Orthodontics
In regard to dental plans, what is coinsurance?
The employee covers a percentage of cost for certain services
Preventive may be free
Other groupings may require a percent paid by the employee
Define a dental health, maintenance organization, HMO
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
Define a dental PPO - preferred provider organization
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
What are advantages of dental HMO’s and PPOs
Cost control
What are disadvantages of HMO’s and PPO’s?
Network difficulty
Generally small networks
Covered services are usually limited
What are advantages of an indemnity dental plan?
What are disadvantages of indemnity dental plans?
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
What are the advantages and disadvantages of a dental PPO
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
What are the advantages and disadvantages of a dental HMO
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
When comparing dental plan design to health plan design, why is dental plan design easier?
There’s an annual benefit cap per participant and less variability in pricing and usage
In regard to dental plan design, what is the term alternate treatment provisions mean?
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.
In regard to dental plan design, what does the term predetermination mean?
All allows the dentist and the patient both to know how much will be paid under the plan
In regard to dental plan design, what is the term coordination of benefits mean?
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
In regard to dental plan design, what’s the term coinsurance mean?
The plan participant, and the plan share the cost usually a percentage
What percentage of adults over the age of 18 wear glasses or contacts?
2 thirds
What percentage of vision plans allow coverage for PRK or Lasik surgery?
30 %
What are complementary and alternative benefits?
Complementary and alternative medicines are used to treat chronic conditions usually side-by-side with traditional methods of treatment
Three general characteristics of complementary and alternative benefits
Typically not used by US US physicians or hospitals
Side-by-side or integrated use
Alternatives to conventional drugs or surgeries
What are the most common complementary and alternative modalities?
Chiropractic services
Acupuncture
Massage therapy
Herbal therapies
Comfort animal
Immersion experience
Long-term care insurance is a supplemental voluntary program. What is the purpose of long-term care insurance?
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
What are the typical features of a long-term care policy?
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
What are restrictions associated with long-term care policy?
Must be organic in nature (no benefits for mental health or substance abuse)
Subject to pre-existing condition, limitations
Coordinate with Medicare
What are tax implications and provisions of a long-term care policy
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
How does critical care insurance work?
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
In regard to supplemental benefits, what is the hospital indemnity insurance plan?
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
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
Maximum annual lifetime, dollar amount maybe no less for mental health than for Medical care
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
Up-tiering
Which program develops customized content, and personalized communication to help employees manage their self-care
Disease management
CDHP
Behavioral health
Long-term care
Disease management
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
Specific payments for particular service are not clear in advance
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
To aid with daily living activities, when an insurable event occurs
