Medicaid TRICARE CHAMPVA Workers Compensation and Discount Card

Medicaid, TRICARE, CHAMPVA, Workers’ Compensation, and Discount Card Programs Chapter 5 1 © 2010 The Mc. Graw-Hill Companies, Inc. All rights reserved.

Learning Outcomes After studying this chapter, you should be able to: 5 -1 Identify two ways Medicaid programs vary from state to state. 5 -2 Discuss Medicaid prescription coverage. 5 -3 Explain who is eligible for TRICARE and CHAMPVA and how to verify eligibility. 5 -4 Discuss the prescription benefit programs offered to TRICARE and CHAMPVA beneficiaries. Chapter 5 2

Learning Outcomes (Continued) 5 -5 Describe the coverage that employees have under workers’ compensation insurance and the possible drug benefits. 5 -6 Briefly discuss discount programs that assist individuals in paying for prescriptions. Chapter 5 3

Key Terms • Catastrophic cap • Categorically needy • CHAMPVA • Defense Enrollment Eligibility Reporting System (DEERS) • Discount card • Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) • Federal Medicaid Assistance Percentage (FMAP) • Fiscal agent • Medicaid Chapter 5 4

Key Terms (Continued) • Medically indigent/needy • Military Treatment Facility (MTF) • Payer of last resort • Sponsors • State Children’s Health Insurance Program (SCHIP) • Temporary Assistance for Needy Families (TANF) • TRICARE Extra • TRICARE for Life • TRICARE Prime • TRICARE Reserve Select (TRS) Chapter 5 5

Key Terms (Continued) • TRICARE Standard • Welfare Reform Act • Workers’ compensation insurance Chapter 5 6

Medicaid • • Medicaid is an assistance program, not an insurance program Pays health care services for people with incomes below the national poverty level Both the federal and state governments pay for Medicaid Administered by a fiscal agent, an organization that processes claims for a government program Chapter 5 7

Medicaid (Cont. ) • The first Medicaid programs were required by federal law as part of the Social Security Act of 1965 • States participate in their Medicaid programs in two ways: 1. Authorizing additional kinds of services or making additional groups eligible 2. Determining eligibility within federal guidelines Chapter 5 8

Medicaid Coverage • According to federal guidelines, Medicaid pays for the following types of health care: • Many types of services – physician, laboratory, x-ray, inpatient and outpatient hospital, rural health clinic, family planning, federally qualified health-center, prenatal and nursemidwife, EPSDT • Home health care and emergency care, and care at a public nursing facility Chapter 5 9

Medicaid Coverage (Cont. ) • States may include additional Medicaid coverage, including: • Many types of services – clinic, ambulance, chiropractic, mental-health, allergy, dermatology, podiatry • Many types of care – emergency room, dental, private-duty nursing • Various other drugs, devices, and services Chapter 5 10

Medicaid Coverage (Cont. ) • • Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) is a prevention, early-detection, and treatment program for children under the age of twenty-one who are enrolled in Medicaid The State Children's Health Insurance Program (SCHIP), part of the Balanced Budget Act of 1997, requires states to develop and implement plans for health insurance coverage for uninsured children Chapter 5 11

Medicaid Eligibility • Generally, Medicaid recipients are people who: • Have low incomes and who have children • Are over the age of sixty-five • Are blind • Have permanent disabilities Chapter 5 12

Medicaid Eligibility (Cont. ) • One group of Medicaid recipients is known as categorically needy • Needs of these beneficiaries are addressed under the Welfare Reform Act • Temporary Assistance for Needy Families (TANF) was created by the Welfare Reform Act and helps with program helps with living expenses Chapter 5 13

Medicaid Eligibility (Cont. ) • Some states extend Medicaid eligibility to include another group of people classified as medically needy or medically indigent • Includes individuals who earn enough money to pay for basic living expenses, but cannot afford high medical bills • Once Medicaid eligibility is determined, the recipient gets an identification card or coupon explaining effective dates and any additional information Chapter 5 14

Medicaid Eligibility (Cont. ) • Pharmacy technician insurance specialists are alert to checking these three points: • Eligibility • Preauthorization • Other insurance coverage • Medicaid is referred to as the payer of last resort, because it is the secondary payer, and claims are filed elsewhere first Chapter 5 15

Medicaid Drug Programs • States offer unique Medicaid prescription drug plans • The following factors vary by state: • Covered and noncovered drugs • Steps required for beneficiaries to receive drugs • Options for obtaining information and registering for a program • Expected reimbursement practices for pharmacies Chapter 5 16

TRICARE • • • TRICARE is the Department of Defense health insurance plan for military personnel and their families, and insurance is automatically provided for or paid by their branch of service Benefits spouses and children of activeduty service members, called sponsors A TRICARE beneficiary must be listed in the Department of Defense Enrollment Eligibility Reporting System (DEERS) Chapter 5 17

TRICARE Standard • • A fee-for-service program Covers medically necessary services provided by a civilian physician when an individual cannot obtain treatment from a military treatment facility (MTF) Individuals must first seek care at a MTF Patient cost-share payments are subject to an annual catastrophic cap, a limit on the total medical expenses that the patient must pay in one year Chapter 5 18

TRICARE Prime • • A managed care plan similar to an HMO Each individual is assigned a primary care manager (PCM) who coordinates and manages that patient's medical care Active-duty service members are automatically enrolled in TRICARE Prime An annual enrollment fee is paid to join, and copayments may apply to some beneficiaries Chapter 5 19

TRICARE Extra • • • An alternative managed care plan for individuals who want to receive services primarily from civilian facilities and physicians rather than from military facilities Members must receive health care services from a select network of health care professionals There is no enrollment fee, but there is an annual deductible Chapter 5 20

TRICARE Reserve Select (TRS) • • A premium-based health plan available for purchase by certain members of the National Guard and Reserve activated on or after September 11, 2001 Provides members and their covered family members with comprehensive health care coverage similar to TRICARE Standard and TRICARE Extra Chapter 5 21

TRICARE for Life (TFL) • • • Initiated in October 2001 to fulfill a promise made to many military personnel at the time of enrollment that they would receive lifelong health care TFL provides military health care coverage to TRICARE beneficiaries who are sixty-five years of age or older TFL pays after Medicare and any other health insurance Chapter 5 22

CHAMPVA • The Civilian Health and Medical Program of the Veterans Administration • Helps pay health care costs for families of veterans who are totally and permanently disabled because of service-related injuries • Also covers the surviving spouse and children of a veteran who died from a service-related disability Chapter 5 23

Beneficiary Identification • • • People who qualify for TRICARE or CHAMPVA are called beneficiaries Beneficiaries get identification cards that contain information needed for claims Pharmacy technician insurance specialist familiarize themselves with the processes followed to verify the eligibility of beneficiaries Chapter 5 24

TRICARE Drug Programs • • • This pharmacy benefit is available to all eligible U. S. uniformed service members The amount a beneficiary pays toward the cost of medication is based on whether the prescription is a generic, formulary, or non -formulary pharmaceutical Copayments are equal for all beneficiaries (except active-duty service members, who receive free medications), depending on where the prescription is filled Chapter 5 25

TRICARE Drug Programs (Cont. ) • TRICARE beneficiaries can fill prescriptions by four methods: 1. At military treatment facility pharmacies 2. Through the TRICARE Mail Order Pharmacy 3. Using TRICARE Retail Network Pharmacies 4. At Non-network pharmacies for a higher cost Chapter 5 26

Military Treatment Facility Pharmacies • • • Convenient and inexpensive option to beneficiaries Prescriptions that are on the MTF formulary may be filled (usually up to a ninety-day supply) at no cost to the beneficiary TRICARE has a basic core formulary Chapter 5 27

TRICARE Mail Order Pharmacy • • • Administered by Express Scripts, Inc. (ESI), is available for prescriptions that beneficiaries take on a regular basis Often a more cost-effective method of receiving prescriptions Prescription refills may be requested by mail, phone, or online Chapter 5 28

TRICARE Retail Network Pharmacies • • Nationwide network of over fifty-four thousand retail pharmacies Beneficiaries who use pharmacies in the ESI network do not have to file claims for reimbursement if the pharmacies are outside their primary region Chapter 5 29

Non-network Pharmacies • Retail pharmacies that are not part of the TRICARE network • Beneficiaries can fill prescriptions at nonnetwork pharmacies, but doing so is the most expensive option • They have to pay for the entire amount initially and then file a claim to receive partial reimbursement Chapter 5 30

Workers’ Compensation • Medical care for work-related injuries or illnesses is covered by this federal or state plan • Such a plan also provides benefits for lost wages and permanent disabilities • Two kinds of situations that require medical care covered: 1. Traumatic injury 2. Occupational disease or illness (also known as a nontraumatic injury) Chapter 5 31

Workers’ Compensation (Cont. ) • Compensation for work-related illnesses and injuries may be one of five types: 1. Medical treatment 2. Lost wages (temporary disability) 3. Permanent disability payments 4. Compensation for dependents of employees who are fatally injured 5. Vocational rehabilitation Chapter 5 32

Workers’ Compensation Drug Programs • • Individuals who receive prescription coverage as a result of workers’ compensation may be provided with thirdparty prescription cards to pay for their prescriptions Patients’ coverage should be verified by contacting their employer, asking for the name of the insurance carrier, and then contacting that carrier Chapter 5 33

Discount Card Programs • A number of states offer a discount card for people who cannot afford prescription drugs • Discount cards offer savings that depend on the drugs • Average savings for commonly prescribed drugs are from 5 percent to more than 40 percent Chapter 5 34