1. Medicaid, TRICARE, CHAMPVA, Workers’ Compensation, and Discount Card Programs
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2. 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.
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3. 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.
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4. 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
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5. 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
TRICARE Extra
TRICARE for Life
TRICARE Prime
TRICARE Reserve Select (TRS)
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6. TRICARE Standard Welfare Reform Act Workers’ compensation insurance
Key Terms (Continued)
TRICARE Standard
Welfare Reform Act
Workers’ compensation insurance
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7. 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
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8. 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:
Authorizing additional kinds of services or making additional groups eligible
Determining eligibility within federal guidelines
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9. 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 nurse-midwife, EPSDT
Home health care and emergency care, and care at a public nursing facility
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10. 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
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11. 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
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12. 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
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13. 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
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14. 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
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15. 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
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16. 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
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17. 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 active-duty service members, called sponsors
A TRICARE beneficiary must be listed in the Department of Defense Enrollment Eligibility Reporting System (DEERS)
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18. 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
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19. 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
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20. 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
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21. 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
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22. 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
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23. 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
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24. 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
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25. 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
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26. TRICARE Drug Programs (Cont.)
TRICARE beneficiaries can fill prescriptions by four methods:
At military treatment facility pharmacies
Through the TRICARE Mail Order Pharmacy
Using TRICARE Retail Network Pharmacies
At Non-network pharmacies for a higher cost
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27. 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
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28. 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
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29. 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
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30. Non-network Pharmacies
Retail pharmacies that are not part of the TRICARE network
Beneficiaries can fill prescriptions at non-network 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
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31. 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 are covered:
Traumatic injury
Occupational disease or illness (also known as a nontraumatic injury)
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32. Workers’ Compensation (Cont.)
Compensation for work-related illnesses and injuries may be one of five types:
Medical treatment
Lost wages (temporary disability)
Permanent disability payments
Compensation for dependents of employees who are fatally injured
Vocational rehabilitation
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33. Workers’ Compensation Drug Programs
Individuals who receive prescription coverage as a result of workers’ compensation may be provided with third-party 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
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34. 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
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