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Medicaid, TRICARE, CHAMPVA,

Workers’ Compensation, and

Discount Card Programs

Chapter 5

© 2010 The McGraw-Hill Companies, Inc. All rights reserved.

Chapter 5 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.

Chapter 5 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.

Chapter 5 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

Chapter 5 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)

Chapter 5 6

Key Terms (Continued)

• TRICARE Standard• Welfare Reform Act• Workers’ compensation insurance

Chapter 5 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

Chapter 5 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:

1. Authorizing additional kinds of services or making additional groups eligible

2. Determining eligibility within federal guidelines

Chapter 5 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

Chapter 5 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

Chapter 5 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

Chapter 5 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

Chapter 5 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

Chapter 5 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

Chapter 5 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

Chapter 5 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

Chapter 5 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)

Chapter 5 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

Chapter 5 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

Chapter 5 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

Chapter 5 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

Chapter 5 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

Chapter 5 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

Chapter 5 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

Chapter 5 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

Chapter 5 26

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 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

Chapter 5 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

Chapter 5 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

Chapter 5 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

Chapter 5 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:

1. Traumatic injury2. Occupational disease or illness (also

known as a nontraumatic injury)

Chapter 5 32

Workers’ Compensation (Cont.)

• Compensation for work-related illnesses and injuries may be one of five types:

1. Medical treatment2. Lost wages (temporary disability)3. Permanent disability payments4. Compensation for dependents of

employees who are fatally injured5. Vocational rehabilitation

Chapter 5 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

Chapter 5 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