MATE GH DP Final Exam Study Guide Test.

MATE GH DP Final Exam Study Guide Test. Benefits included in PPACA definition of essential health benefits - CORRECT ANSWER 1. Ambulatory patient services 2. Emergency services 3. Hospitalization 4. Maternity and newborn care 5. Mental health and substance-abuse disorders 6. Prescription drugs 7. Rehabilitative services and devices 8. Laboratory services 9. Preventative and wellness services and chronic disease management 10. Pediatric services, including oral and vision care Cost control features of comprehensive medical plans - CORRECT ANSWER 1. Requiring second surgical opinions 2. Full coverage for certain diagnostic tests - to detect early certain medical conditions 3. Preadmission certification requirements for hospitalizations 4. Utilization reviews 5. Enhanced reimbursement for procedures performed at an outpatient facility Benefits typically provided with no cost sharing in medical plans - CORRECT ANSWER (this helps reduce the use of more expensive forms of care) 1. Outpatient diagnostic tests, x-rays, and laboratory exams 2. Outpatient surgery or procedures performed at an ambulatory care facility, doctor's office, or surgical center 3. Home health care 4. Second surgical opinions for specific medical procedures Types of HMO plans - CORRECT ANSWER 1. Individual practice association (IPA) model - the HMO contracts with individual physicians or associations of physicians 2. Group model - the HMO purchases services from an independent multispecialty group of physicians 3. Network model - same as the group model except more than one multispecialty group is used 4. Staff model - the physicians are salaried employees of the HMO Wellness and preventive benefits typically provided by HMOs - CORRECT ANSWER 1. Routine physical exams 2. Preventive screenings and diagnostic tests for early detection of certain diseases 3. Prenatal and well-baby care 4. Immunizations for prevention of diseases 5. Vision and dental checkups 6. Allowances for health club memberships Potential impacts on plan design due to PPACA - CORRECT ANSWER 1. Standardization of certain benefits due to guidelines on minimum essential coverage 2. Continuing exodus from employer-provided health care for early retirees, since they will have access to coverage through health exchanges 3. Diminished role for flexible spending accounts due to annual contribution limit of $2,500 4. More conservative contributions to HSAs due to tax increase from 10% to 20% on distributions not used for qualified medical expenses 5. Greater reliance on outsourcing health plan administrative services, due to new administrative requirements 6. Curtailment of health plan offerings by certain employers, since their employees will have coverage available in the exchanges Rating approaches for health insurance - CORRECT ANSWER 1. Community rating - everyone in a given geographic area pays the same rate 2. Adjusted community rating - similar to community rating, but rates vary based on characteristics and past claims data of the plan sponsor 3. Experience rating - recent claims data is used to establish the appropriate rates 4. Cost-plus and self-insured approaches a) The sponsor pays its own claims, along with an administrative charge to an insurer or TPA who handles claims processing b) Those who use this approach may also purchase aggregate and specific stop-loss insurance Decisions an organization must make to manage health care risk - CORRECT ANSWER 1. What mode of health care delivery system will be used? 2. What benefits will be provided? 3. What contractual, financial, or payment arrangement will be negotiated with insurers or providers? Types of risk-sharing models - CORRECT ANSWER 1. Case management fee - the PCP is paid a set fee per member for overall case management services, and is also paid for services rendered 2. Physician incentive or bonus - bonuses are paid to the PCP for certain positive performance, such as good financial results, quality assurance compliance, and member satisfaction 3. Fee-for-service with a "withhold" - a withheld percentage is placed in a risk pool. Amounts are either returned or retained each year, based on the results of the risk pool. 4. Capitation for defined services - a fixed monthly payment is made for each member 5. Capitation with a withhold - a portion of the capitation payment is withheld as a tool to reduce referrals. The withhold is returned at the end of the year, depending on performance. 6. Capitation for complete services - a capitation is paid for all services, including specialist and hospital services 7. Budgeted capitation - a pool is set up (funded directly from premiums) for a group of PCPs for the year. When the pool is empty, no further monies are paid out for services. Surpluses may be shared with providers. 8. Salaried physicians - physicians are employed by the staff-model HMO and are paid a salary Types of primary utilization management programs - CORRECT ANSWER These are found in all forms of managed care (typically handled by telephone) 1. Precertification - reviews medical necessity and identifies case management opportunities 2. Concurrent review - monitors patient care to shorten the length of stay 3. Discharge planning - assesses what services will be needed after discharge 4. Large case management - identifies members with high risk for problems and tries to improve the coordination of care Types of expanded utilization management programs - CORRECT ANSWER These are found with stronger forms of managed care, such as HMOs 1. Referral management (gatekeeper approach) - members gain access to care by PCP referrals 2. Outpatient precertification - requires prior authorization for certain procedures 3. On-site concurrent review - places clinically-trained nurses at hospitals to review cases 4. Centers of excellence - these networks of facilities perform high-cost procedures 5. Prenatal advisory services - identify pregnant women at risk for delivering unhealthy babies, and provide education on proper prenatal care Benefits covered by vision and hearing care plans - CORRECT ANSWER Vision 1. Vision examination 2. Lenses - tinted, oversized, and photochromatic lenses are consider cosmetic extras and are usually not covered 3. Frames - plans either limit the choice of frames or give a dollar allowance for each year Hearing 1. Otologic and audiometric examinations 2. Hearing instruments Typical elements of consumer-driven health plans (CDHPs) - CORRECT ANSWER 1. A high-deductible health plan (HDHP) 2. An individual health account to pay for expenses not covered by the HDHP 3. Information and tools to provide health education and help find the highest-quality providers at the lowest cost 4. A communications program to encourage consumerism and healthy behaviors 5. A health coach or consultant to help individuals use available information and provide guidance on use of health care providers 6. For serious chronic conditions, a proactive medical professional to coordinate care for the patient Basic plan structures of CDHPs - CORRECT ANSWER 1. First-dollar coverage provided through a health care account 2. Employee is responsible for the difference between the account amount and the deductible 3. After the deductible, the plan coinsurance and copayments apply 4. Deductibles, coinsurance, and copayments differ for single versus family coverage and in-network versus out-of-network services Types of health care accounts - CORRECT ANSWER (see separate lists for comparisons of these accounts) 1. Health savings account (HSA) a) Must accompany a high-deductible health plan with a minimum deductible ($1,200 individual, $2,400 family) and maximum out-of-pocket limit ($5,950 individual, $11,900 family) (year 2011 amounts, indexed for inflation) b) Can be used to pay for qualified medical expenses, health insurance premiums in limited circumstances, LTC premiums, and LTC services c) Owned by the employee, who gets to keep the unused balance upon terminating employment 2. Health reimbursement arrangement (HRA) - can be used to pay for qualified medical expenses, health insurance premiums, and LTC premiums 3. Flexible spending account (FSA) a) Can be used to pay for qualified medical expenses b) The contribution amount must be specified at the beginning of the period, and the employee can use the full amount at any time in the coverage period c) Funds not used by the end of the period are forfeited (some of the FSA information is from Rosenbloom chapter 25) Comparison of key features of health care accounts - CORRECT ANSWER Convert table to words Tax treatment of health care accounts - CORRECT ANSWER Convert table to words Plan design considerations for CDHPs - CORRECT ANSWER 1. Establishing the parameters of the HDHP 2. Selecting a type of health care account 3. Level of preventive care coverage a) Most offer an initial health screening or physical at no, or very low, cost b) Also included are immunizations, routine annual physicals, and well-mother and well-baby visits 4. Whether the CDHP will be a full replacement plan or one of multiple options. A full replacement plan will minimize adverse selection and maximize cost savings, but may face employee resistance. 5. Employer contribution strategy a) Must decide how much to contribute to the employees' accounts b) CDHP contributions are often set to compare favorably with other options 6. For HRA plans, whether to permit carryovers of unused balances Categories of mental disorders - CORRECT ANSWER 1. Adjustment disorders 2. Anxiety disorders 3. Childhood disorders 4. Eating disorders 5. Mood disorders 6. Cognitive disorders 7. Personality disorders 8. Psychotic disorders 9. Substance-related disorders Types of behavioral healthcare benefit plans - CORRECT ANSWER 1. Fully insured arrangements - the managed behavioral healthcare organization (MBHO) assumes the financial risk for the provided service. The premium is usually 3% to 6% of the medical plan's premium. 2. Shared-risk arrangement - a variation of fully-insured, where there is a maximum amount the purchaser agrees to pay. Any amount above the maximum is paid by the MBHO. 3. ASO - the MBHO handles medical management, utilization review, claims payments, and other administrative functions. The purchaser assumes the financial risk. Basic types of employee assistance programs - CORRECT ANSWER 1. Full-service EAP - offers a predetermined number of face-to-face visits with a counselor. Includes an array of work/life services and consultation services. 2. Work life benefits - does not offer face-to-face visits, but replaces them with telephone or web-based access to EAP counselors Advantages of employee assistance programs - CORRECT ANSWER 1. Easy access to timely problem resolution 2. Less stigma is attached than with behavioral healthcare 3. EAPs are cost effective because of their focus on early intervention 4. There is regular communication between the EAP and its members Cost control methods and programs for behavioral health care - CORRECT ANSWER 1. Preauthorization is usually required to access treatment 2. Predictive modeling and risk assessment - predicts high-risk users and then intervene to avoid preventable costs 3. Provider performance measurement - to measure utilization and appropriateness of treatment 4. Case management - coordinate the member's care to ensuring appropriate treatment 5. Utilization review - to determine the medical necessity and appropriateness of treatment 6. Outcomes management - identifies risks early to prevent emergencies and hospitalizations 7. Coordination of care - since many disorders coexist with each other, treatment needs to be coordinated to ensure a proper overlap of drugs, testing, and advice 8. Depression disease management programs - emphasize prevention through patient empowerment tools 9. Substance abuse relapse programs - encourage individuals to remain sober while confronting day-to-day life Elements of prescription drug plans - CORRECT ANSWER 1. Member eligibility cards 2. Online claim adjudication 3. Tiered copays or deductibles and coinsurance 4. Pharmacy networks providing discounts for branded medications 5. Mail service 6. Maximum allowable cost pricing for generics 7. Formularies and/or preferred drug lists 8. Prior authorizations for certain high-cost medications 9. Therapeutic interchange or switching Employer options for managing a pharmacy benefit plan - CORRECT ANSWER 1. Manage the benefit and adjudicate claims internally 2. Outsource the benefit management to a health plan, PBM, or TPA 3. Contract directly with pharmacies and adjudicate claims internally Commonly excluded drugs for prescription drug plans - CORRECT ANSWER 1. Medications for smoking cessation, obesity, and cosmetic conditions 2. Biotechnology medications administered by a health-care professional (this is usually covered under the medical benefit instead) 3. Lifestyle drugs (such as hair loss drugs) 4. Over-the-counter medications Reasons to have a standalone drug plan, rather than combining with medical - CORRECT ANSWER 1. Under the indemnity plan, there are typically no discounts for prescription drugs 2. Medical claim processers often cannot make coverage determinations for drugs as effectively as can the PBM 3. There is limited data in the medical claims processing systems for reviewing drug trends 4. Rebates and other drug cost-savings programs are not available through medical claims processers Factors impacting the cost of a prescription benefit - CORRECT ANSWER 1. Increased demand for many drugs due to advertising 2. Demographics of the population 3. Benefits, copays, and formulary design 4. Drug cost and the mix of branded products covered 5. Drug utilization 6. Costs charged by the PBM 7. Drug discounts, rebates, and other cost savings programs 8. Fraud and misuse of drugs 9. Ability of the plan to manage costs Techniques used by plan sponsors to control pharmacy costs - CORRECT ANSWER 1. Review benefit design and how it fits into the overall medical program 2. Analyze experience to identify areas needing better management 3. Use pharmacy management tools and techniques (see separate list of cost management tools) 4. Anticipate financial impact of new drugs and set policies for them before they are released Types of drug utilization review programs - CORRECT ANSWER 1. Concurrent review - occurs at the point of service and flags potential overuse based on clinical edits (such as too-soon refills, duplicate claims, drugs requiring prior authorization, and quantity limits) 2. Retrospective review - pharmacists or nurses review patient profiles to determine patient compliance or suggest alternative therapies 3. Prospective review - educating physicians and patients about drugs or drug therapy Types of formularies - CORRECT ANSWER 1. Open formularies - enrollees can use any covered drug prescribed for them. Typically includes hundreds of possible medications and several options per category. 2. Preferred formularies - encourage patients to use preferred drugs in return for a reduced copayment 3. Closed formularies - nonformulary drugs are not covered Advantages and disadvantages of formularies - CORRECT ANSWER 1. Advantages a) Reduce costs b) Encourage patients to use the most effective medications c) Educate patients and physicians about cost-effective alternatives to expensive brand drugs 2. Disadvantages a) Need for constant communication to physicians and patients about what drugs are preferred b) Member dissatisfaction when formulary changes cause their copays to change c) Member and physician dissatisfaction when their first choice isn't on the formulary Prescription drug plan cost management tools - CORRECT ANSWER 1. Reduce the pharmacy network size without compromising access (to improve discounts) 2. Offer mail service or 90-day retail prescriptions 3. Adopt a plan design that encourages generic substitution 4. Use a formulary that promotes cost effective drugs 5. Practice utilization management that targets high-cost users 6. Perform physician profiling 7. Educate patients about alternatives to high-cost therapies 8. Monitoring for fraud and abuse 9. Quantity limits and maximum dollar limits on all prescriptions 10. Step-therapy programs (members must try one drug before another, based on clinical criteria) 11. Use of drug utilization review programs (see separate list) 12. Using a pharmacy case management program 13. Prior authorization - certain prescriptions must be pre-approved by the PBM (this last point came from a similar list in study note GH-D127-10) Services offered by PBMs - CORRECT ANSWER (the chapter's lists of ways PBMs control costs are merged into this list due to their similarities) 1. Improving the prescribing and dispensing process through real-time claims adjudication 2. Maintaining retail and mail order networks that offer discounts and monitor performance 3. Performing drug utilization review 4. Providing data and reporting regarding drug use and industry trends 5. Controlling the cost of prescriptions dispensed 6. Account management and support 7. Communicating to patients regarding program use 8. Educational components for patients and physicians 9. Contracting with pharmacies to negotiate drug prices and rebate arrangements 10. Developing and managing formularies and prior authorization programs 11. Maintaining patient compliance programs 12. Operating disease management programs Sources of revenue for PBMs - CORRECT ANSWER 1. Charging payers an administrative fee per transaction 2. Retaining rebate administrative fees negotiated with manufacturers 3. Filling mail service prescriptions from their wholly-owned mail order pharmacies 4. Disease management, education, and value-added programs 5. Securing discounts on drugs 6. Retaining the pharmacy spread 7. Retaining the spread in maximum allowable charge (MAC) list payments for generics 8. Reducing payments to pharmacies Questions to ask when choosing a PBM - CORRECT ANSWER (this list is a subset of the many questions listed in the chapter) 1. What are the options and pricing of the provider network that the PBM offers? 2. Are services and performance offerings backed by guarantees and significant financial penalties? 3. What kind of reports does the PBM offer? 4. What types of drug utilization review edits are performed routinely? 5. How does the PBM work with physicians to educate and modify prescribing patterns? 6. What types of educational programs are offered to patients? 7. What drugs are preferred by the PBM and can a client make changes to the preferred list? 8. Do enrollees experience difficulty in getting prescriptions filled because of technical problems? 9. What is the PBM's reputation with physicians and pharmacies? 10. What kind of cost savings has the PBM produced for its clients? 11. Is the PBM willing to agree to terms you find acceptable? 12. Is your organization geared up to change PBMs if needed? The last 2 items on this list are from the paper ?Effective contracting with PBMs ...? Definitions of drug types - CORRECT ANSWER 1. Brand name medication - a medication made by one manufacturer under a patent issued by the US Patent Office 2. Generic or multisource medication - a medication produced by multiple manufacturers after the brand-name medication loses patent protection 3. Authorized generics - brand drugs that the supplier authorizes to be sold under a generic label 4. Branded generics - brand-name drugs that contain the same active ingredient as the original branded drug but can act differently because they contain slightly different compounds 5. Biotechnology medications - drugs that are manufactured by reengineering proteins, manipulating genes, and other sophisticated techniques for generating new molecules Terms used in drug pricing - CORRECT ANSWER 1. Average wholesale price (AWP) - price assigned by the drug manufacturer as a reference price for all discounts paid to pharmacies and PBMs 2. Wholesale acquisition cost (WAC) - price the manufacturer charges to the wholesaler. It is the list price before any rebates, discounts, or other price concessions. 3. Maximum allowable cost (MAC) - cost ceiling for reimbursement of generic drugs. Created in various ways, such as the average AWP of all manufacturers, the lowest AWP, or a discount off AWP 4. Average manufacturer price (AMP) - average price paid to the manufacturer for drugs distributed to the retail pharmacy after deducting customary prompt payment discounts 5. Average sales price (ASP) - manufacturer's average price to all purchasers, net of discounts, rebates, chargebacks, and credits for drugs 6. Widely available market price (WAMP) - price that a prudent physician or supplier would pay for the drug, net of any routine price concessions FDA guidelines to ensure that generic drugs are interchangeable with brand drugs - CORRECT ANSWER 1. Pharmaceutical equivalence - uses the same active ingredients 2. Bioequivalence - is absorbed into the bloodstream at the same rate and extent 3. Therapeutic equivalence - is proven to be safe and effective and is both pharmaceutically equivalent and bioequivalent Key dimensions of medical benefit plans - CORRECT ANSWER (any medical plan can be defined by its position on these dimensions or continuums) 1. Definition of covered services and conditions under which those services will be covered 2. Degree to which the individual participates in the cost of the service 3. Degree to which the provider participates in the risk related to the cost of the service Services covered by medical policies - CORRECT ANSWER 1. Facility services - includes acute care hospitals, emergency rooms, outpatient facilities, psychiatric facilities, alcohol and drug treatment programs, skilled nursing facilities, and home health care 2. Professional services - includes surgeries, office visits, home visits, hospital visits, emergency room visits, and preventive care 3. Diagnostic services 4. X-ray and lab services 5. Prescription drugs 6. Durable medical equipment 7. Ambulance 8. Private duty nursing 9. Wellness benefits 10. Nurse help lines 11. Disease management benefits Purposes for having the insured share in the cost of the medical plan - CORRECT ANSWER 1. Control utilization - studies have shown drastic reductions in utilization when a plan is subject to deductibles, copays, or coinsurance 2. Control costs - requiring cost sharing lowers the premium and can potentially lead to more affordable coverage 3. Control risk to the insurer - requiring cost sharing results in a benefit program that more truly represents an insurable risk