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Pharmacy Billing and Reimbursement PTCB Test Prep Feb 4th, 2020

Complete Guide to Healthcare Insurance Plans!

healthcare insurance plans

Introduction

In the PTCB test, candidates can expect MCQ questions on the spectrum of healthcare insurance plans. It’s important that you understand the differences between the various kinds of insurance coverage – as well as what to do if multiple insurance plans need to be used at the same time.

Sample PTCB practice questions include:

Prescription drugs are covered under what part of Medicare?

  1. Part A
  2. Part B
  3. Part C
  4. Part D

Disabled patients under the age of 65 on low incomes are entitled to which healthcare plan?

  1. Medicare Part D only
  2. Medicare
  3. Medicare and Medicaid
  4. None of the above

Which part of Medicare covers outpatient/medical coverage?

  1. Part A
  2. Part B
  3. Part C
  4. Both A and B

With these sample PTCB questions in mind, let’s review the differences between Medicare and Medicaid that you need to know.

What is Medicare and Medicaid?

Both Medicare and Medicaid are forms of insurance reimbursement that comes from the Centers for Medicare and Medicaid (CMS).

Medicare is a federal program for patients:

  • Over the age of 65
  • Under 65, but disabled

Medicare is offered to both groups of patients irrespective of their income level.

Medicaid is a government-funded program for patients on low incomes.

It’s possible to be eligible for both Medicaid and Medicare – what is referred to as dual eligibility.

There are 4 parts to Medicare that candidates need to know.

  • Part A – inpatient hospital stays, hospice and nursing home stays
  • Part B – Outpatient hospital and doctor visits, durable medical equipment*
  • Part C – Private companies can offer Medicare (Part A and Part B only)
  • Part D – Prescription drugs

Examples of “durable medical equipment” include blood glucose monitors, walking sticks, and wheelchairs etc.

Private companies – under Part C – can offer insurance coverage. This is referred to as Medicare Advantage Plan.

Other Government Plans

Of course, there are other government plans aside from Medicare and Medicaid.

For example, there is the TRICARE plan – which covers dependents of those active members of the military, as well as those who have retired from active military service.

CHAMPVA is another government program. CHAMPVA was established to assist in paying healthcare expenses for veterans and their families who have been impacted by disability.

There are also in-work insurance schemes, too. Take worker’s compensation insurance, for example. Here, it may be possible to claim healthcare costs back if you have been injured whilst at work. It’s essential that accurate and complete documentation is maintained to ensure that the worker is not billed for these costs.

 Given the multitude of insurance plans, it’s not uncommon for people to have more than one plan. In these cases, it’s essential that – when a claim needs to be made – that the primary payer of the healthcare costs is established. Any other costs are billed to a secondary payer.

The purpose is clear – to avoid overpaying and to avoid the possibility of duplicate payments. Coordinating this process and ensuring that the correct primary and secondary payers are identified is known as coordination of benefits.

Check back to our PTCB blog for more on pharmacy billing /reimbursement and healthcare insurance plans that you need to know. Test your knowledge of insurance plans by registering an account with PTCB Test Prep.

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