What is a benefit structure in healthcare?
A benefit structure outlines how a health plan covers medical services, including what is paid by the insurer and what costs are the responsibility of the patient. It defines deductibles, copays, coinsurance, covered services, exclusions, and out-of-pocket maximums.
Why is benefit structure important?
Most therapies on the market are oral, self-administered drugs, which are managed under the pharmacy benefit. Members can go to a retail or specialty pharmacy and fill their prescription on their own, without requiring a doctor. Each of these drugs has its own National Drug Code (NDC) on the package, which serves as an FDA identifier. Currently, there are approximately 90,000 active NDCs on the market.
All drugs that require administration by a doctor or other medical professional inside a medical facility are managed by the medical benefit, which covers the care a member receives in person. As these drugs are typically given as part of a medical procedure, they are associated with CPT codes or J-codes (for services like surgeries and tests) as well as HCPCS billing codes (for medical devices and supplies).
What are the main components of a benefit structure?
- Premiums
- Deductibles
- Copayments and coinsurance
- Out-of-pocket maximums
- Formularies and tiering
- Network rules (in-network vs. out-of-network)
- Coverage limitations and prior authorizations
