HIPAA and other federal laws

Question 1

Who does HIPAA apply to?

Answer 1

Covered entities:
1. Health plans
2. Data clearinghouses
3. Health care providers
4. Business associates who assist covered entities with provision of health care

Question 2

What is protected health information (PHI)?

Answer 2

Includes all health care information relating to patient’s
health/condition, treatment/care, payment and any
information that identifies or could be reasonably expected
to identify the patient

Question 3

HIPAA violations are regulated by which 2 entities?

Answer 3

HHS and the Office
for Civil Rights (OCR)

Question 4

What is the federal agency in charge
of creating regulations for and operating/administrating Medicare and Medicaid?

Answer 4

CMS, The Centers for Medicare and Medicaid Services,

Question 5

Difference between medicare and medicaid

Answer 5

Medicare is mainly for the elderly (over 65)
– Individuals older than 65
– People with permanent disabilities
– People who have been exposed to environmental health hazards
– Individuals of all ages with End Stage Renal Disease
Medicaid is mainly for low income individuals
- Memory device: When you donate clothing or food, you are providing “aid,” so you are
aiding those in need

Question 6

What are dual eligibles?

Answer 6

Individuals who qualify for medicare AND medicaid

Question 7

What is entitlement?

Answer 7

“Entitlement” definition: individuals who qualify have a legal right to (are entitled to) and are guaranteed benefits from a government program as
granted through legislation authorizing the program

Question 8

Medicare Parts and their coverage

Answer 8

Part A: Hospital insurance (inpatient)
Part B: Medical insurance (outpatient)
Part C: Managed care (Advantage plans, HMO or PPO, can be used instead of traditional Medicare
Part D: outpatient Prescription Drug Benefit

Question 9

True or false: Each Part D Sponsor is required to incorporate a Medication Therapy
Management Program (MTMP) into their plans’ benefit structure and submit an MTMP description annually to CMS for review and approval.

Answer 9

True

Question 10

What are the 6 protected Medicare Part D medication classes?

Answer 10

– Antidepressants
– Antipsychotics
– Anticonvulsants
– Antiretrovirals
– Antineoplastics
– Immunosuppressants

Question 11

How long are pharmacies required to keep records related to Medicare Part D?

Answer 11

Pharmacies are required to maintain books, records and documents related to Medicare
Part D Program for a minimum of 10 years

Question 12

Which part of Medicare covers DME?

Answer 12

Medicare Part B covers medically necessary DME that physicians prescribe for in home use

Question 13

Medicare Providers must comply with requirements known
as what in order to be reimbursed by Medicare?

Answer 13

the Medicare Conditions for Participation or Conditions for
Coverage

Question 14

What is fraud?

Answer 14

Acting in a dishonest manner with the intent to obtain a benefit
for service that you know you are not entitled to

Question 15

What is waste?

Answer 15

Behavior or conduct that results in the use of more resources
than needed

Question 16

What is abuse?

Answer 16

Inappropriately taking advantage of the Medicare Part D
program for personal benefit

Question 17

Who is Florida Medicaid administered by?

Answer 17

Administered by Agency for Health Care Administration (AHCA)

Question 18

Which two entities may determine Florida Medicaid eligibility?

Answer 18

Department of Children and
Families (DCF) or Social Security Administration

Question 19

True or false: Medicaid prescriptions must be written on tamper resistant prescription pads

Answer 19

True. Medicaid prescriptions must be written on tamper resistant
prescription pads in accordance with section 409.912 (8)(a)(5)

Question 20

Omnibus Budget Reconciliation Act of 1990 (OBRA’90)

Answer 20

OBRA ’90 establishes expanded standards of pharmacy practice
– Only states can regulate professional practice, so this had to be an indirect approach
– The federal government made OBRA requirements a condition of
participating (a Condition of Participation) in Medicaid, so states were required to adopt OBRA requirements to continue receiving funds under Medicaid

Question 21

True or false: OBRA requires pharmacists to counsel patients each pickup

Answer 21

False. OBRA states that pharmacists must make an OFFER to counsel patients

Question 22

Poison Prevention Packaging Act
(15 USC §§ 1471 – 1474)

Answer 22

. Requires use of child-resistant
containers for packaging most OTC
drugs and nearly all prescription drugs with some exceptions
. Patients or their prescribing physician may request the use of
noncompliant containers for their prescriptions

Question 23

Medicare Prescription Drug Improvement and
Modernization Act of 2003

Answer 23

. Signed into law by President George W. Bush on December 3, 2003
. Established new Medicare Part D drug benefit effective 2006
* Created provisions for Medication Therapy Management (MTM) and pharmacist reimbursement for drug therapy management of
patients with multiple
chronic diseases taking multiple covered medications
who are expected to exceed annual spending limit

Question 24

What is MTM?

Answer 24

It stands for medication therapy
management which is a term used to describe health care services provided by pharmacists

Question 25

What is DUR?

Answer 25

OBRA requires pharmacists to use drug utilization review to ensure safe and effective drug therapy to improve quality and outcomes of drug therapy.

Question 26

3 parts of DUR

Answer 26

• Retrospective review
  – DUR board evaluates data on drug use on a continual basis and determines ideal drug
  therapy and whether actual use is consistent with this ideal; make recommendations on
  improvements and educational programs
• Educational programs
  – Goal to improve use of medication based on findings of the DUR board
  – Variety of formats: face-to-face, symposia, written materials
• Prospective review
  – Pharmacists evaluate prescribed drug therapy and apply their clinical knowledge on
  correct medication use
  – It is a continuous improvement process because new drugs, patients, and health care
  professionals are always entering the system

Question 27

Three areas under DUR prospective review

Answer 27

» Screening
» Counseling
» Documentation

Question 28

True or false: Containers must be manufactured such that 80 percent of children less
than 5 years of age cannot open
them, but 90 percent of adults can

Answer 28

True