HIPAA and other federal laws Flashcards
Who does HIPAA apply to?
Covered entities:
1. Health plans
2. Data clearinghouses
3. Health care providers
4. Business associates who assist covered entities with provision of health care
What is protected health information (PHI)?
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
HIPAA violations are regulated by which 2 entities?
HHS and the Office
for Civil Rights (OCR)
What is the federal agency in charge
of creating regulations for and operating/administrating Medicare and Medicaid?
CMS, The Centers for Medicare and Medicaid Services,
Difference between medicare and medicaid
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
What are dual eligibles?
Individuals who qualify for medicare AND medicaid
What is entitlement?
“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
Medicare Parts and their coverage
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
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.
True
What are the 6 protected Medicare Part D medication classes?
– Antidepressants
– Antipsychotics
– Anticonvulsants
– Antiretrovirals
– Antineoplastics
– Immunosuppressants
How long are pharmacies required to keep records related to Medicare Part D?
Pharmacies are required to maintain books, records and documents related to Medicare
Part D Program for a minimum of 10 years
Which part of Medicare covers DME?
Medicare Part B covers medically necessary DME that physicians prescribe for in home use
Medicare Providers must comply with requirements known
as what in order to be reimbursed by Medicare?
the Medicare Conditions for Participation or Conditions for
Coverage
What is fraud?
Acting in a dishonest manner with the intent to obtain a benefit
for service that you know you are not entitled to
What is waste?
Behavior or conduct that results in the use of more resources
than needed
What is abuse?
Inappropriately taking advantage of the Medicare Part D
program for personal benefit
Who is Florida Medicaid administered by?
Administered by Agency for Health Care Administration (AHCA)
Which two entities may determine Florida Medicaid eligibility?
Department of Children and
Families (DCF) or Social Security Administration
True or false: Medicaid prescriptions must be written on tamper resistant prescription pads
True. Medicaid prescriptions must be written on tamper resistant
prescription pads in accordance with section 409.912 (8)(a)(5)
Omnibus Budget Reconciliation Act of 1990 (OBRA’90)
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
True or false: OBRA requires pharmacists to counsel patients each pickup
False. OBRA states that pharmacists must make an OFFER to counsel patients
Poison Prevention Packaging Act
(15 USC §§ 1471 – 1474)
. 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
Medicare Prescription Drug Improvement and
Modernization Act of 2003
. 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
What is MTM?
It stands for medication therapy
management which is a term used to describe health care services provided by pharmacists
