Medicare, Medicaid, OBRA

Question 1

Who is eligible for Medicare?

Answer 1

65y and older
-Permanent disability
-End stage renal disease
-Exposure to environmental health hazards

Question 2

Part A and B of Medicare

Answer 2

Part A: Hospital Insurance

Part B: Medical Insurance

Question 3

Part C and D of Medicare

Answer 3

Part C: Medicare Advantage (A+B+, no D)

Part D: Drug Insurance

Question 4

In terms of Marketing Medicare plans, what are things that are allowed?

Answer 4

-inform patients about plans your pharmacy accepts
-distribute marketing materials, including enrollment forms
-display brochures/posters - most be for all plans
-use medicare.gov to help patients find plans
-announce new plan affiliations

Question 5

In terms of Marketing, what are things that are NOT allowed?

Answer 5

-Rank plans, other than through CMS
-direct, urge, or steer patients into a plan
-accept enrollment forms
-accept compensation for helping to find a plan

Question 6

Medicare, Medicaid
Which one is a primarily federally funded program?

Answer 6

Medicare

part of the paycheck goes in, you get medical services in return

Medicaid (TennCare) is State and Federally funded

Question 7

Who does TennCare serve?

Answer 7

-low-income children
-low income parents of minor children
-pregnant women
-elderly
-Disabled

Question 8

OBRA 90

Answer 8

Omnibus Budget Reconciliation Act of 1990

-improved patient care by requiring pharmacists to do Drug Review, patient counseling, documentation, many more

Question 9

Drug Use Review

Answer 9

Screening prescriptions (looking for DDIs)

Counsel patients

Documentation

Question 10

What must pharmacists do with the patient after screening prescriptions?

Answer 10

Offer to discuss

Question 11

What should be included when counseling?

Answer 11

Patient counseling standards

-Name and description of the drug
-dosage form, dosage, route, duration
-common side effects, interactions, contraindications
-storage
-self-monitoring
-refill information
-action if missed dose

-> this is part of the Duty and Standard of Care of a Pharmacist!

Question 12

Does TN require pharmacists to document counseling?

Answer 12

No

different in other states

Question 13

When is the pharmacist require to counsel based on the TN Board of Pharmacy?

Answer 13

Pharmacists shall counsel patients on NEW PRESCRIPTIONS

Pharmacists shall not be required to counsel a patient when it is refused

Pharmacist or designee (techs) shall offer for pharmacist to counsel on refills

Question 14

Which document information is required to maintain based on ORBA 90?

Answer 14

-Demographics: Name, address, phone number, DOB, gender

-Significant medical history: disease states, allergies, drug reactions, medication list and devices

-Pharmacists comments relative to drug therapy: patients preference (generic), comments about issues with a side effect

Question 15

What is HIPAA?

Answer 15

Health Insurance Portability Accountability Act of 1996

Question 16

Who must comply to HIPAA?

Answer 16

Covered Entities

-Health Plans: HMO, government programs (Medicaid, Medicare, vet programs)

-Helthcare Clearinghouse: Middleman between provider and insurance

-Healthcare provider

-Business associates: associates who help carry out healthcare service: administrators, consultants, transcriptionists

Question 17

What is PHI?

Answer 17

Protected Health Information

-Name, Addresses, Numbers, Dates, Images
-electronic, oral, and paper information

-does NOT include de-identied information

Question 18

What is the Notice of Privacy Practices?

Answer 18

inform patients how the pharmacy intends to disclose their information

-needs to be provided to each patient on the first day of service

-> the patient then has to sign the “Acknowledgment of Notice”

-> may not refuse treatment to a patient who refuses to sign acknowledgment

Question 19

Who can sign the Acknowledgment of Notice on behalf of the patient?

Answer 19

-parent
-legal guardian
-power of attorney

-NO friends or relatives, wife, husband

Question 20

When is the disclosure and use of PHI permitted?

Answer 20

TPO (Treatment, Payment, Operations)
Treatment
Payment
Operations: Quality assessment, fraud detection, audits, certifications, business management

Question 21

What is the Minimum Necessary Requirement?

Answer 21

minimum amount of PHI necessary to accomplish
the objective

Question 22

What are the exceptions of the Minimum Necessary Requirement?

Answer 22

-Communications to the patient or other providers regarding the treatment of a patient

-When authorized by the patient

-When required by law or by DHHS for compliance and enforcement purposes

Question 23

What does the pharmacy need to in case of a Breach of PHI?

Answer 23

notify the patient by first-class mail or electronically within 60 days after breach discovered
-> if >500 affected the pharmacy must notify media within 60 days and notify the DHHS immediatly

Question 24

Exceptions of Breach of PHI

Answer 24

-Unintentional, in good faith, and does not result in further use or disclosure

-Unauthorized person to whom PHI has been disclosed will probably not remember it

-When inadvertent between two authorized individuals at the same facility and not further used or disclose