Medicare/ Medicaid Flashcards
What is Medicare and Medicaid and Why Are They So Important?
Medicare and Medicaid are government health insurance programs by which the federal government (Medicare) and state & federal government (Medicaid) pay for health care
Medicare covers certain services and their coverage decisions are important, not only because it directly affects those who use Medicare (called “beneficiaries”), but insurance companies often follow Medicare coverage guidelines
medicare (federal)
- mainly for the elderly ( over 65)
- Memory device: You “care” about your grandparents, so Medicare is the federal program caring for the elderly by providing them health care coverage
- ELDERLY PEOPLE ARE NOT THE ONLY GROUP COVERED BY MEDICARE– it also covers other groups, but this is the big one
medicaid (state & federal)
- 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 individuals who qualify for both medicare and medicaid coverage referred to as ?
dual eligibles
-responsible for a high amount of health care costs to the system as they tend to have numerous complex health care issues, so accordingly, potential health care cost reduction solutions tend to focus on this population
The federal government enacted Medicare in 1965 as part of the Social Security Act to reduce health care costs for:
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
Medicare is federal heath insurance; it is considered an entitlement.. what does entitlement mean?
“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
what are examples of entitlement?
Medicare, Social Security, and Medicaid
What are the four main components of medicare according to the law?
- Part A: Hospital Insurance (inpatient)
- Part B: Medical insurance (outpatient)
- Part C: Managed care (medicare advantage plans - HMO or PPO)
- Part D: Prescription Drug Benefit ( outpatient prescription drug Insurance)
(T/F) Beneficiaries pay a monthly premium to obtain Part B or C and for Part D; they do not have to pay to obtain Part A because Medicare taxes are already taken out of their paycheck during their working years, but they may have a deductible for hospital costs (about $1000)
true
There is also Medicare Supplement Insurance called
Medigap
HMO and PPOs are types of managed care plans that…
contract with health care providers and facilities to provide health care at a reduced cost within a network
PBMs are pharmacy benefit managers who …
manage prescription drug benefits for clients (health insurers, large self-insured employers, or Medicare Part D drug plans) with the specific intent to lower costs of drugs. PBMs negotiate with drug manufacturers and pharmacies to determine access to and cost of available drugs.
PBMs also process pharmacy claims, administer rebates, set up clinical programs, establish retail pharmacy networks, communicate with providers and patients, analyze drug interaction data, and provide mail order services
HMO (Health maintenance organization plan) generally
-Patients must go to providers, physicians and hospitals within the network (on the plan’s list)
-If you go outside the network, there will be no coverage, unless you have a point-of- service option in your plan that allows for out-of-network coverage where you pay a higher cost for services
-Usually must choose a PCP (primary care physician) and usually need a referral to see a specialist
PPOs ( Preferred Provider Organization plan )
No restrictions on providers, but members pay less for in network providers and pay
more for out of network providers
Don’t need to choose a PCP and usually don’t need a referral to see a specialist
With the increased flexibility of a PPO, why would someone choose an HMO?
It is usually cheaper; you generally pay more for insurance premiums with the PPO plan
Medicare Prescription Drug Improvement and Modernization Act of 2003
Established new Medicare Part D drug benefit
effective 2006
Created provisions for Medication Therapy Management (MTM)
what did the Affordable care act required a minimum set of MTM services (otherwise the quality of plans varied); what does the minimum services include?
An annual comprehensive medication review provided in person or with telehealth technologies (e.g., telephones, videoconferences) by a licensed pharmacist or other qualified provider
Follow-up interventions as warranted based on the findings of the annual medication review or the targeted medication enrollment and which may be provided in person or using telehealth technologies.
Medicare Part D plan sponsors must have a process to:
Assess, at least quarterly, the medication use of individuals who are at risk but not enrolled in the MTM program, including individuals who have undergone a transition in care (e.g., a hospitalization or stay in a skilled nursing facility), if the prescription drug plan sponsor has access to that information.
Automatically enroll targeted beneficiaries, including beneficiaries identified in the quarterly assessment.
Allow beneficiaries to opt-out of enrollment in the MTM program.
There are many different Medicare Part D Plans to choose from and they are by law required to cover all or substantially all of the drugs in six groups (referred to as “protected” classes of medications):
Antidepressants
Antipsychotics
Anticonvulsants
Antiretrovirals
Antineoplastics
Immunosuppressants
medicare part d tiers
In each plan, drugs are put in groups called tiers and the patient’s co-pay will be set at a certain level according to what tier the drug is categorized into
Tier 1 is the lowest co-pay level and Tier 4 is the highest co- pay
Medicare Formulary: Drug must be for medically accepted indications. What is covered/not?
-Investigational drugs not covered
-Off-label use may be covered
-Biologics, insulin and associated medical supplies (swabs, needles, syringes, etc) covered
Formularies and tiers are set by ?
Pharmaceutical and Therapeutics (P&T) committees for the plan (consisting of doctors and pharmacists)
what are the drugs not required to be covered under Medicare Pard D
Weight loss/weight gain drugs (except for cachexia caused by AIDS, cancer, or other diseases)
Fertility drugs
Sexual dysfunction drugs (unless being used for another FDA approved indication)
Cosmetic or hair growth drugs
Cough and cold drugs for cold symptoms
Vitamins and minerals (but prenatal and fluoride preparations are covered and niacin is covered when used for prescribed treatment and not when used as a dietary supplement)
Nonprescription (OTC) drugs
Non FDA Approved drugs
DESI drugs – drugs proven safe, but not effective
Drugs covered by Medicare Parts A or B
Drugs only available from the manufacturer that require testing
Barbiturates and benzodiazepines are covered for all indications, although barbiturates may require prior authorization
Pharmacies are required to maintain books, records and documents related to Medicare Part D Program for a minimum of?
10 years
Does Medicare part B cover necessary durable medical equipment (DME) physicians prescribed for home use ?
Yes , but patient must have a written prescription for it
Medicare providers must comply with requirements know as what in order to be reimbursed by medicare?
Conditions of Participation (CoPs) or Conditions for Coverage (CfCs)
why are Conditions of Participation (CoPs) and Conditions for Coverage (CfCs) important ?
management in the hospital because they want to get paid by Medicare and any insurance companies that follow Medicare guidelines, so they want to make sure they meet these requirements
What are pharmacies filling part D prescriptions required to provide to staff?
Fraud, Waste, and Abuse (FWA) training
fraud
Acting in a dishonest manner with the intent to obtain a benefit for service that you know you are not entitled to
Waste
Behavior or conduct that results in the use of more resources than needed
Abuse
Inappropriately taking advantage of the Medicare Part D program for personal benefit
eligibility for Florida Medicaid is determined by
- Department of Children and Families (DCF) or Social Security Administration
Low income families (parents, caretaker relatives of children) with children, children, pregnant women, non- citizens with medical emergencies, aged and/or disabled individuals not currently receiving supplemental security income
In what kind of pad must medicaid prescription be written on ?
tamper resistant prescription pads in accordance with section 409.912 (8)(a)(5)
False Claim Act
Prohibits false or fraudulent claims to be filed with the US Government (including Federal health care programs)
Examples of false claims
billing for prescriptions that don’t exist, billing different drug products than those actually dispensed, billing for prescriptions filled but not picked up, inappropriate use of dispense as written codes, splitting prescriptions to obtain additional dispensing fees
Anti- Kickback laws
prohibits any remuneration (payment for services) in return for generating Medicare, Medicaid or other federal healthcare program business
- no kickbacks, bribes, and rebates
Is it considered a kick back if Medicare Part D beneficiaries use brand name drug manufacturers coupons to purchase their medications when also billing to medicare part D
yes
OBRA ’90
Arguably one of the most important federal pharmacy laws because it mandated direct pharmacy practice changes
establishes expanded standards of pharmacy practice
DUR (Drug Utilization Review)
OBRA requires pharmacists to use drug utilization review to ensure safe and effective drug therapy to improve quality and outcomes of drug therapy.
What are the three parts of DUR
retrospective review
educational programs
prospective review
what is the Prospective review of DUR
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
– Three areas under prospective review:
» Screening
» Counseling
» Documentation
Prospective DUR: Screening
- Pharmacists detect potential problems
State plan required to provide for review of drug therapy before each prescription filled or delivered to an individual at point of sale or point of distribution
Prospective DUR: Counseling
Requirement of OBRA: Pharmacist must make an offer to counsel patients
It is not a requirement to counsel, it is a requirement to make an offer to counsel as we learned in state law
Prospective DUR: Documentation
Pharmacists must make a “reasonable effort” to document a written record of patient information including pharmacist’s evaluation of patient’s drug therapy
Documentation must maintained at least for the following:
Patient name and address
Phone number, date of birth, gender
Individual history (disease states, known allergies and drug reactions, comprehensive list of medications and devices
Pharmacist comments relevant to patient’s drug therapy
If patient refuses to provide any of the above information, pharmacist should document their refusal in the system; pharmacist can refuse to fill the prescription without sufficient information
1970 Poison Prevention Packaging Act
Enacted to protect children from accidental poisonings by household substances
Poison Prevention Packaging Act Required use of
child-resistant containers for packaging most OTC drugs and nearly all prescription drugs with some exceptions
- must be so 80% of children can’t open
- 90% of adults can
- may not be reused, unless glass
- may dispense reverse containers ( child resistant on one side and not on the other)
- drugs in institutional are exempt
Request for Non Resistant Containers
- Patients or their prescribing physician may request the use of noncompliant containers for their prescriptions
- Requests are permitted under the law to be oral, but in practice, pharmacists should obtain and keep documentation to protect themselves
— document and signature needed
blanket waiver
Patients may request a “blanket waiver” that all their prescriptions be dispensed in non resistant packaging
Prescribers may not issue blanket waivers and can request a waiver only on an individual prescription and its refills
required child resistant
- aspirin containing
- controlled substances
- prescription drugs
- iron containing drugs
- dietary supplements containing iron
-acetaminophen - more than 1 gram
-diphenhydramine - more tha 66 mh - ibuprofen - 1 gram
- loperamide - more that 0.045
- mouth wash
- lidocaine
-dibucaine - naproxen- 250 mn or more
-ketoprofen - 50 mg or more - floride - 50 mg or more
minoxidil
All legend drugs and controlled substances must be packaged in child-resistant containers EXCEPT:
Sublingual dosage forms of nitroglycerin
Sublingual and chewable forms of isosorbide dinitrate in strengths of 10mg or less
Erythromycin ethylsuccinate granules for oral suspension and oral suspensions in packages containing not more than 8 g of the equivalent of erythromycin
Cyclically administered oral contraceptives, conjugated estrogens (not more than 32mg of drug), and norethindrone acetate tablets(no more than 50mg of drug) in manufacturer’s memory-aid (mnemonic) dispenser packages
