Medicare, Medicaid, OBRA Flashcards
Who is eligible for Medicare?
65y and older
-Permanent disability
-End stage renal disease
-Exposure to environmental health hazards
Part A and B of Medicare
Part A: Hospital Insurance
Part B: Medical Insurance
Part C and D of Medicare
Part C: Medicare Advantage (A+B+, no D)
Part D: Drug Insurance
In terms of Marketing Medicare plans, what are things that are allowed?
-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
In terms of Marketing, what are things that are NOT allowed?
-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
Medicare, Medicaid
Which one is a primarily federally funded program?
Medicare
part of the paycheck goes in, you get medical services in return
Medicaid (TennCare) is State and Federally funded
Who does TennCare serve?
-low-income children
-low income parents of minor children
-pregnant women
-elderly
-Disabled
OBRA 90
Omnibus Budget Reconciliation Act of 1990
-improved patient care by requiring pharmacists to do Drug Review, patient counseling, documentation, many more
Drug Use Review
Screening prescriptions (looking for DDIs)
Counsel patients
Documentation
What must pharmacists do with the patient after screening prescriptions?
Offer to discuss
What should be included when counseling?
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!
Does TN require pharmacists to document counseling?
No
different in other states
When is the pharmacist require to counsel based on the TN Board of Pharmacy?
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
Which document information is required to maintain based on ORBA 90?
-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
What is HIPAA?
Health Insurance Portability Accountability Act of 1996
Who must comply to HIPAA?
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
What is PHI?
Protected Health Information
-Name, Addresses, Numbers, Dates, Images
-electronic, oral, and paper information
-does NOT include de-identied information
What is the Notice of Privacy Practices?
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
Who can sign the Acknowledgment of Notice on behalf of the patient?
-parent
-legal guardian
-power of attorney
-NO friends or relatives, wife, husband
When is the disclosure and use of PHI permitted?
TPO (Treatment, Payment, Operations)
Treatment
Payment
Operations: Quality assessment, fraud detection, audits, certifications, business management
What is the Minimum Necessary Requirement?
minimum amount of PHI necessary to accomplish
the objective
What are the exceptions of the Minimum Necessary Requirement?
-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
What does the pharmacy need to in case of a Breach of PHI?
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
Exceptions of Breach of PHI
-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
