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federal mpje chapter 3 > Section D: Medicare and Medicaid > Flashcards

Section D: Medicare and Medicaid Flashcards

1
Q

The Medicare Prescription Drug Improvement and Modernization Act of 2003 is also known as

A

MMA

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2
Q

MMA is composed of what four programs

A

Medicare Part A, Medicare Part B, Medicare Part C, Medicare Part D

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3
Q

What is Medicare Part A, B, C, and D

A

Part A- provides hospitalization insurance
Part B- provides medical insurance for physician services
Part C- Medicare Managed Care (Medicare Advantage)
Part D- Medicare prescription drug program

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4
Q

What is the CMS

A

Center for Medicaid and Medicare Services developed and currently supervises the MMA

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5
Q

What is MA

A

Medicare Advantage- plans that cover everything the original Medicare covered but may offer lower costs and extra services.

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6
Q

What is MA-PD

A

Medicare Advantage Prescription Drug Plan

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7
Q

What is MTM

A

Medication Therapy Management

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8
Q

What is PDP

A

Prescription Drug Plan- Medicare prescription drug plan that covers only outpatient drugs and are intended for people in original Medicare who have no other drug coverage

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9
Q

Can patients enroll in both a PDP and MA plan

A

No

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10
Q

What is TrOOP

A

True out of Pocket Expense to the individual

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11
Q

What is another form of managed care which requires you to generally utilize only doctors and hospitals in the plan’s network, except in emergencies or special situations

A

HMO’s

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12
Q

Since January 2006 Medicare beneficiaries have been able to enroll in Medicare Part D prescription drug plans aka

A

PDP’s

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13
Q

The prescription drug plans cost to the beneficiary depends on

A

the beneficiary’s income

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14
Q

If the beneficiary is not in a low income category, they will pay

A

a monthly premium, have an annual deductible, and have co-payment responsibilities

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15
Q

Should a husband and wife have their own PDP’s

A

Yes, because the premiums, deductibles, and percentages are based upon an individual

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16
Q

Can Part D Deductibles be waived or reduced by insurance companies

A

Yes, but they may charge a higher premium or higher co-payment

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17
Q

What are co-payments for a prescription drug based on

A

a tier system

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18
Q

What is a tier 1, 2, 3, and 4 drug

A

Tier 1 - least expensive generic drug
Tier 2- preferred brand name drug
Tier 3- non-preferred brand name drug
Tier 4- rarer, higher cost drugs

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19
Q

Once the beneficiary has enrolled in Medicare Part D, the premium and deductible cannot change between what dates

A

January 1- December 31

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20
Q

Can the co-payment change

A

Yes only if the the drug is moved to another tier

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21
Q

Can the beneficiary change plans and if so when

A

Yes only once a year unless he or she moves out the plan’s area, into a nursing home, or the plan stops the service in the area

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22
Q

All Rx benefit programs must accept participation from any pharmacy that agrees to the terms and conditions of their drug plan. This is referred to as the

A

“any willing provider clause”

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23
Q

Pharmacists are eligible to receive payment from Medicare for providing MTM, if the patient is enrolled in

A

Medicare Part D

24
Q

Importation of drugs from Canada and some other countries may be permitted if whom certifies that the importation poses an additional risk to the public health

A

HHS- Human Health Services

25
Q

In 2008 Medicare Part D began to cover the cost of vaccines and their administration, which formerly was covered by

A

Part B

26
Q

Companies desiring to develop their own formularies must have a Pharmacy and Therapeutics Committee with the majority of members comprised of

A

physicians and pharmacists

27
Q

Under the standard Medicare Part D plans, what drugs are generally not covered

A
  1. barbiturates
  2. benzodiazepines
  3. weight loss or weight gain drugs
  4. hair growth drugs
  5. drugs that increase fertility
  6. prescription vitamins except pre-natal and fluoride products
  7. outpatient drugs for which the manufacturer requires monitoring
28
Q

Formulary changes by plans, such as drug removal or reduction to a less favorable tier must be done with whose approval

A

CMS

29
Q

How many days of notice should be given to CMS, state prescription plans, pharmacies, and plan enrollees

A

60 day notice

30
Q

What is the exception for not having a 60 day notice

A

A formulary drug that has a new black box warning, which may be removed at any time.

31
Q

If an enrollee is taking the drug being switched, he or she must be allowed to obtain the drug without penalty for how much longer

A

for the rest of the plan year

32
Q

Those individuals who become eligible for Medicare have an initial enrollment period that begins

A

three months before and lasts three months after the month of their birthday , in other words a time span of seven months

33
Q

Failure to enroll in a plan may result in a

A

late enrollment penalty

34
Q

A benefeciary’s monthly premium is based upon the individual coverage they have chosen and may be paid

A

directly each month or deducted from monthly Social Security Checks

35
Q

Anyone enrolling in Medicare may no longer contribute to health savings accounts (HSA’s), what are HSA’s

A

a medical savings account intended to ease the cost of medical care for working individuals

36
Q

HSA’s are available to whom

A

taxpayers in the US who are enrolled in a high deductible health plan (HDHP)

37
Q

What is a medigap policy

A

health insurance sold by private insurance companies to fill the “gaps” in the original Medicare Plan coverage

38
Q

The medigap policy is sometimes referred to as

A

Medicare Supplemental Insurance

39
Q

Health insurance companies are not permitted to sell new Medigap policies that cover drugs. However, people who already have such policies may keep them. T/F

A

True

40
Q

A medigap policies must be clearly identified on the cover as

A

“Medicare Supplemental Insurance”

41
Q

The Centers for Medicare and Medicaid Services (CMS) has stated that MTM programs must “evolve and become a cornerstone of the Medicare prescription drug benefit”. CMS has committed itself to increasing access to MTM and reducing eligibility restrictions for beneficiaries. T/F

A

True

42
Q

Medicare Part D sponsors must automatically enroll qualified beneficiaries into MTM unless

A

they opt-out

43
Q

Beneficiaries must be targeted for MTM enrollment how often

A

quarterly

44
Q

Medicare Part D sponsors must target beneficiaries who have

A

multiple chronic disease states- usually 2-3 or more

are taking many Part D medications- sponsors may set
the minimum number of drugs from 2-8

are predicted to incur a predetermined annual cost from Part D medications.

45
Q

Sponsors are not required to provide interactive consultations to long term care (LTC) residents T/F

A

True

46
Q

What population is covered under MMA

A

Medicare beneficiaries

47
Q

At what intervals may a patient with a Medicare PDP or MA card change his/her provider?

A

once a year

48
Q

A pharmacy providing services under MMA may establish a formulary limiting the drugs to

A

at least one drug from each of the 8 therapeutic categories

49
Q

Which of the following is (are) NOT permissable under the MMA

A

requiring a beneficiary to use a mail order pharmacy

requiring a beneficiary to use a mail order pharmacy for 90 day supplies of a maintenance drug

50
Q

What acronym will eventually replace AWP (average wholesale price) when calculating drug product prices under the MMA

A

ASP (average sales price)

51
Q

The term “donut hole” refers to

A

a dollar range in which the beneficiary must pay for all prescription drugs

52
Q

A client who becomes eligible for Medicare Part D on April 1st of the present year must enroll within a certain time span without a penalty T/F

A

True

53
Q

An individual will become eligible for Medicare Plan D on July 4th of a certain year. What is the maximum time span for her to enroll in a PDP without penalty?

A

April 1st- October 31st

Remember 3 months prior and 3months after bday

54
Q

Mrs. Stenson is about to file for social security as she is turning 65. Which portions of Medicare will she be automatically be enrolled

A

Medicare A and B ( hospitalization and physician services)

55
Q

When a patient asks who has to pay the expense designated as TrOOP, the pharmacist should state it is

A

Patient

federal mpje chapter 3 (1 decks)

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