Section D: Medicare and Medicaid Flashcards
The Medicare Prescription Drug Improvement and Modernization Act of 2003 is also known as
MMA
MMA is composed of what four programs
Medicare Part A, Medicare Part B, Medicare Part C, Medicare Part D
What is Medicare Part A, B, C, and D
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
What is the CMS
Center for Medicaid and Medicare Services developed and currently supervises the MMA
What is MA
Medicare Advantage- plans that cover everything the original Medicare covered but may offer lower costs and extra services.
What is MA-PD
Medicare Advantage Prescription Drug Plan
What is MTM
Medication Therapy Management
What is PDP
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
Can patients enroll in both a PDP and MA plan
No
What is TrOOP
True out of Pocket Expense to the individual
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
HMO’s
Since January 2006 Medicare beneficiaries have been able to enroll in Medicare Part D prescription drug plans aka
PDP’s
The prescription drug plans cost to the beneficiary depends on
the beneficiary’s income
If the beneficiary is not in a low income category, they will pay
a monthly premium, have an annual deductible, and have co-payment responsibilities
Should a husband and wife have their own PDP’s
Yes, because the premiums, deductibles, and percentages are based upon an individual
Can Part D Deductibles be waived or reduced by insurance companies
Yes, but they may charge a higher premium or higher co-payment
What are co-payments for a prescription drug based on
a tier system
What is a tier 1, 2, 3, and 4 drug
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
Once the beneficiary has enrolled in Medicare Part D, the premium and deductible cannot change between what dates
January 1- December 31
Can the co-payment change
Yes only if the the drug is moved to another tier
Can the beneficiary change plans and if so when
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
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
“any willing provider clause”
Pharmacists are eligible to receive payment from Medicare for providing MTM, if the patient is enrolled in
Medicare Part D
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
HHS- Human Health Services
In 2008 Medicare Part D began to cover the cost of vaccines and their administration, which formerly was covered by
Part B
Companies desiring to develop their own formularies must have a Pharmacy and Therapeutics Committee with the majority of members comprised of
physicians and pharmacists
Under the standard Medicare Part D plans, what drugs are generally not covered
- barbiturates
- benzodiazepines
- weight loss or weight gain drugs
- hair growth drugs
- drugs that increase fertility
- prescription vitamins except pre-natal and fluoride products
- outpatient drugs for which the manufacturer requires monitoring
Formulary changes by plans, such as drug removal or reduction to a less favorable tier must be done with whose approval
CMS
How many days of notice should be given to CMS, state prescription plans, pharmacies, and plan enrollees
60 day notice
What is the exception for not having a 60 day notice
A formulary drug that has a new black box warning, which may be removed at any time.
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
for the rest of the plan year
Those individuals who become eligible for Medicare have an initial enrollment period that begins
three months before and lasts three months after the month of their birthday , in other words a time span of seven months
Failure to enroll in a plan may result in a
late enrollment penalty
A benefeciary’s monthly premium is based upon the individual coverage they have chosen and may be paid
directly each month or deducted from monthly Social Security Checks
Anyone enrolling in Medicare may no longer contribute to health savings accounts (HSA’s), what are HSA’s
a medical savings account intended to ease the cost of medical care for working individuals
HSA’s are available to whom
taxpayers in the US who are enrolled in a high deductible health plan (HDHP)
What is a medigap policy
health insurance sold by private insurance companies to fill the “gaps” in the original Medicare Plan coverage
The medigap policy is sometimes referred to as
Medicare Supplemental Insurance
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
True
A medigap policies must be clearly identified on the cover as
“Medicare Supplemental Insurance”
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
True
Medicare Part D sponsors must automatically enroll qualified beneficiaries into MTM unless
they opt-out
Beneficiaries must be targeted for MTM enrollment how often
quarterly
Medicare Part D sponsors must target beneficiaries who have
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.
Sponsors are not required to provide interactive consultations to long term care (LTC) residents T/F
True
What population is covered under MMA
Medicare beneficiaries
At what intervals may a patient with a Medicare PDP or MA card change his/her provider?
once a year
A pharmacy providing services under MMA may establish a formulary limiting the drugs to
at least one drug from each of the 8 therapeutic categories
Which of the following is (are) NOT permissable under the MMA
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
What acronym will eventually replace AWP (average wholesale price) when calculating drug product prices under the MMA
ASP (average sales price)
The term “donut hole” refers to
a dollar range in which the beneficiary must pay for all prescription drugs
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
True
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?
April 1st- October 31st
Remember 3 months prior and 3months after bday
Mrs. Stenson is about to file for social security as she is turning 65. Which portions of Medicare will she be automatically be enrolled
Medicare A and B ( hospitalization and physician services)
When a patient asks who has to pay the expense designated as TrOOP, the pharmacist should state it is
Patient
