Section D: Medicare and Medicaid

Question 1

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

Answer 1

MMA

Question 2

MMA is composed of what four programs

Answer 2

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

Question 3

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

Answer 3

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

Question 4

What is the CMS

Answer 4

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

Question 5

What is MA

Answer 5

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

Question 6

What is MA-PD

Answer 6

Medicare Advantage Prescription Drug Plan

Question 7

What is MTM

Answer 7

Medication Therapy Management

Question 8

What is PDP

Answer 8

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

Question 9

Can patients enroll in both a PDP and MA plan

Answer 9

No

Question 10

What is TrOOP

Answer 10

True out of Pocket Expense to the individual

Question 11

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

Answer 11

HMO’s

Question 12

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

Answer 12

PDP’s

Question 13

The prescription drug plans cost to the beneficiary depends on

Answer 13

the beneficiary’s income

Question 14

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

Answer 14

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

Question 15

Should a husband and wife have their own PDP’s

Answer 15

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

Question 16

Can Part D Deductibles be waived or reduced by insurance companies

Answer 16

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

Question 17

What are co-payments for a prescription drug based on

Answer 17

a tier system

Question 18

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

Answer 18

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

Question 19

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

Answer 19

January 1- December 31

Question 20

Can the co-payment change

Answer 20

Yes only if the the drug is moved to another tier

Question 21

Can the beneficiary change plans and if so when

Answer 21

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

Question 22

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

Answer 22

“any willing provider clause”

Question 23

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

Answer 23

Medicare Part D

Question 24

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

Answer 24

HHS- Human Health Services

Question 25

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

Answer 25

Part B

Question 26

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

Answer 26

physicians and pharmacists

Question 27

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

Answer 27

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

Question 28

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

Answer 28

CMS

Question 29

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

Answer 29

60 day notice

Question 30

What is the exception for not having a 60 day notice

Answer 30

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

Question 31

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

Answer 31

for the rest of the plan year

Question 32

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

Answer 32

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

Question 33

Failure to enroll in a plan may result in a

Answer 33

late enrollment penalty

Question 34

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

Answer 34

directly each month or deducted from monthly Social Security Checks

Question 35

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

Answer 35

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

Question 36

HSA's are available to whom

Answer 36

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

Question 37

What is a medigap policy

Answer 37

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

Question 38

The medigap policy is sometimes referred to as

Answer 38

Medicare Supplemental Insurance

Question 39

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

Answer 39

True

Question 40

A medigap policies must be clearly identified on the cover as

Answer 40

"Medicare Supplemental Insurance"

Question 41

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

Answer 41

True

Question 42

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

Answer 42

they opt-out

Question 43

Beneficiaries must be targeted for MTM enrollment how often

Answer 43

quarterly

Question 44

Medicare Part D sponsors must target beneficiaries who have

Answer 44

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.

Question 45

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

Answer 45

True

Question 46

What population is covered under MMA

Answer 46

Medicare beneficiaries

Question 47

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

Answer 47

once a year

Question 48

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

Answer 48

at least one drug from each of the 8 therapeutic categories

Question 49

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

Answer 49

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

Question 50

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

Answer 50

ASP (average sales price)

Question 51

The term "donut hole" refers to

Answer 51

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

Question 52

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

Answer 52

True

Question 53

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?

Answer 53

April 1st- October 31st | Remember 3 months prior and 3months after bday

Question 54

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

Answer 54

Medicare A and B ( hospitalization and physician services)

Question 55

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

Answer 55

Patient