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22 Cards in this Set
- Front
- Back
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What did Title XIX of the Social Security Act of 1935 establish?
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Medicaid
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How is eligibility for medicaid determined?
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Via an individual's income and assets
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True or False
States, by law, have to offer prescription coverage under medicaid |
False
(But all states do provide coverage) |
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What is the federal department responsible for regulating Medicaid?
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Centers for Medicare and Medicaid Services (CMS) within the Department of Health and Human Services
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What is the state department responsible for regulating Medicaid?
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Bureau of Health Care Financing within the Department of Health Services
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What are the federal mandates which stipulate requirements for patient eligibility for Medicaid?
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1) Aid to families with dependent children
2) SSI recipients (aged, blind, disabled) 3) Qualified Medicare Beneficiaries (QMBs) |
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What are the state mandates which outline eligibility for Medicaid?
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"Medically Needy"
1) Other aged and/or disabled 2) Other children 3) Mentally Ill 4) Pregnant Women 5) Family planning services |
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Name the five Wisconsin Medicaid programs
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1) BadgerCare Plus
2) BadgerCare Plus Core 3) BadgerCare Plus Basic 4) Family Care Program 5) SeniorCare |
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Which Wisconsin Medicaid program is typically responsible for those over the age of 65?
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SeniorCare
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What does it mean when a pharmacy "agrees to assignment"?
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They accept the risk of dispensing a product without immediate payment.
Payment is "assigned" to the pharmacy on regular intervals |
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What is a National Provider Identifier (NPI)?
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ID used by practitioners and facilities to identify and bill for services
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How much notice must be given in advance for terminating provider status?
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30 days
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How long are prescriptions valid for from the date of issuance?
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1 year
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What is a Preferred Drug List (PDL)?
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A list of drugs, usually by drug class, outlining which products are preferred per an insurance plan
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What are Diagnosis Restricted Drugs?
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These are drugs that require a specific diagnosis prior to dispensing.
Typically one will enter a diagnosis code, given on the order, when processing the insurance claim to ensure payment. |
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What is a Prior Authorization (PA)?
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This is the process of gaining approval of a non-preferred drug per a patient's insurance.
Typically a physician will fill out the specific paperwork for a payer and then submit a copy to both the pharmacy and the insurer |
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What are the typical reasons a prior authorization is approved?
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1) Previous treatment failure with a preferred drug
2) Condition that prevents the use of a preferred drug 3) Clinically significant drug interaction with another medication 4) Intolerable side effect experienced using a preferred drug |
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Define: "Maximum Allowable Cost (MAC)"
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The upper limit for the cost of a drug as determined by CMS.
This is often used to calculate reimbursement for pharmacies from Medicaid programs |
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Define: "Categorically Needy"
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1) Aid to families with dependent children
2) SSI recipients 3) Qualified Medicare Beneficiaries (QMBs) |
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Who funds Medicaid?
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The state and federal government
The federal government will reimburse a certain percentage of expenditures |
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What does the federal government mandate as the type of population eligible for Medicaid?
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The "Categorically Needy"
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What does the state government mandate as the type of population eligible for Medicaid?
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The "Medically Needy"
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