Pharm Care/management Test 2 Set 3

Front 1

Private Health Insurance
a)invented by whom?
b)and when for who? (2)

Back 1

a)accident insurance firms first offered "health insurance"
b1)1849 for California gold rush workers
b2)1860 railroad workers

Front 2

Most early plans
a)covered...
b)GOAL

Back 2

a)INCOME LOSS, not health costs from illness/accidents
b)protect loss of income

Front 3

____ was first to offer prepaid hospital care (and when to who) and problem w/ this?

Back 3

1929 Baylor University Hospital; offered care to dallas teachers

ONLY worked @ the BU hospital

Front 4

American Hospital Association early insurance plan (3)

Back 4

1)established statewide Blue Cross hospital insurance
2)patient pays bill
3)Blue Cross reimburses pt

Front 5

____ created Blue SHIELD for...

Back 5

California Medical Assn

for medical (physician) payments

Front 6

Blue Cross fxn
Blue Shield fxn

Back 6

BC) hospital reimbursement
BS) medical reimbursement (physician)

Front 7

Insured rates pre and post WW2

Back 7

Pre- 5%
Post- over 50%

Front 8

What caused mass incr in insured post WW2

Back 8

Manufacturing jobs giving health insurance to attract workers so the companies could meet quota's

Front 9

Post WW2 BC/BS controlled by hospitals/physicians and their GOAL was...

Back 9

PROTECT providers from financial loss

Front 10

Indemnity insurance def

Back 10

guaranteed reimbursement that was generous and little attention to costs

Front 11

By 1950s Blue Cross & Blue Shield merged result (1) and goal (1)

Back 11

1)most health insurance plans now offered MAJOR MEDICAL INSURANCE
2)offset expenses incurred by catastrophic illness/injury

Front 12

Why did early indemnity insurance need to change?

Back 12

due to little attention to controlling costs the system would implode

Front 13

Rx outpatient coverage was rare until...

Back 13

the 1970s

Front 14

Reasons for scarcity of Rx coverage b4 1970s (4)

Back 14

1)hospital-medical services largest portion of costs
2)small $ amounts for Rx's w/ a large # of claims
3)different from original principles of health insurance
4)antitrust laws prohobited pharmacists from cooperatively negotiating fees w/ insurance co's

Front 15

Health insurance is ____ to most

Back 15

financial security

Front 16

How does Rx coverage violate principles of health insurance (3)

Back 16

1)not substantial loss
2)may not represent accidental/unpredictable hazard
3)administrative costs high

Front 17

Why include Rx drug coverage? (2)

Back 17

1)often preventive in nature
2)less expensive than alternatives

Front 18

Indemnity insurance
a)def.
b)problems (3)

Back 18

a)reimbursement to patient for cost of medical expenses (pt pays provider)
b1)pt must collect/keep receipts for claim forms
b2)company must process thousands of pt claims
b3)NO incentive to control costs

Front 19

Service Benefit program (2)

Back 19

1)healthcare provider submits claims to insurer and pays them directly
2)standardized, automated claims, contracts involved

Front 20

Fee-for-Service?

Back 20

fee paid to provider for each service provided

Front 21

Managed Health Care (2)

Back 21

1)payment utilizes cost controls
2)utilization controls using pt and claims databases to improved quality of care

Front 22

Third Party
a)what are the 3 party's
b)can be....
c)ex...

Back 22

a)patient, provider, payer (payer is the 3rd party)
b)multiple participants, segments
c)medicare beneficiary

Front 23

Insurance Premium def

Back 23

amt paid monthly to insurer to purchase the insurance policy

Front 24

Cost-sharing mechanisms (4)

Back 24

1)deductible
2)copayment
3)coinsurance
4)tiered co-payment

Front 25

Deductible? (3)

Back 25

1)patient pays ALL expenses until specified out-of-pocket amount reached
2)applies to first dollar of each period (annually)
3)discourages hog wild use

Front 26

Copayment?

Back 26

pt pays set specified fee for each service

Front 27

Coinsurance?

Back 27

pt pays specified PERCENTAGE of cost

Front 28

Tiered co-payment (3 and ex)

Back 28

Tier 1- preferred generics
Tier 2- preferred brand products
Tier 3- non-preferred brand products

OU AETNA plan

Front 29

Viscious Cycle of insurance (4)

Back 29

Comprehensive Coverage --> stimulates demand --> increases prices --> more insistence on comprehensive coverage LEADS back to comprehensive coverage

Front 30

Patients want what out of insurance (viewpoints)

Back 30

convenient access to providers, quality services, low out-of-pocket costs

Front 31

Employers want what out of insurance (viewpoints)

Back 31

balance b/w healthy, satisfied employees and controlling amount spent on health benefits

Front 32

Administrators want what out of insurance (viewpoints)

Back 32

satisfy employer groups

Front 33

Providers want what out of insurance (viewpoints)

Back 33

control of their practice, adequate payment

Front 34

Who got healthcare included in social security?

Back 34

LBJ

Front 35

Medicare is the principal social health insurance program for...(3)

Back 35

1)persons 65 & older
2)some ppl w/ disabilities under age 65
3)ppl w/ end stage renal disease

Front 36

What put Medicare/caid into social security

Back 36

Title 18 of the SSA in 1965

Front 37

Medicare was originally designed to..

Back 37

compliment SS retirees, survivors, and disabled

Front 38

Medicare Parts (4)

Back 38

1)Part A- hospital insurance
2)Part B- physician insurance
3)Part C- Medicare Advantage
4)Part D- Rx drug coverage

Front 39

Medicare Advantage? (2)

Back 39

1)done thru the private sector
2)only for those elgible for medicare A&B

Front 40

Medicare is controlled by who?
Medicaid is controlled by who?

Back 40

CARE) federal govt
CAID) state govt

Front 41

Where do $ for Part A come from (2)

Back 41

1)hospital insurance trust fund
2)payroll tax 1.45% on employers and employees

Front 42

Cost sharing mechanisms used by Part A (3)

Back 42

1)premiums
2)deductibles
3)coinsurance

Front 43

Part A elgibility (2)

Back 43

1)atleast 65yo (can get as early as 62, but will only get 70% of benefits for rest of life)
2)entitled to SS benefits

Front 44

Automatic elgibility to Part A @ no cost if...

Back 44

made 40 or more quarters of SS payments

Front 45

For 65 yo non-SS beneficiaries...(2)

Back 45

Monthly premium of:
a)$215 for 30-39 quarters of SS payments
b)$400 for less than 30 quarters of SS payments

Front 46

Part A coverage/cost
a)# of days covered and where
b)deductible
c)coinsurance (3)

Back 46

a)150 days annually @ hospital and skilled nursing facility
b)For days 1-60 around $900-$1000
c1)For days 61-90, 25% per day
c2)For days 91-150, 50% per day
c3)Over 150 days you pay all costs

Front 47

Lifetime reserve of Part A

Back 47

60 days

Front 48

Part A coinsurance @ SNF's

Back 48

12.5% for days 21-100

Front 49

Part B
a)aka...
b)enrollment type

Back 49

a)Supplemental Medical Insurance (SMI)
b)VOLUNTARY

Front 50

Part B funding sources (5)

Back 50

a)deductibles ($125)
b)monthly premiums ($90)
c)deducted from SS check
d)co-insurance is 20% of approved charges
e)federal treasury (taxes)

Front 51

Part B pays for...(4)

Back 51

1)medicare elgible physician services
2)outpatient hospital services
3)home health visits for persons w/o part A
4)DME

Front 52

Medicare Reform could include (4)

Back 52

1)only Part A @ risk of bankrupting
2)higher cost sharing
3)increase payroll tax
4)decreased benefits

Front 53

Restructing for medicare reform could include... (4)

Back 53

1)increase age requirement
2)defined contribution
3)individual savings account
4)managed care

Front 54

Why are legal immigrants good for SS?

Back 54

add workers to add to the SS fund

Front 55

General Info about Medicare claims made... (3)

Back 55

1)20% make no claims
2)30% make claims less than $500
3)10% of users consume 70% of program payments

Front 56

Medi-gap?

Back 56

covers 75% of deductibles and coinsurances that medicare doesn't cover

Front 57

Medicare Advantage fxn?

Back 57

to help manage costs?

Front 58

1st attempt by medicare for Rx drugs and why didn't it work?

Back 58

1988 Catastrophic Coverage- provided broad coverage of outpatient medications

Organized groups of old ppl objected to taxes and incr in premiums (so got repealed)

Front 59

Pre-part D Rx coverage of medicare included only...(3)

Back 59

1)diabetic supplies (CMS form 1500)
2)immunosuppressives (organ transplant)
3)cancer meds

Front 60

Before Part-D
a)% of ppl that pay more than $1000/year for Rx's
b)% of ppl w/o any Rx coverage

Back 60

a)20%
b)30%

Front 61

Issues in Rx coverage? (questions that needed to be answered) (5)

Back 61

1)who to cover?
2)how should CMS admin it? (public or private)
3)how comprehensive of coverage?
4)how do you controls costs if gov't becomes primary purchaser of drugs for the elderly?
5)How do you finance it?

Front 62

Part D was gently phased in by... (2)

Back 62

1)Medicare Modernization Act of 2003 (MMA)
2)phased in by giving drug discount cards @ first

Front 63

MMA impact on pharmacy (3)

Back 63

1)drug discount cards
2)addition of part D plans
3)payment for MTM

Front 64

First Phase-Drug discount cards
a)how provided
b)who elgible
c)provisions for...

Back 64

a)private plans (not Medicare) pharmacists expected to proved them, gov't not involved
b)VOLUNTARY participation for all medicare elgible pts excluding those w/ medicaid elgibility
c)for low income beneficiaries

Front 65

Part D
a)who elgible
b)dual elgibility?
c)Why limited opportunity to enroll w/o penalty?

Back 65

a)VOLUNTARY, if you get part A you are elgible for part D
b)If dual elgible for medicare and medicaid you must enroll in part D to keep gettin Rx benefits (no more medicaid Rx benefits)
c)want ppl to sign up early to avoid adverse selection

Front 66

Adverse selection?

Back 66

person signs up for insurance right when they get sick

Front 67

What is Part D's LOW INCOME assistance?

Back 67

if greater than 150% FPL you are elgible for more extensive coverage

Front 68

How is CMS administering Part D?

Back 68

Thru PRIVATE SECTOR, medicare recipients must select and sign up for a plan in their area

Front 69

Basically 2 types of coverage for Part D

Back 69

a)plans that are Part D only using PDP's
b)plans that are integrated w/ medicare a,b,c (medicare advantage)

Front 70

Regarding insurance programs what is it illegal for a DPh to do?

Back 70

help pt select a plan, but can make 2-3 recommendations

Front 71

Part D requirements when offering plans? (2) and what if requirements not met?

Back 71

1)at least 2 qualifying plans must be available
2)at least one must be a part D plan only

If 2 plans not available, beneficiary given opportunity to enroll in fallback plan arranged by the federal govt

Front 72

CMS Standard Benefit structure for Part D (5)

Back 72

1)monthly premium of about 35$
2)Deductible is the first $250 you spend (you pay 100% of your first 250$)
3)Pay 25% co-pay until your total health care costs are up to 2400$
4)Gap in coverage until $3850 spent (you pay 100% b/w 2400 and 3850$)
5)Catastrophic coverage after $3850 (you pay 5% after this)

Front 73

Catastrophic coverage? (3)

Back 73

$2 for generic
$5 for brand
or 5% of price of the med

Front 74

Why do benefit thresholds change every year?

Back 74

to grow @ same rate as growth of drug expenditures

Front 75

Low income coverage in Part D (2)

Back 75

1)if <135% FPL, no premiums, deductible, gap coverage, nominal copays
2)if 136-150% FPL, plan benefits on a sliding scale

Front 76

MTM
a)requires...
b)gives pharmacists...
c)pays pharmacist for...
d)DPh's must get...

Back 76

a)payments for pharmacists pt care services
b)provider status
c)for non-dispensing activity
d)must get PROVIDER #

Front 77

To qualify for Part D coverage of MTM pt must...(3)

Back 77

1)have multiple chronic diseases
2)taking multiple meds covered by part D
3)identified as likely to incur high annual med costs

Front 78

New administrative part of Part D (3)

Back 78

1)requires electronic prescribing
2)requires use of counterfeit proof Rx pads on part D Rx's
3)standard benefit ID card

Front 79

Part D formularies
a)determined by...

Back 79

a)individual PDP

Front 80

Individual PDP formularies
a)must be developed and reviewed by...
b)must include...
c)must be..

Back 80

a)by a P&T committee
b)include atleast 1 physician and pharmacist w/ expertise in care of elderly/disabled
c)be based on scientific evidence (but often based on economic evidence)

Front 81

Bottom line on insurace for pts (2)

Back 81

1)maximize benefits
2)minimize personal expenditures

Front 82

Bottom line on insurace for providers

Back 82

maximize reimbursement

Front 83

Bottom line on insurance for supplier

Back 83

induced demand (ppl abusing insurance)

Front 84

Blue Cross created by...
Blue Shield created by...
Goal of each

Back 84

BC- hospitals
BS- physicians
ENSURE PAYMENT

Front 85

Carve-out?

Back 85

When a TP insurance separates the Rx coverage from other health benefits

Front 86

Contractor of Rx drug coverage in an insurance program?

Back 86

PBM (pharmacy benefit manager)

Front 87

PBM fxns (9)

Back 87

1)MANAGER OF RX BENEFITS
2)PROGRAM ADMINISTRATOR
3)PROCESSES CLAIMS
4)contracts w/ providers
5)tracts elgible beneficiaries
6)develops formulary system
7)conducts DUR
8)reimburses providers
9)audits providers

Front 88

Reimbursement from an insurance co =

Back 88

dispensing fee plus ingredient cost

Front 89

Methods of determining cost of "ingredient" (4) (which does no one use and which is used most frequently)

Back 89

1)AWP (average wholesale price) (NOT USED)
2)EAC (estimated acquistion cost)****
3)WAC (wholesaler acquistion cost)
4)MAC (maximum allowable cost)

Front 90

Impact of health insurance on pharmacy (2)

Back 90

1)steady decreasing dispensing fee (so pharmacies need to be efficient w/ computers and techs)
2)low reimbursement b/c of anti-trust laws

Front 91

Reimbursement and anti-trust laws?

Back 91

the laws dont let pharmacists get together and reject contracts

Front 92

How to avoid anti-trust laws and try to incr reimbursement?

Back 92

use pharmacy organizations like PPOK to gather large # of pharmacies together to act as a chain for buying purposes

Front 93

Medicare Part D is run by...

Back 93

individual PDP's not the govt!!!

Front 94

When Medicaid was originally created as part of LBJ's "Great Society" it was to be...

Back 94

a short-term stop gap to be replaced by national health care

Front 95

Medicaid was est by... (2)

Back 95

1)1965 Amendments to social security act
2)Title XIX of SSA

Front 96

Medicaid...
a)____ program
b)provides medical benefits to...
c)guarantees coverage for...

Back 96

a)federal and state entitlement program
b)medical benefits to poor or who have no health insurance
c)basic health and long-term care services

Front 97

Medicaid is ____ run

Back 97

STATE

Front 98

States have flexibility to determine certain aspects of medicaid like... (3)

Back 98

1)setting reimbursement rates
2)broadening of elgibility requirements
3)benefits offered

Front 99

Medicaid is offered where?

Back 99

each state, u.s. territory, and DC

Front 100

Medicaid and its eligibility vary...

Back 100

state-to-state

Front 101

Are states reqd to have Medicaid?

Back 101

NO, but all participate

Front 102

For a state to recieve matching federal funds for medicaid...(5)(but which are optional) (3)

Back 102

Must offer:
1)inpatient hospital
2)outpatient hospital
3)physician services
4)home health services
5)prenatal care

1)outpatient Rx drugs
2)physical therapy
3)optometrist/glasses

Front 103

Federal share of cost of Medicaid is determined by...(4)

Back 103

1)FMAP
2)which is based on state per capita income compared to nat'l average
3)no greater than 83%
4)no less than 50%

Front 104

OK's FMAP is ___ indicating...

Back 104

decreasing

state is doing better economically

Front 105

Medicaid accounted for what % of federal funds to OK?

Back 105

40%

Front 106

Limit on amt federal govt spends on Medicaid (3)

Back 106

1)NONE
2)Must match state spending per set %
3)as state spending increases federal spending must incr accordingly

Front 107

Who makes the medicaid payments to providers?

Back 107

oklahoma health care authority (OHCA)

Front 108

Medicaid does not provide health care for all poor unless... (5)

Back 108

1)kids
2)pregnant
3)aged
4)blind
5)disabled

Front 109

3 broad groups for basis of elgibility to Medicaid and what is special about these...

Back 109

1)mandated categorically needy (you are reqd to give these ppl funds if you want federal funds)
2)optionally categorically needy
3)medically needy

Each group varies state-to-state

Front 110

Mandated Categorically needy (7)

Back 110

1)ppl who get federally assisted income maintenance programs (like welfare)
2)Temporary Assistance for Needy Families (TANF)
3)ppl getting Social Security Income (SSI) (who are aged, poor, blind or disabled)
4)Eligibility based on income and asset level
5)pregnancy related services
6)children under 6
7)Families up to 133% FPL

Front 111

Optional categorically needy? (3)

Back 111

1)do not meet requirements for mandated coverage
2)but share many characteristics of mandated
3)usually kids/pregnant w/ income below 185% FPL

Front 112

SCHIP (State children's insurance program)
a)purpose
b)result

Back 112

a)help states cover uninsured low income kids
b)less than 10% of kids uninsured

Front 113

SCHIP eligibility (5)

Back 113

1)less than 19yo
2)family income less than 185% FPL
3)not eligible for medicaid
4)no credible insurance
5)pregnant women less than 185% FPL (in OK)

Front 114

Medically needy? (3)

Back 114

1)persons that would be eligible for categorically needy groups but their income is above the limit allowed by the state
2)ppl who "spend down" to get medicaid eligiblity (by having high medical expenses)
3)typical medically needy individual: Old in nursing home

Front 115

Majority of Oklahoma Medicaid recipients were...

Back 115

kids 18 and under

Front 116

Average monthly total Rx costs per pt (how much incr since 2000 in %) (and how much are they incr per year)

Back 116

a)40%
b)10%

Front 117

Drug Rebate Program?

Back 117

Pharmaceutical Manufacturers gave $100million to states

Front 118

OHCA Pharmacy Program before 2004 (2)

Back 118

1)3 Rx limit/month
2)resulted in incr hospital costs

Front 119

OHCA Pharmacy Program after 1-1-2004 (2)

Back 119

1)6 Rx/month
2)Rx may be greater than 100 units or 34 days supply

Front 120

Medicaid Reimbursement formula

Back 120

Ingredient cost:
a)for brand EAC = AWP-12%
b)for generic SMAC
PLUS DISPENSING FEE $4.15

Front 121

Why do states like medicaid?

Back 121

2x better reimbursement than TP so putting more $ into state pharmacies

Front 122

Advantage Waiver Program? (3)

Back 122

1)for ppl on verge of being in nursing home
2)house & community based waiver clients
2)get 7 additional Rx's w/o prior auth

Front 123

In Advantage Waiver Program what do they have to do to be monitored BY MTM WITH A PRIOR AUTH PROGRAM? (2)

Back 123

1)greater than 3 brand drugs/month
2)and 13 generic Rx/month

Front 124

OHCA Drug Management Programs

Back 124

1)Prior Auth
2)by COP
3)via pharmacy management consultants

Front 125

prior auth form is filled out by...

Back 125

pharmacy and dr.

Front 126

Prior Auth categories (4)

Back 126

1)arthritis/NSAIDS
2)anti-ulcer meds
3)BP meds
4)meds for ADHD

Front 127

Medicare
a)philosophy
b)funding
c)eligibility
d)administered by...

Back 127

a)social insurance entitlement concept
b)cost sharing using social security taxes, monthly premiums
c)65 or older/disabled
d)federal admin

Front 128

Medicaid
a)philosophy
b)funding
c)eligibility
d)administered by...

Back 128

a)medical assistance welfare concept
b)federal & state funding (general taxes)--nominal pt cost
c)low income and needy
d)state admin