Longitudinal 3 Unit 1 and 2 Objectives

Pharmacy Practice Models (4)

-Dispensing/Distribution

-Pharmaceutical care

-Clinical Services (eg, MTM)

-Patient-Centered Medical Home Model

Pharmaceutical Care: What does it require?

Requires the pharmacist to work in concert with the patient and the patient's other healthcare providers to promote health, to prevent disease

Clinical Services (eg, MTM): 5 Core Elements

Medication therapy review, a personal medication record, a medication-related action plan, intervention or referral, and documentation and follow-up

Patient-Centered Medical Home Model: Description

Model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety

Medicare: Type of Program and Income Requirements

Federal and None

Medicare: Eligibility (2)

Those 65+, those under 65 receiving Social Security Disability Insurance (SSDI) for a certain amount of time, and those under 65 with kidney failure requiring dialysis or transplant

Medicare Eligibility: For Those Who Are 65+

-Collect or qualify to collect Social Security or Railroad Retirement benefits

- OR are a current U.S. resident and either

A U.S. citizen

- OR a permanent resident having lived in the U.S. for five years in a row before applying for Medicare

Medicare Eligibility: Under 65 (3)

-Received SSDI or Railroad Disability Annuity for total disability for 24+ months

-Immediate eligibility if diagnosed with ALS and receiving SSDI

-Eligible with ESRD if they or a family member have sufficient Medicare work history

Medicare: Initial Enrollment (3)

Seven-month period including the three months before, the month of, and three months following a beneficiary's 65th birthday

Medicare: Part A

Hospital/inpatient benefits

Medicare: Part B

Doctor/outpatient benefits

Medicare: Part C

Medicare advantage plans provide inpatient and outpatient benefits

Medicare: Part D

Prescription drug benefits

What are the two main components of Original Medicare?

Part A and Part B

What optional coverage can you choose to buy with Original Medicare?

Part D and Medigap policy

What do Medicare Advantage Plans include?

Part A and Part B benefits, and sometimes Part D coverage

Does Medigap work with Medicare Advantage Plans?

No, Medigap does not work with these plans!!

Medicare Part C (Medicare Advantage Plans): Description

Health plans run by private companies that provide Part A and Part B benefits

Medicare Part C (Medicare Advantage Plans): Approved by?

Approved by medicare

Medicare Part C (Medicare Advantage Plans): What do most plans include?

Most plans include prescription drug coverage—Part D

Medicare Part C (Medicare Advantage Plans): What services may they provide? (2)

May provide vision and dental services

Medicare Part C (Medicare Advantage Plans): Who pays for care?

-Medicare pays the plan every month for beneficiaries' care

Medicare Part C: What do beneficiaries have to use?

Beneficiaries may have to use in-network doctors/ hospitals

Medicare Part C: If the plan leaves Medicare, beneficiaries can? (2)

-Join another MA Plan, or

-Return to Original Medicare

Medicare Advantage Plan Costs

Beneficiaries still pay the monthly Part B premium

- Additional monthly premium may be required for some plans

Who can join an MA plan? (2)

-To be eligible, one must be enrolled in Medicare Part A and Medicare Part B.

-One must live in the plan's service area

Medicare Part D: What is it?

Outpatient prescription drug benefit for anyone with Medicare

Eligibility for Part D

Individual is eligible for Part D if they have Part A or Part B

Ways to Get Part D Coverage (2)

If beneficiary has Original Medicare, they can purchase a stand-alone prescription drug plan (PDP); If beneficiary has MA Plan, Part D is generally included, and beneficiary receives all Medicare benefits from one plan (MA-PD)

Part D: Premiums (2)

Stand-alone plans and MA Plans may have monthly premium

Medigap Policy: What is it?

Private health insurance for individuals sold by private insurance companies that supplements Original Medicare.

Necessity of Medigap (2)

Original Medicare is expensive; Medigap policies will pay all or part of the beneficiaries' cost-sharing.

Medigap Coverage Exclusions (6)

Medigap does NOT cover outpatient prescription drugs, hearing aids, vision care and eyeglasses, long-term care, dental care, or private duty nurses.

What is the main purpose of the Inflation Reduction Act (IRA)?

To make prescription drugs more affordable for people on Medicare.

What new power does the IRA give to Medicare regarding drug prices?

It allows Medicare to negotiate drug prices with manufacturers.

What is the capped monthly cost for insulin for Medicare patients under the IRA?

$35 per month.

How does the IRA limit annual out-of-pocket drug costs for Medicare patients?

It prevents patients from paying unlimited amounts for prescriptions.

What measure does the IRA implement to control drug price increases?

It prevents drug companies from raising prices faster than inflation.

Who is required to have MTM Programs?

Each Part D Sponsor is required to incorporate a Medication Therapy Management Program (MTMP) into their plans' benefit structure.

Two Groups of Targeted Beneficiaries for MTM Programs: (4)

-Have several chronic conditions

-Take multiple Part D medications

-Are expected to have high annual drug costs

-Are considered at-risk due to drug misuse and have coverage limits under a drug management program (DMP)

Group 1: MTM Eligibility Criteria: What is the minimum threshold for diseases that sponsors may set?

Sponsors may set this minimum threshold at two or three diseases.

What are the nine core chronic conditions that Part D sponsors may target? (10)

Alzheimer's Disease, Chronic Heart Failure (CHF), Diabetes, Dyslipidemia, End-Stage Renal Disease (ESRD), Hypertension, Respiratory Disease, Bone Disease-Arthritis, Mental Health, and HIV/AIDS.

What is the minimum number of covered Part D drugs a beneficiary must have filled for MTM program eligibility?

Sponsors may set this minimum threshold at any number equal to or between two and eight.

What method must sponsors use to enroll beneficiaries in MTM programs?

Sponsors must enroll beneficiaries using an opt-out method of enrollment only.

What does CMR stand for in the context of MTM programs?

CMR stands for Comprehensive Medication Review.

What is the purpose of a CMR?

A CMR is a systematic process of collecting patient-specific information, assessing medication therapies to identify medication-related problems, developing a prioritized list of medication-related problems, and creating a plan to resolve them.

Who can provide MTM services? (3)

MTM services may be furnished by pharmacists or other qualified providers, including physicians and registered nurses.

What are Drug Management Programs (DMPs) designed for?

DMPs are designed for beneficiaries who are at risk for misuse or abuse of frequently abused drugs (FADs) such as opioids and benzodiazepine medications.

Importance Of Medicare Part D Medication-Related Quality Measures: (5)

- Ensures optimum therapeutic outcomes for targeted beneficiaries through improved medication use

-Reduces the risk of adverse events

-Is developed in cooperation with licensed and practicing pharmacists and physicians

-Describes the resources and time required to implement the program if using outside personnel and establishes the fees for pharmacists or others

-May be furnished by pharmacists or other qualified providers

Medicare Parts C and D Quality Measures: Average Scoring

Only a small number of plans receive a 5-star summary rating from CMS, with most plans receiving 3 to 4 stars

Medicare Parts C and D Quality Measures: What is it?

CMS creates plan ratings that indicate the quality of Medicare plans on a scale of 1 to 5 stars with 5 stars being the highest rating

Medicare Parts C and D Quality Measures: How is it determined?

The overall star rating is determined through numerous performance measures across several domains of performance

Medicare Parts C and D Quality Measures: Part D Star Ratings: What are they based on?

The stars are assigned based on performance measures across four domains

Medicare Parts C and D Quality Measures: Impact on Pharmacies

-Pharmacies don't get a Star Rating from CMS

-Pharmacies that positively impact Star Ratings can see benefits such as preferred pharmacy network status, which may allow them to offer lower co-pays and have access to more patients

Low Income Subsidy (LIS) OR Extra Help: Eligibility

Annual income & resources cannot exceed the following

Resources that count in determining eligibility for LIS include: (2)

- Cash in a checking or savings account and

- Stocks, bonds, mutual funds and IRA's

Resources which are not included in determining eligibility for LIS include: (5)

- Primary residence and household items

- Land they need for self-support, such as rental property or for growing produce which they will consume

- Vehicles

- Burial plot or space

- Life insurance policies

Who should be screened for eligibility for LIS?

All Medicare participants should be encouraged to be screened foreligibility for LIS

Benefits of LIS:

There's alot!!

Federal and State Programs for Limited Income Individuals: (3)

- Medicare Savings Programs (MSPs)

- Four Medicare Savings Programs (MSPs)

- SenioRx

Medicare Savings Programs (MSPs): Description

Beneficiaries can obtain assistance with applications by contacting their local State Health Insurance and Assistance Program (SHIP) or Aging and Disability Resource Centers (ADRCs)

Four Medicare Savings Programs (MSPs): (4)

-Qualified Medicare Beneficiary (QMB)

-Specified Low-Income Medicare Beneficiary (SLMB)

-Qualifying Individual (QI)

-Qualified Disabled and Working Individual (QDWI)

Qualified Medicare Beneficiary (QMB): What does it pay for?

QMB pays for Part A and Part B premiums

Specified Low-Income Medicare Beneficiary (SLMB): What does it pay for?

Pays Part B Premium only

Qualifying Individual (QI): What does it pay for?

Pays Part B Premium only

Qualified Disabled and Working Individual (QDWI): What does it pay for?

Helps pay for Medicare Part A premiums only

What is SenioRx?

A state funded prescription drug assistance program that assists in obtaining free or low cost prescription drugs from pharmaceutical companies

Who Qualifies for SenioRx? (3)

If they are at least 55 years of age with no prescription drug coverage and have a chronic medical condition and meet annual household income limits.

OR If they have a disability at any age and have been deemed disabled by Social Security or have applied for disability and are waiting on a decision, or have a doctor's declaration of disability, or they are in the 24-month Medicare waiting period.

OR They have Medicare and have reached their Medicare Part D coverage gap

The State Health Insurance Assistance Program (SHIP): What does it provide?

Provides education, counseling, and information to Medicare beneficiaries on their health coverage including Medicare, Medicare Supplement, Medicare Savings Programs, Medicaid, Prescription Drugs, Plan Comparisons, Billing and Claims, Rights and Protections, and Long-Term Care options

What is the standard benefit in Medicare Part D?

The minimum that plans must offer.

Do most Medicare Part D plans offer a true standard benefit?

Very few plans offer a true standard benefit

What is the purpose of True Out-of-Pocket (TrOOP) cost?

To compare plans

What does True Out-of-Pocket Cost (TrOOP) include? (2)

All payments for medications listed on a plan's formulary and purchased at a network or participating pharmacy

What is the description of True Out-of-Pocket Cost (TrOOP)?

The actual dollar amounts you pay for services or prescription drugs that count towards your Medicare Part D plan's annual out-of-pocket maximum limit, triggering catastrophic coverage once reached.

What does TrOOP not include?

Premiums!!!

Medicaid: What is it?

A social welfare program that provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities

Medicaid: Benefits

Offers benefits not normally covered by Medicare, including nursing home care and personal care services

Medicaid: Administration

Administered by states, according to federal requirements

Medicaid: Funding (2)

Federal (71.97%) and State (28.03%) governments jointly fund Medicaid

Medicaid Eligible Individuals in Alabama: (8)

- Supplemental Security Income (SSI) recipients (aged, blind, and disabled)

- Nursing home residents with low income

- Certain Medicare beneficiaries (who qualify for MSP)

- Parents or caretakers of dependent children in low-income households

- Pregnant women

- Infants born to Medicaid-eligible pregnant women

- Children ages 0 - 18 in low-income households

- Children in foster care or custody of Department of Youth Services

Medicaid Covered Services (8)

- Hospital services

- Hospice services

- Doctor services

- Laboratory services

- Prescription drugs

- Home health services

- Nursing home care services

- Other services include: dental services (recipients under 21), eye care foradults, family planning, mental health services, maternity services

Medicaid Covered Prescriptions

Medicaid pays for most medications legally prescribed by a doctor or authorized health professional

Medicaid Covered Services - Special Considerations: (3)

- Quantity limit

- Mandatory maintenance supply program

- Vaccine administration

Medicaid Covered Services - Quantity Limit and Exception: Description

- Five total drugs per month (4 of which may be brand name) per recipient

o Exception: Prescriptions for Medicaid eligible children and nursing home residents are excluded from these limitations

Medicaid Covered Services - Maintenance Supply: Description

A three-month supply of a maintenance prescription will NOT be counted towards the monthly prescription quantity limit

- Examples: ACEi, ARBs, Statins

Medicaid Covered Services - Vaccine Administration: Description

Reimburse Medicaid-enrolled pharmacy providers for the administration of all Advisory Committee on Immunization Practices (ACIP) recommended vaccines, including:

- COVID-19, influenza, Tdap, pneumococcal, and hepatitis A/B vaccines for eligible recipients age ≥19 and shingles vaccine for those age ≥50

Medicaid Covered Services - Medicaid Preferred Drug List (PDL): Description

The AL Medicaid Preferred Drug List (PDL) is the list of drugs covered by AL Medicaid without prior approval

Impatient (Hosptial): Method of Reimbursment (3)

- Diagnosis Related Group (DRG)

- Per Diem

- Capitation

Outpatient (Provider): Method of Reimbursmet (2)

- Fee-for-service (FFS)

- Capitation

Diagnosis Related Group (DRG): Description

A billing bundle used to group patients by diagnosis or treatment, providing hospitals with a fixed payment per case

What factors are used to determine a DRG? (3)

Diagnosis code (ICD-10), age and sex of the patient, and expected length of stay (LOS) in the hospital

Diagnosis Related Group (DRG): Payment

Hospitals receive one fixed payment per case, regardless of the actual cost of care

Which Medicare part utilizes the DRG reimbursement?

Inpatient Medicare Part A

Per Diem: Description

For inpatient services that provides a fixed amount for a patient day in the hospital, regardless of a hospital's charges or costs incurred for caring for that particular patient

Per Diem: Plan That Utilizes

Inpatient: Medicaid

Fee-for-Service (FFS): Description

A method in which doctors and other health care providers are paid for each service performed

Fee-for-Service (FFS): Examples

Tests and office visits

Fee-for-Service (FFS): Plan that Utilizes (3)

Outpatient: Medicaid, Medicare Part B, PPO

Fee-for-Service (FFS): Who often uses this method?

Preferred Provider Organizations (PPOs)often use this method of reimbursement in the outpatient setting (e.g. BCBS)

Capitation: Description

Fixed, pre-arranged monthly payments received by a physician, clinic, or hospital perpatient enrolled in a health plan, or per capita (per "head")