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www.pharmacyexam.com Krisman
The principal disadvantage of this reimbursement It provides health insurance for those over 65 years
method is due to a fixed monthly rate; pharmacies of age and for certain disabled individuals,
are at high risk for costs and utilization of services regardless of age.
over which they have very limited control.
It has two components, Part A and Part B.
To encourage more and more pharmacies to accept
payment via this reimbursement method, the Part A provides the hospitalization insurance
managed care plans are trying to use several without any charge to Medicare members. Part B
methods. insures members against medical expenses with a
small amount of monthly premium. This premium is
These include: deducted from the beneficiary’s Social Security
check. The person does not need to select Part B
1. Applying stop-loss provisions that cap potential coverage.
losses.
Part A normally covers medical supplies and rent of
2. Carving out certain high-cost disease states. medical appliances; it does not cover prescription
drugs for outpatients.
3. Creating risk pools that include large numbers of
pharmacies that share risk. Part B Medicare partially covers the outpatient
services such as laboratory tests, X-rays and certain
4. Including physicians and pharmacies in the same ambulance services. It does not cover prescription
risk pool. costs for outpatients.
45. (c) The Centers for Medicare & Medicaid 46.(d) All. A Drug Utilization review may include:
Services (CMS), previously known as the Health
Care Financing Administration (HCFA), is a federal 1. Known allergies.
agency within the United States Department of 2. Rational therapy-contraindication.
Health and Human Services (HHS) that administers 3. Reasonable dose, direction for use and route of
the Medicare program and works in partnership administration.
with state governments to administer Medicaid, the 4. Duplication of therapy.
State Children's Health Insurance Program (SCHIP), 5. Drug-drug, drug-food and drug-disease
and health insurance portability standards. interactions.
6. Adverse drug reactions.
In addition to these programs, CMS has other 7. Overutilization or underutilization of prescribed
responsibilities, including the administrative drugs.
simplification standards from the Health Insurance
Portability and Accountability Act of 1996 (HIPAA), 47.(a) The PPPA (Poison Prevention Packaging Act)
quality standards in long-term care facilities (more was passed in 1970 to protect young children from
commonly referred to as nursing homes) through its accidental poisoning of drugs.
survey and certification process, clinical laboratory
quality standards under the Clinical Laboratory 48.(d) Before enactment of Part D, the majority of
Improvement Amendments, and oversight of Medicare beneficiaries already had some form of
HealthCare.gov. outpatient prescription drug coverage.
Medicare is title XVIII of the Social Security Act of These sources of coverage included:
1935.
1. Retiree health programs,
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