Name: Score:
80 Multiple choice questions
Definition 1 of 80
-Medicaid has broad outpatient Rx coverage, while original Medicare had very limited coverage
-Before Part D, an estimated 35-40% of elderly Americans had no Rx insurance
Medicare Advantage Plan
Traditional (Indemnity) Plan
Purchasers
Medicare Part D General Description
Definition 2 of 80
-Patients: receive care
-Providers: give the care and get paid
-Purchasers: pay for care: individuals, employers, government
The three Ps of Managed Care
PBM Functions: Management
PBM Functions: Cost Control
Health savings account (HSA)
,Definition 3 of 80
-Health practitioners may be employees of the HMO
-Payment may be capitated (per member per month fixed amount regardless of number of
members using services)
-The use of a "gatekeeper" (primary care physician (PCP))
-The use of a referral system for specialty treatment
Health savings account (HSA)
Health Maintenance Organizations (HMOs)
Average Manufacturers' Price (AMP)
Medication-related Measures and HEDIS
Definition 4 of 80
-Part D benefits are provided through private prescription drug plans (PDPs) that contract with
federal government
-In 2024, 709 PDPs will be available nationwide
Medicare Part A covers
Medicare Eligibility
Fee-for-service (FFS) payments
Types of Part D Plans
,Term 5 of 80
Catastrophic coverage
-Starts the first time a recipient enters the hospital after Medicare coverage begins.
-Ends when the recipient has been out of the hospital for 60 days in a row.
-The enrollee's cost sharing amount is set for each benefit period.
-Persons (citizens and permanent residents) 65 years of age or older
-Persons who have received SS disability for 24 months regardless of age
-End Stage Renal Disease (ESRD) and Amyotrophic Lateral Sclerosis (ALS) patients
regardless of age
-For 2023, if a Medicare Part D beneficiary has spent out-of-pocket $7,400 the member
automatically gets 'catastrophic coverage'
-Beneficiary pays out-of-pocket only a co-insurance (5% or less) or co-pay for the rest of
the year
-29% of PDPs charge no deductible
-Most PDPs charge tiered copays rather than the 25% co-insurance
-79% offer no gap coverage (if offered, usually generics)
-Some MA-PDs do not charge an additional premium for Rx coverage.
Definition 6 of 80
-Dual-eligibles (Medicaid and Medicare) will be automatically enrolled and randomly assigned to
a Part D plan. They may switch to a Part D plan of their choice.
-Enrollees may change Part D plans during the open enrollment period each year (Oct 15 through
Dec 7).
Enrollment Part D (cont)
Capitation Payment Systems
Part C - Medicare Advantage
Enrollment Part D
, Term 7 of 80
Medicaid Benefits
-Many states have been moving towards providing care for Medicaid recipients through
MCOs (HMOs and PPOs)
-State Medicaid agencies contract with MCOs for the provision of health care services
-Over 2/3 of Medicaid enrollees are in MCOs nationwid
-MA ~ 70% of enrollees are in MCOs
-Approximately 80% of Medicaid Rxs are paid for by MCOs/PBMs
-PBM payment formulas are used resulting in lower payments to pharmacies
-PBMs must adhere to the Medicaid Preferred Drug List
A program added to the Social Security system in 1965 that provides hospitalization
insurance for the elderly and permits older Americans to purchase inexpensive coverage
for doctor fees and other health expenses.
-Persons (citizens and permanent residents) 65 years of age or older
-Persons who have received SS disability for 24 months regardless of age
-End Stage Renal Disease (ESRD) and Amyotrophic Lateral Sclerosis (ALS) patients
regardless of age
pays for hospital care, outpatient care, certain nursing facilities, doctors, laboratory and x-
ray services, prescriptions, Long-Term Care, and some home health care after current
assets are exhausted.
Term 8 of 80
Dependent
the actual amount paid by a pharmacy to a supplier for a product.
an amount above the product cost and service cost which yields a return on the owners'
investment in the pharmacy.
spouse and/or children of the subscriber under a family plan
-Rx drugs
-Biological products
-Certain vaccines
-Insulin and supplies
80 Multiple choice questions
Definition 1 of 80
-Medicaid has broad outpatient Rx coverage, while original Medicare had very limited coverage
-Before Part D, an estimated 35-40% of elderly Americans had no Rx insurance
Medicare Advantage Plan
Traditional (Indemnity) Plan
Purchasers
Medicare Part D General Description
Definition 2 of 80
-Patients: receive care
-Providers: give the care and get paid
-Purchasers: pay for care: individuals, employers, government
The three Ps of Managed Care
PBM Functions: Management
PBM Functions: Cost Control
Health savings account (HSA)
,Definition 3 of 80
-Health practitioners may be employees of the HMO
-Payment may be capitated (per member per month fixed amount regardless of number of
members using services)
-The use of a "gatekeeper" (primary care physician (PCP))
-The use of a referral system for specialty treatment
Health savings account (HSA)
Health Maintenance Organizations (HMOs)
Average Manufacturers' Price (AMP)
Medication-related Measures and HEDIS
Definition 4 of 80
-Part D benefits are provided through private prescription drug plans (PDPs) that contract with
federal government
-In 2024, 709 PDPs will be available nationwide
Medicare Part A covers
Medicare Eligibility
Fee-for-service (FFS) payments
Types of Part D Plans
,Term 5 of 80
Catastrophic coverage
-Starts the first time a recipient enters the hospital after Medicare coverage begins.
-Ends when the recipient has been out of the hospital for 60 days in a row.
-The enrollee's cost sharing amount is set for each benefit period.
-Persons (citizens and permanent residents) 65 years of age or older
-Persons who have received SS disability for 24 months regardless of age
-End Stage Renal Disease (ESRD) and Amyotrophic Lateral Sclerosis (ALS) patients
regardless of age
-For 2023, if a Medicare Part D beneficiary has spent out-of-pocket $7,400 the member
automatically gets 'catastrophic coverage'
-Beneficiary pays out-of-pocket only a co-insurance (5% or less) or co-pay for the rest of
the year
-29% of PDPs charge no deductible
-Most PDPs charge tiered copays rather than the 25% co-insurance
-79% offer no gap coverage (if offered, usually generics)
-Some MA-PDs do not charge an additional premium for Rx coverage.
Definition 6 of 80
-Dual-eligibles (Medicaid and Medicare) will be automatically enrolled and randomly assigned to
a Part D plan. They may switch to a Part D plan of their choice.
-Enrollees may change Part D plans during the open enrollment period each year (Oct 15 through
Dec 7).
Enrollment Part D (cont)
Capitation Payment Systems
Part C - Medicare Advantage
Enrollment Part D
, Term 7 of 80
Medicaid Benefits
-Many states have been moving towards providing care for Medicaid recipients through
MCOs (HMOs and PPOs)
-State Medicaid agencies contract with MCOs for the provision of health care services
-Over 2/3 of Medicaid enrollees are in MCOs nationwid
-MA ~ 70% of enrollees are in MCOs
-Approximately 80% of Medicaid Rxs are paid for by MCOs/PBMs
-PBM payment formulas are used resulting in lower payments to pharmacies
-PBMs must adhere to the Medicaid Preferred Drug List
A program added to the Social Security system in 1965 that provides hospitalization
insurance for the elderly and permits older Americans to purchase inexpensive coverage
for doctor fees and other health expenses.
-Persons (citizens and permanent residents) 65 years of age or older
-Persons who have received SS disability for 24 months regardless of age
-End Stage Renal Disease (ESRD) and Amyotrophic Lateral Sclerosis (ALS) patients
regardless of age
pays for hospital care, outpatient care, certain nursing facilities, doctors, laboratory and x-
ray services, prescriptions, Long-Term Care, and some home health care after current
assets are exhausted.
Term 8 of 80
Dependent
the actual amount paid by a pharmacy to a supplier for a product.
an amount above the product cost and service cost which yields a return on the owners'
investment in the pharmacy.
spouse and/or children of the subscriber under a family plan
-Rx drugs
-Biological products
-Certain vaccines
-Insulin and supplies
