Medicare: part D
Outside of the 6 covered drug categories what else is covered?Biologicals
Insulin and insulin syringes
Smoking cessation drugsMIPPA requires that plans pay electronic pharmacy claims within how many days?14 days
30 days for claims submitted by other meansPharmacies can NOT do what in regard to plan and provider marketing? (4)Direct, urge, or steer patient to a particular plan
Compare different plan benefits unless created by CMS
Collect or accept Medicare enrollment applications
Accept compensation for conducting enrollment or marketing activitiesAccording to Medicare, how long must records be kept?10 yearsDurable medical equipment, prosthetics orthotics, and supplies (DMEPOS):
Pharmacy accreditation exception: must meet all criteria which is? (5)Total Billings by pharmacy for DMEPOS are <5% of total pharmacy sales for the previous 3 years
Pharmacy has been enrolled as a DMEPOS suppliers and has had a provider number for at least 5 years
No final adverse actions were imposed in the past 5 years
Submit attestation that it meets the above
Pharmacy aggress to submit requested materialsMedicaid:
Medicaid provides health cost to who? (4)Poor
Blind
Disabled
Those on welfareWhat are the joint state/federal Medicaid programs?CMS and AHCCCSMedicaid:
Eligibility requirements?Income AND assetsWhat created the Medicaid Drug Rebate Program?OBRA '90Medicaid:
If manufacturers want to participate in Medicaid rebate program they must also sign up to participate in what other programs?Section 340B drug pricing: used for community health centers
Federal supply schedule: VA pricingFalse claims to Medicare or Medicaid can result in what?Exclusion based on OIG list
May be on list for up to 10 yearsEMTALA:
This was enacted in response to what?"Patient dumping" where a hospital refuses admission to persons lacking health insuranceEMTALA:
What are the three main requirements?Medical screening
Stabilizing treatment
Women in laborFederal anti trust laws are designed to?Protect competition and keep prices lowFederal anti trust laws: definitions
Monopoly?Only one supplier of a service, or
A single business holding greater than 40% of the market shareFederal anti trust laws: definitions
Price fixing?An agreement among competitors or a single business to affect the price or allocation of services whether prices are fixed at a min, max, or within some range; usually done in necessity servicesFederal anti trust laws:
What are the two sections of the Sherman Anti Trust Act?Section 1: restraint of trade
Section 2: monopoliesFederal anti trust laws: Sherman anti trust act
Who can violate section 1?2 or more competitors if they have an informal or formal agreement between them
Ex. 2 or more independent pharmacies TOGETHER agree to reject a third party planFederal anti trust laws: Sherman anti trust act
Section 1 does what?Makes every contract, combination, or conspiracy in RESTRAINT OF TRADE unlawfulFederal anti trust laws: Sherman anti trust act
Section 2 does what?Prohibits monopolies, attempts to monopolize, or conspiracies to monopolizeFederal anti trust laws: Sherman anti trust act
Is being a monopoly illegal?NO!!! It is illegally for a monopoly to exploit its power for the purpose of harming competitionFederal anti trust laws: Sherman anti trust act
In deciding a violation, the courts apply what?The rule of reason or the per se ruleFederal anti trust laws: Sherman anti trust act
Rules of reason?Is the net effect of the action promoting competition or suppressing it?Federal anti trust laws: Sherman anti trust act
Per se rule?Essentially, "if you did it, you are guilty of doing it"Federal anti trust laws:
What is the Robinson-Patman Act?Makes it unlawful for a manuf to charge 2 different prices to 2 purchases who are getting the exact same product in the exact same quantity and are considered competing buyers....if it substantially injures competitorsFederal anti trust laws:
The Robinson-Patman Act was passed to protect who?Small business grocery stores against chain operators who were engaging in unfair purchasing operationsFederal anti trust laws:
According to the Robinson-Patman Act, is it illegal to charge hospital pharmacies different than retail pharmacies?No, it is not illegal since the two are not competitors. Manuf can charge different prices to bothFederal anti trust laws:
What does the nonprofit institutions act do?Provides an exemption from the Robinson-Patman Act to the following types of institutions when purchases are for "own use": nonprofit schools, public libraries, universities, churches, charitable institutions
