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Medicare Part D introduced a
whole new vocabulary to pharmacists, all
sorts of abbreviations, acronyms, and titles are being
tossed around. Do you know what PDP, SSA, and LIS
mean?
You better! Now is the time to brush up
on your Medicare terminology!
PPA through its Medicare Task Force has compiled the following list of important
definitions, abbreviations, acronyms, and other terminology
that you will come across if you have not already.
This list will continue to be a good resource list. Special thanks to
Stephen H. Paul, R.Ph., Ph.D. of Temple
University School of Pharmacy for his work on pulling all
the terminology together!
Also see - more key terminology!
The
practice of pharmacy continues on it evolutionary
metamorphosis from collecting and preparing nostrums through
the provisions of advanced pharmaceutical care services to
individual patients. Along with this development new words
and acronyms come into the lexicon of knowledge of the
pharmacist. The lead up to passage of the Medicare
Modernization Act of 2003 has spawned a whole new school.
The following is a compilation of words and acronyms that
pharmacists in all settings will find useful in discussions
with patients, colleagues, and other professionals about MMA.
The terms being used for this new legislation are
continually being introduced so you must be diligent in
keeping your vocabulary up to date. For example MTMS
(Medication Therapy Management Services) really does not
have a distinct definition that realistically separates it
from MTM (Medication Therapy Management). It is anticipated
that during the last quarter of 2005 there will be a working
terminology for MTMS.
APhA:
(American Pharmacists Association) A
professional association of pharmacists that is dedicated to
improving medication utilization and advancing beneficiary
care. This organization jointly developed, with NACDS, the
“Medication Therapy Management in Community Pharmacy
Practice – Core Elements of an MTM Service.”
Catastrophic Coverage:
Once a
beneficiary has paid out a specific sum of money that can
change each year, the out-of-pocket amount that has to be
paid is only 5% of the prescription charge.
CMS:(Centers
for Medicare & Medicaid Services) Formerly known as the
Health Care Financing Administration (HCFA). This is the
federal agency responsible for administering the Medicare,
Medicaid, SCHIP (State Children's Health Insurance), HIPAA
(Health Insurance Portability and Accountability Act), CLIA
(Clinical Laboratory Improvement Amendments), and several
other health-related programs.
CMS-1500:
(Form CMS-1500) This form and instructions are used by
non-institutional providers and suppliers to bill Medicare,
Part B covered services. The document is also used for
billing some Medicaid covered services.
CCRx:
(Community Care Rx) a group of pharmacies that will be
providing pharmaceuticals and professional services to
Medicare Part D prescription beneficiaries
Donut hole
and/or gap:
The place in the prescription drug benefit where the
beneficiary must pay for 100% of the out-of-pocket
prescription charges.
Dual
Eligibles:
Beneficiaries who qualify for both Medicare and Medicaid.
Medicare provides payment for acute health services.
Medicaid covers Medicare premiums and cost sharing.
Medicaid patients whose income and assets are below specific
levels and meet other qualifications are eligible for long
term care services. Prescription coverage is available until
December 31, 2005.
ICD-9:
(International Classification of Diseases, Ninth Revision)
The classification system used to code and classify
mortality data from death certificates.
ICD-9-CM:
(International Classification of Diseases, Ninth Revision,
Clinical Modification) The classification system used to
code and classify morbidity data from the inpatient and
outpatient records, physician offices, and most National
Center for Health Statistics (NCHS) surveys.
JCPP:
(Joint Commission of Pharmacy Practitioners) A national
coalition of pharmacy associations
that have been
extremely active in developing MTM guidelines.
LIS:
(Limited Income Subsidy) Additional financial assistance
available for beneficiaries who have limited income and
resources to help pay for prescription pharmaceuticals
starting January 1, 2006. Other acronyms including QMB, QI,
and SLMB will provide more information.
MA-PD:
(Medicare Advantage Prescription Drugs) Approved
prescription plans that coordinate drug coverage within the
managed care plan of the patient.
Medicaid:
A health care program for the qualified poor that uses State
and Federal monies to pay for health care. Requirements for
participation can vary from State to State.
Medicare:
A health care program for the qualified aged and or
disabled.
MMA:
(Medicare Modernization Act) The official name of the
legislation is the
Medicare Prescription Drug, Improvement and
Modernization Act of 2003 (Pub. L. 108-173). This
legislation provides seniors and individuals with
disabilities with a prescription drug benefit.
Medication
Therapy Management in Community Pharmacy Practice – Core
Elements of an MTM Service:
The
framework for a pharmacist program to improve patient care,
augment written, verbal, and visual communication among
providers, and optimized pharmaceutical usage to improve
patient health outcomes.
MTM:
(Medication Therapy Management) A program that may be
provided by a pharmacist that is constructed to insure that
the medication plan is appropriate to optimize therapeutic
outcome through improved drug use, reduce the risk of
adverse health events.
MTMS:
(Medication Therapy Management Services) Services enabling
pharmacists to collaboratively manage beneficiaries’
medication therapy and be accountable for therapeutic
outcomes. This definition is still under development.
NACDS:
(National Association of Chain Drug Stores) An association
representing retail chain pharmacies and suppliers. This
group jointly developed, with APhA, “Medication Therapy
Management in Community Pharmacy Practice – Core Elements of
an MTM Service.
NCPA:
(Formerly known as the National Community Pharmacists
Association) The organization helped to create the CCRx
program and is working closely with CMS in the Medicare Part
D program.
NCPCP:
(National Council for Prescription Drug Programs, Inc. (NCPDP)
is a not-for-profit accredited standards development
organization consisting of over 1,300 members representing
virtually every sector of the pharmacy services industry.
NCPDP's Telecommunication Standard Version 5.1 is the
official standard for pharmacy claims in the Health
Insurance Portability and Accountability Act (HIPAA)
PACE:
(Pharmaceutical Assistance Contract for the Elderly)
A program offering
comprehensive prescription coverage to older
Pennsylvanians. The State funded program covers most
prescription medications, and diabetic non-prescription
products of insulin, syringes and insulin needles.
PACE:
(Programs of All-inclusive Care for the Elderly) Provide
continuous care and services offering individuals eligible
for nursing home care the option of continuing to live in
the community. Because these health care costs are
traditionally paid for through the Medicare, Medicaid and
patients, access to a comprehensive system of care that
encompasses preventive, primary, acute and long term care is
usually not possible. One goal of the PACE model is the
commingling of monies from different funding streams in
order to deliver a comprehensive set of services focused on
the health and well-being of patients.
Part A:
A section of the Social Security Act that
enables the federal government to assist in the payment for
inpatient hospital care, skilled nursing facility care,
hospice care and limited home health services.
Part B:
A section of the Social Security Act that aids in the
payment of physician services, selected pharmaceuticals,
outpatient hospital care, x-rays, diagnostic tests, durable
medical equipment, some preventive services, home health
professional visits and mental health services.
Part C:
A section of the Social Security Act that used to be known
as Medicare+Choice. It refers to Medicare Advantages
plans. HMOs and PPOs, special private fee-for-services
plans, and medical savings accounts that are combined with
high deductible insurance plans are examples of Part C
choices for eligible beneficiaries.
Part D:
A section of the Social Security Act that refers to the
Medicare Drug Benefit. This section will provide
pharmaceuticals under prescription drug plans (PDPs) and
Medicare Advantage Prescription Drugs (MA-PD) utilizing
various approved formularies.
PBM:
(Pharmacy Benefit Manager) An organization that controls the
drug benefit in the medical plan. A PBM can also work for a
self-funded plan, insurance company, PPO, or HMO. The PBM
controls claim processing, eligible pharmacies, pharmacist
fees, drug cost reimbursement, generic substitution,
rebates, and formularies of clients. It also provides drug
utilization review services--monitoring physician
prescribing and providing physician education on appropriate
drug use as defined by a specific plan. Some programs
provide disease state management.
PDP:
(Prescription Drug Plan) A voluntary insurance drug
formulary program for eligible Medicare patients who have
selected the traditional fee-for-service plan.
PhRMA:
(Pharmaceutical Research and Manufacturers of America) The
association representing the country’s leading
pharmaceutical research and biotechnology companies.
PMA:
(Pharmaceutical Manufacturers Association) The former name
for PhRMA.
PSTAC:
(Pharmacists Services Technical Advisory Coalition) A
coalition of various pharmacy associations that are
developing new procedural billing codes for government
health programs, insurance companies, and managed care
organizations for the provision of clinical services.
QMB:
(Qualified Medicare Beneficiary) A beneficiary who receives
a complete subsidy of monthly premiums and reductions in
cost sharing for the Medicare prescription drug benefit.
This category is based on income eligibility of 100% or less
of the federal poverty income level and the amount of liquid
assets.
QI:
(Qualifying Individual) A beneficiary who receives a
complete subsidy of monthly premiums and reductions in cost
sharing for the Medicare prescription drug benefit. This
category is based on income eligibility of 120 to 135% of
the poverty guideline and the amount of liquid resources the
beneficiary owns.
QIO:
(Quality Improvement Organizations Under the control of CMS,
the QIO program consists of a network of fifty-three QIOs
responsible for every state, territory, and the District of
Columbia. QIOs work with consumers, physicians, hospitals,
and other caregivers to refine care delivery systems with
the objective of having patients get the right care at the
right time, especially among underserved populations. This
program also protects the integrity of the Medicare trust
fund by ensuring payment for services is made only for those
that are medically necessary. The staff of the numerous
organizations investigates beneficiary complaints about
quality of care.
SLMB:
(Specific Low-Income Medicare Beneficiary) A beneficiary who
receives a complete subsidy of monthly premiums and
reductions in cost sharing for the Medicare prescription
drug benefit. This category is based on income eligibility
of 100 to 120% of poverty guideline and the amount of liquid
assets (resources).
SPAP:
(State Pharmacy Assistance Program) Various state
prescription benefit programs that provide assistance for
paying for prescriptions. These programs may be means
tested. In Pennsylvania eligible seniors receive
prescription benefits under the PACE (Pharmaceutical
Assistance Contract for the Elderly).
SSA:
(Social Security Administration) The government agency
administering the Social Security legislation benefits to
eligible recipients.
SSI:
(Supplemental
Security Income) A Federal income supplement program funded
by general tax revenues and not Social Security taxes. It
is designed to help aged, blind, and disabled people, who
have little or no income. This provides funds to meet basic
needs to pay for food, clothing, and shelter.
TPA:
(Third Party Administrator): A firm that performs
administrative functions (e.g., claims processing,
enrollment, pharmacy network, etc.) for self-funded plans,
unions, PPOs, and/or HMOs.
TrOOP:
(True or Total Out-Of-Pocket Costs) Prescription deductibles
and coinsurance that a beneficiary must pay before the
“catastrophic” coverage for patients becomes available. For
the year 2006 $3,600 has to be paid before the government
will pay 95% of all the prescription charges. The TrOOP will
change each year.
Your Feedback needed!
Tell us what else you need to know about Medicare.
Send your questions to
ppa@papharmacists.com
and mark Medicare ? in the subject line.
We will work on establishing a Frequently Asked Questions
(FAQ) section next.
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