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Medicare Key Terminology

Medicare Key Terminology

What Every Pharmacist Should Know!

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.


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