Guys, does anyone know the answer?
get mrs. jenkins is enrolled in both part a and part b of medicare. she has recently also become eligible for medicaid and would like to enroll in a ma-pd plan. since this is her first experience with medicare advantage, she is concerned that she will be locked into a plan and unable to make any coverage changes for at least a year if not longer. what should you tell her? from EN Bilgi.
An Economic History of Medicare Part C
Context: Twenty-five years ago, private insurance plans were introduced into the Medicare program with the stated dual aims of (1) giving beneficiaries a choice of health insurance plans beyond the fee-for-service Medicare program and (2) transferring ...
Milbank Q. 2011 Jun; 89(2): 289–332.
An Economic History of Medicare Part C
Thomas G Mcguire, Joseph P Newhouse, and Anna D Sinaiko
Author information Copyright and License information DisclaimerThis article has been corrected. See Milbank Q. 2013 March; 91(1): 210.
This article has been cited by other articles in PMC.
AbstractContext: Twenty-five years ago, private insurance plans were introduced into the Medicare program with the stated dual aims of (1) giving beneficiaries a choice of health insurance plans beyond the fee-for-service Medicare program and (2) transferring to the Medicare program the efficiencies and cost savings achieved by managed care in the private sector.Methods: In this article we review the economic history of Medicare Part C, known today as Medicare Advantage, focusing on the impact of major changes in the program's structure and of plan payment methods on trends in the availability of private plans, plan enrollment, and Medicare spending. Additionally, we compare the experience of Medicare Advantage and of employer-sponsored health insurance with managed care over the same time period.Findings: Beneficiaries' access to private plans has been inconsistent over the program's history, with higher plan payments resulting in greater choice and enrollment and vice versa. But Medicare Advantage generally has cost more than the traditional Medicare program, an overpayment that has increased in recent years.Conclusions: Major changes in Medicare Advantage's payment rules are needed in order to simultaneously encourage the participation of private plans, the provision of high-quality care, and to save Medicare money.Keywords: Medicare, managed care, health care costs
The Medicare Advantage (MA) program, formally Part C of Medicare, originated with the Tax Equity and Fiscal Responsibility Act (TEFRA), which authorized Medicare to contract with risk-based private health plans, or those plans that accept full responsibility (i.e., risk) for the costs of their enrollees' care in exchange for a prospective, monthly, per-enrollee payment. This program has been called a variety of names over the past three decades (e.g., Medicare Advantage, Medicare+Choice). In this article, we refer to the program by both its current names, Part C and Medicare Advantage (MA). TEFRA was passed in 1982, and the rules to implement risk-based contracting were completed in 1985. Those beneficiaries who choose to enroll in an MA plan continue to pay, directly to Medicare, their required Part B premium for physicians' services and, if they elect it, their Part D premium for drug coverage. In return, they receive health insurance for all services through (and may pay supplemental premiums to) their MA plan. For these beneficiaries, enrollment in an MA plan replaces not only traditional Medicare but also a Medicare supplemental insurance policy (i.e., Medigap). The MA plans themselves receive, directly from the Medicare program, a predetermined, monthly, risk-adjusted payment to cover each beneficiary's care. (Later we will describe in detail the beneficiaries' enrollment decisions and plan payment.)
Over the past twenty-five years the MA program has pursued two stated goals. The first is to expand Medicare beneficiaries' choices to include private plans with coordinated care and more comprehensive benefits than those provided through traditional Medicare (TM) (MedPAC 2001, chap. 7). The second is to take advantage of efficiencies in managed care and save Medicare money (Prospective Payment Assessment Commission 1997, chap. 3).
Reducing Medicare program or on-budget spending is different from reducing economists' notion of social cost, which reflects the opportunity cost of the resources actually used for medical care. Although we focus here primarily on the perspective of the budget, we believe that there is a third goal, which is related to the economists' social cost concept: to minimize the inefficiencies induced by the inevitable errors in TM's administered price system, by allowing the health plans and providers to negotiate prices or, in some cases, to integrate the finance and delivery functions. An example is a group or staff model Health Maintenance Organization (HMO).
On first glance, the two stated goals appear to be at odds with each other. An obvious way to increase access to MA plans would be for Medicare to increase the plan payments, thereby making it more attractive for plans to enter the Medicare market. But doing so would contradict efforts to save Medicare money. In principle, however, it is possible to attain both stated goals (as opposed to having no MA program). Traditional Medicare (TM), which consists of Part A (mainly hospital insurance), Part B (mainly physician services), and, as of 2006, Part D (prescription drug coverage) is on an unsustainable cost path, due in part to pricing errors that make certain services or sites of care either profitable (provide economic rents) or unprofitable (Ginsburg and Grossman 2005; Newhouse 2002) and in part to utilization induced by supplemental insurance coverage from former employers or purchased individually (MedPAC 2010b). Including the 16 percent of those Medicare beneficiaries also eligible for Medicaid, who cannot realistically afford the amount of cost sharing in TM, such supplemental coverage is held by the majority of beneficiaries (Atherly 2001; Christensen, Long, and Rodgers 1987; Dowd et al. 1992). Furthermore, TM's fee-based physician payments, which are based on volume and hospital payments based on admissions, accommodate variations in provider practice patterns, in turn absolving providers from pressure to restrain overuse. Geographic variations in utilization and quality create business opportunities in places like south Florida (one of the highest per-capita TM spending regions in the United States), where private managed care plans ought to be able to expand choice to beneficiaries and to provide care that is just as good as or better than TM for less money (Dartmouth Medical School 1999; Fisher et al. 2003a, 2003b). If the MA program induced the plans to enter the right markets and the right beneficiaries to choose those plans, creating choice for the beneficiaries could save Medicare money and achieve both stated goals of the Part C program.
Part D / Prescription Drug Benefits
Introduction to Medicare Part D This section constitutes an introduction to Part D. For more detailed information on any of the topics in this section, please click on the links within the topics. There, you will also find relevant legislative, statutory and CFR citation. Prior to 2006, Medicare paid for some drugs administered during a […]
Part D / Prescription Drug Benefits
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Introduction to Medicare Part D
ELIGIBILITY FOR PART D
PART D COVERED DRUGS
THE PART D STANDARD BENEFIT
Part D Enrollment
THE MEDICARE SAVINGS PROGRAMS
Part D Appeals and Grievances
Recent Articles and Updates
Introduction to Medicare Part D
This section constitutes an introduction to Part D. For more detailed information on any of the topics in this section, please click on the links within the topics. There, you will also find relevant legislative, statutory and CFR citation.
Prior to 2006, Medicare paid for some drugs administered during a hospital admission (under Medicare Part A), or a doctor’s office (under Medicare Part B). Medicare did not cover outpatient prescription drugs until January 1, 2006, when it implemented the Medicare Part D prescription drug benefit, authorized by Congress under the “Medicare Prescription Drug, Improvement, and Modernization Act of 2003.” This Act is generally known as the “MMA.”
The Part D drug benefit (also known as “Medicare Rx”) helps Medicare beneficiaries to pay for outpatient prescription drugs purchased at retail, mail order, home infusion, and long-term care pharmacies.
Unlike Parts A and B, which are administered by Medicare itself, Part D is “privatized.” That is, Medicare contracts with private companies that are authorized to sell Part D insurance coverage. These companies are both regulated and subsidized by Medicare, pursuant to one-year, annually renewable contracts. In order to have Part D coverage, beneficiaries must purchase a policy (i.e., enroll in a plan) offered by one of these companies.
The costs associated with Medicare Part D include a monthly premium, an annual deductible (sometimes waived by the plans), co-payments and co-insurance for specific drugs, a gap in coverage called the “Donut Hole,” and catastrophic coverage once a threshold amount has been met.
Individuals with incomes up to 150 percent of the federal poverty level can receive help with their Part D costs for premiums, deductibles and co-pays through the Part D Low Income Subsidy (known as “LIS” or “Extra Help”), which is administered by the Social Security Administration.
Within parameters established in law, plans are free to establish their own formularies. There is an appeal process for members who need drugs that are not on their plan’s formularies.
Plans revise their formularies every year, adding new drugs, eliminating others, and generally charging higher co-pays and co-insurance for drugs. Beneficiaries need to re-evaluate their plan options every year to be sure their chosen plan will continue to meet their financial and medical needs.
Many Part D plan sponsors offer multiple plans that may be viewed as analogous to commercial “good, better and best” options. Buyers need to evaluate these choices carefully as it is sometimes the case that the “best” (and most expensive) plans offer little or no extra value for their higher prices.
Following 2010 regulations, Medicare required plans to eliminate their low enrollment plans and to consolidate duplicative plans. This lowered the overall number of plans available to beneficiaries, but there are still many plans to choose from and their differences are now more transparent to consumers.SOURCES OF PART D COVERAGE
Medicare doesn’t administer Part D directly. It contracts with private companies that are approved to sell Part D insurance coverage. There are two main sources of Part D coverage:
• PDPs (Prescription Drug Plans) – these are stand-alone companies that sell prescription drug coverage only. They do not offer hospital or medical coverage.
PDP plan sponsors have a four-digit identifier that begins with the letter “S.” The different plan options offered by the sponsor each have a unique three-digit suffix identifier. For example, in 2015, United HealthCare sponsored the AARP Preferred Plan (S5820-002).
• MA-PDs (Medicare Advantage Prescription Drug Plans) – these plans offer hospital, medical and prescription drug coverage under a single policy. Medicare Advantage plans are sometimes called “Part C” of Medicare. There are different types of MA-PDs, e.g., including HMOs, PPOs, PFFS plans, and SNPs). Plans need to identify their plan type in their plan names. People who wish to enroll in a Medicare Advantage plan must take their prescription drug coverage from the same plan, unless they are enrolled in a PFFS that does not offer prescription drug coverage.
MA-PD plan sponsors have a four-digit identifier that begins with the letter “H.“The various plan options offered by the plan sponsor each have a unique three-digit suffix. For example, in 2015, Anthem sponsored the MediBlue HMO Standard Plan (H5854-008).MA-PD PLAN TYPES DESCRIPTIONHealth Maintenance Organization (HMO) These plans follow a “gatekeeper” model. Members must choose a primary care physician (PCP) from the plan’s network of providers. Members may not disenroll from the plan if their PCP leaves the network. Members may not see a specialist without a referral from their PCP. Members must use network providers, or the plan will not cover the service. Individuals who belong to an HMO type MA-PD must take their prescription drug coverage through their HMO plan, not a separate PDP.