Medicare Part D , also called the Medicare prescription drug benefit , is an optional US federal government program to help Medicare recipients pay for prescription drugs prescribed themselves through premium prescription drug insurance (almost cost all professionally managed recipes are covered in Option B Section of Medicare USA). Part D was originally proposed by President Clinton in 2000 and ratified as part of the Medicare Modernization Act of 2003 (which also made changes to the public health C part Medicare plan plan) and entered into force on 1 January 2006.
Video Medicare Part D
Program specifications
Feasibility and registration
Individuals in Medicare are eligible for drug coverage prescribed under Part D plan if they apply for benefits under Medicare Part A and/or Part B. Recipients benefit from Part D drugs through two types of plans managed by private insurance companies: beneficiaries can join a stand-alone Prescription Drug Plan (PDP) for drug coverage only or they may join a Part C public health plan that together covers all hospitals and medical services covered by Medicare Part A and Part B at least, and usually includes additional health care costs not covered by Medicare Part A and B include prescription drugs (MA-PD). (NOTE: Medicare beneficiaries need to register for Parts A and B to select Section C whereas they only require A or B to select Section D.)
About two-thirds of all Medicare recipients are registered directly in Part D or receive Part-D benefits-such as through the public Part C Medicare health plan. Large groups of other Medicare beneficiaries get prescription drug coverage under plans offered by former employers or through the Veterans Administration. It is also possible that former employers or unions may sponsor the Section D plan for former employees/members (the plan is called the Employer Group Exemption Plan).
Medicare beneficiaries can apply directly through the plan administrator, or indirectly through an insurance broker or exchange - called Medicare Plan Finder - run by the Medicare and Medicaid Service Centers (CMS) for this purpose; beneficiary benefits and any additional payments and support rights are the same regardless of the registration channel. Beneficiaries who already have a plan may choose a different plan or discard Section C/D during the annual enrollment period or during other times throughout the year. For some time, the annual enrollment period has been from 15 October to 7 December each year but that changed for Part C in 2019. Low-income seniors in Extra Social Security Assistance/LIS and many middle-income elderly on state pharmaceutical assistance programs may choose different plan or drop Part C/D (or join the C/D section plan for it) as often as once a month. Another special enrollment state applies.
Medicare beneficiaries are eligible for but do not enroll in Part D when they first qualify and then wish to register, pay a penalty for late registration, essentially a premium surtax, if they do not have acceptable coverage through other sources such as employers or Veterans Administration US. This penalty is equal to 1% of the national premium index times the number of full calendar months they are eligible for but not listed in Part D and has no coverage that can be credited through other sources. Penalties increase the Part D premium for beneficiaries, when and if they choose coverage.
In May 2018, registrations exceeded 44 million, including those who are self-contained Part D and those listed in section C of the plan (which includes Part-D-like coverage). About 20% of the beneficiaries use the EGWP drug plan in which the former employer receives a Part D subsidy on their behalf. The last two groups do not have the same freedom of choice that belongs to the standalone Part D Group because they must use the Part D plan chosen by the administrators of Part C or their former employer.
As of May 2018, over 700 contract drug plans have been signed between CMS and administrators, which in turn means several thousand plans because administrators can change plans based on the county. Each district may have at least three to 30 packages from which the beneficiaries can vote. This allows participants to choose the plan that best meets their individual needs. Although the number of available plans has declined since the start of the program, almost all districts offer many options.
Plan administrators are required to offer plans with at least "standard" or equivalent actuarial minimum benefits to the standard, and they can also offer plans with more benefits (for example, not deductible during the initial spending phase). The terms "standard", "actuarial equivalent," and "more generous" relate to the co-pay/formulary/"donut-hole" (see Note)/pharmaceutical preference plan and have no direct relevance to the recipient benefits. in addition to increasing or decreasing personal preferences. Every plan is approved by CMS before it is marketed.
(NOTE: Often said donut hole will be removed, it is not technically correct. "Donut hole" is also called the phase of the expenditure gap; at a time the joint payment in the gap is 100%. 2019, standard "co-pay" in the gap will be 25 %, just as in the initial discharge phase It is also important to note that relatively few people as a percent of the total number of people in Medicare who were ever financially affected by donut holes or catastrophic expenditure phases.)
Medicare offers an interactive online tool called Medicare Plan Finder that allows comparison of coverage and cost for all plans in a geographic area. This tool lets users enter a list of drugs along with pharmaceutical preferences and Social Security-Extra-Help/LIS and related status. Finder can show the total annual cost of the recipient for each plan along with detailed details of the monthly premium packages, deductibles and prices for each drug during each phase of expenditure (start, gap, disaster). Plans are required to update the site at current prices and formulary information every week of the year.
Costs for beneficiaries
Distribution of recipient fees (deductibles, coinsurance, etc. )
The Medicare Modernization Act (MMA) establishes the standard drug benefits that must be offered by all parts of D. The standard benefits are defined in terms of benefit structures and without the mandate of drugs to be borne. For example, in 2013, the standard allowance required by beneficiaries of $ 325 is deductible, then a 25% coinurance payment by the recipient of the drug charge up to the initial coverage limit of $ 2,970 (full retail cost of the prescription) is required. Once this initial coverage limit is reached, the recipient must pay all prescription drug costs until the total out-of-pocket expenses reach $ 4,750 (excluding any premiums and fees paid by the insurer) minus 52.5% discount in this gap, called as a "Donut Hole". Once the recipient reaches the Out-of-Pocket Threshold, he becomes eligible for disaster coverage. During disaster coverage, he pays more than 5% coinsurance, or $ 2.65 for generic drugs and $ 6.60 for branded drugs. The amount of disaster coverage is calculated per year and beneficiaries who reach disaster coverage by the end of the year will re-start its deductible at the beginning of the next benefit year. Although not common, not all years of benefits coincide with the calendar year. The donut-hole and catastrophic thresholds dropped slightly in 2014.
Standard benefits are not the most common benefit mix offered by Part D plan. Only 11% of plans in 2010 offer the standard benefits described above. Plans vary greatly in formularies and share costs. Most eliminate deductibles and use co-payment of tiered drugs rather than coinsurance. The only out-of-pocket costs that count towards exiting the coverage gap and into the disaster coverage are True Out-Of-Pocket (TrOOP) spending. TrOOP expenditure only accumulates when medicines on the formulary plan are purchased in accordance with the limitation of the drugs. Monthly premium payments are not calculated against TrOOP.
Under the Patient Protection and Affordable Care Act of 2010, the gap coverage effect of the "Donat Hole" should be gradually reduced through a combination of measures including brand prescription drug discounts, generic drug discounts and gradual increase in percentage of out-of-pocket expenses covered while in the donut hole. The "Donut Hole" will continue to exist after 2020 but the effect will change in some unspecified way, because the plan administrator must treat out the pocket costs under the same disaster level whether or not the insured is in the donut hole or not. That is, under the design of "standard benefits" all recipes at all levels can be charged 25% co-pay whereas in 2014 hundreds of drugs in Level 1 are available without co-pay.
Most plans use specific drug levels, and some have their own benefit levels for injecting drugs. The distribution of recipient fees can be higher for medicines at this level.
The monthly (weighted) monthly premium paid by beneficiaries for the PDP was $ 35.09 in 2009, an increase of $ 29.89 in 2008. Premiums are projected to increase to $ 38.94 for 2010 as well. In 2014, it averages around $ 30 per month. The average premium is a misleading statistic because of the average premium offered, not the paid premium. Most insurance companies offer very low cost packages (for example, $ 15 per month) that few choose. This lowers the average, but does not reflect what is happening in the market.
In 2007, 8% of beneficiaries enrolled in the PDP chose one with multiple coverage gaps. Among beneficiaries in the MA-PD plan, enrollment in plans offering gap coverage was 33% (up from 27% in 2006). Premiums are significantly higher for plans with gap coverage. These plans became less common due to the closing break. The fact that the Social Security Assistance/LIS beneficiaries have never been affected by the gap and the fact that many state pharmaceutical aids programs that protect middle-income middle-aged people in the gap is the reason this advantage gap has never been so popular.
Part D's main sponsors drop the more expensive options, and develop the less expensive ones.
Low-income subsidies and intermediate income assistance
One option for those struggling with drug costs is low-income subsidies. Beneficiaries with incomes below 150% of the poverty line are eligible for low-income subsidies, which help pay all or part of monthly premiums, annual deductions and joint payments. The CMS estimates that 12.5 million Part D beneficiaries qualify for low-income subsidies in 2009.
The subsidy award is awarded the rate with the following effects for the 2013 benefits year:
Perhaps the most important benefit of External Social Security/LIS Assistance other than "free" is the fact that the recipient has no exposure to the donut "fee hole" and can change the plan every month. In addition, in many states, the state pharmaceutical aids program provides equal protection in the gap for the middle-income elderly and allows beneficiaries to change the other one-time plan throughout the year in addition to the annual registration/re-registration period.
Excluded drugs
While CMS does not have an established formulary, drug coverage Part D excludes drugs that are not approved by the Food and Drug Administration, prescribed for off-label use, drugs not available on prescription for purchase in the United States, and medicines for which payment will be available under Part B.
Section D coverage does not include any drugs or classes of drugs that may be excluded from Medicaid coverage. This may include:
- Drugs used for anorexia, weight loss, or weight gain
- Medicines are used to promote fertility
- Medicines are used for erectile dysfunction
- Drugs used for beauty purposes (hair growth, etc.)
- Drugs are used to relieve symptoms of cough and colds
- Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
- Medicines requiring the manufacturer as a condition for the sale of the associated test or any monitoring service to be purchased exclusively from the manufacturer or its designee
While these drugs are excluded from basic Section D coverage, drug plans may include them as additional benefits, provided they meet the definition of Part D drugs. However plans that include excluded drugs are not allowed to pass these costs to Medicare, and plans are required to pay CMS if they are known to have been charged Medicare in these cases. Part D plans may include all benzodiazepines and barbiturates used in the treatment of epilepsy, cancer or chronic health disorders. Both classes of this drug were originally issued, until their reassignment in 2008 by the Medicare Improvement for Patients and Providers Act.
Planning a formulary
Part D of the plan is not required to pay for all of the closed Part D drugs. They make their own formularies, or lists of illegal drugs they will pay, as long as the formulary and benefit structure are not found by CMS to prevent registration by certain Medicare recipients. Part D plans that follow formulary classes and categories established by the United States Pharmacopoeia will pass the first discrimination test. Plans can change the drugs on their formularies during the year with 60 days notice for the affected parties.
The average number of joint payments for each drug only applies in general during the initial period before the coverage gap.
The main differences between different Part D plan plans are related to the coverage of branded drugs.
Typically, each Plan formulary is organized into a tier, and each tier is associated with the specified co-pay amount. Most formularies have between 3 and 5 levels. The lower the tier, the lower the co-pay. For example, Level 1 may include all the generic drugs that Plan likes, and each drug in this level may have a joint payment of $ 5 to $ 10 per prescription. Level 2 may include preferred brand drug from Plan with a co-pay of $ 40 to $ 50, whereas Tier 3 can be ordered for unfavorable brand medicines covered by plans with higher joint payments, possibly $ 70 up $ 100. Levels 4 and higher usually contain special drugs, which have the highest added value as they are generally more expensive. In 2011 in the United States more and more Medicare health insurance plan Part D has added a special rate.
Beneficiary support
The CMS is funding a national counselor program to help all Medicare recipients, including a double, with a choice of plans. This program is called the State Health Insurance Assistance Program (KAPAL).
Maps Medicare Part D
History
Medicare Part D was originally proposed by President Clinton in 2000. This was based on a previous proposal developed by Congressman Nancy Pelosi and Senator Tom Dashcle. This late 1990's/2000 proposal - with the exception of the expenditure phase structure but includes the fact that Medicare itself will not negotiate - substantially the same as the current Part D.
At the start of the program in January 2006, it is expected that eleven million people will be covered by Medicare Part D; of them, six million will qualify double. Approximately two million people covered by employers are likely to lose their employee benefits.
As of January 30, 2007, nearly 24 million people received prescription drug coverage through Medicare Part D (PDPs and MA-PDs combined), according to CMS. Medicare offers other methods for receiving drug coverage, including the Retired Drug Subsidy. Federal retirement programs such as TRICARE and the Federal Employee Health Benefits Program (FEHBP) or alternative sources, such as the Department of Veterans Affairs. Including people in this category, more than 39 million Americans are covered for prescription by the federal government.
A survey released by AARP in November 2007 found that 85% of applicants reported satisfaction with their drug plans, and 78% said they had made a good choice in choosing their plans.
Program costs
By the end of 2008, the average annual expenditure per beneficiary for Section D was $ 1,517, making total program spending for 2008 $ 49.3 billion.
From a budget perspective, Part D is effectively three different programs. Based on budget number 2012:
- Around $ 26 billion was spent on the approximately 10 million Medicare recipients of low income (20% of Medicare) mentioned above and the drug costs of some people in Part C. These costs were previously covered (Part D) by Medicaid, Veterans Medical Administration and the state pharmaceutical aids program.
- Around $ 20 billion is premium support that allows about 10 million Medicare middle-income recipients and the rest of the people in Part C (about half of them in Medicare altogether) get drug coverage. After the first five years of Part D, government-accountability-office research indicates that the expenditures in this Part D Budget appear to hold other Medicare costs associated with provider services. The middle income part of the Part D program can actually pay for itself in the long term.
- Approximately $ 13 billion from part D of the budget includes reinsurance for the cost of catastrophic drugs as described above. Part D pays 95% of the cost of more than about $ 6,000 from a year's pocket in retail. Part of this budget helps about 1% of people in Medicare who are seriously ill.
Use of cost
Medicare Part D Cost-Benefit Steps refers to restrictions placed on medicines covered in special formularies for a plan. Cost utilization consists of techniques that seek to reduce insurance costs. The three main cost utilization measures are quantity limits, prior authorization and gradual therapy.
Quantity limits refer to the maximum number of drugs that can be excluded during a particular calendar period. For example, a plan may determine that it will include 90 pills of medication given within 30 days.
Previous authorization requirements require health workers to receive official approval of the plan before agreeing to cover certain recipes. This can be used by insurance companies for drugs that are often misused. The previous authorization helped ensure that the patient received the correct medication.
Step therapy is a process in which a plan requires an individual to try, and prove ineffective, one or more specific low-cost drugs before a higher-cost drug in the same therapy class is approved.
Implementation problem
- Alignment of plans and Healthcare Providers: PDP and MA are valued for focusing on low-cost drugs for all beneficiaries, while providers are rewarded for quality care - sometimes involving expensive technology.
- Conflicting Objectives: The plan should have a tiered exemption process for recipients to obtain higher-level drugs at a lower cost, but plans should provide medically necessary exclusions. However, the rule rejects the assignee the right to request a storied exemption for certain high-cost drugs.
- Lack of standardization: Since each plan can design the level of its formulary and tier, drugs that appear in Tier 2 in one plan may be in Tier 3 in another plan. Co-pay can vary across plans. Some plans have no deductibles and coinsurance for the most expensive drugs vary greatly. Some plans may require step therapy, which means that patients should use generic drugs first before companies pay for higher-priced medicines. Patients can appeal and accountants are asked to respond within a short period of time, thus not further burdening the patient.
- The standards for electronic prescribing for Medicare Part D conflict with regulations in many US states.
Impact on beneficiaries
A 2008 study found that the percentage of Medicare recipients who reported illegal drugs because costs fell with Part D, from 15.2% in 2004 and 14.1% in 2005 to 11.5% in 2006. The percentage reported other basic needs to pay for medicines also declined, from 10.6% in 2004 and 11.1% in 2005 to 7.6% in 2006. The sickest beneficiaries reported no reduction, but fewer who reported no longer need to pay for drugs.
A parallel study found that D Part beneficiaries skipped doses or switched to cheaper drugs and many did not understand the program. Another study found that Part D resulted in an average increase in average drug utilization and reduced average out-of-pocket expenditure. Further research by the same group of researchers found that the net effect among beneficiaries was a decrease in the use of generic drugs.
A further study concluded that despite substantial reductions in out-of-pocket costs and a moderate increase in utilization among Medicare recipients during the first year after Part D, there was no evidence of improvement in the use of emergency departments, inpatient care, or on the preference of health utilities for those who eligible for Part D during its first year of implementation. It was also found that there was no significant change in the trend of double expenditure spending, total monthly spending, day-pills, or the total number of prescriptions due to Section D.
Criticism
The federal government is not allowed to negotiate the price of Part D drugs with drug companies, as federal agencies do in other programs. The Department of Veterans Affairs, allowed to negotiate drug prices and make formularies, is estimated to pay between 40% and 58% less on medicines, on average, than Part D.
Although generic versions of drugs [often prescribed for parents] are now available, plans offered by three of the five insurers [Example Medicare Part D] currently exclude some or all of these drugs from their formularies.... Furthermore, the price for the generic version is not much lower than the equivalent of their brand-name. The cheapest price for simvastatin (generic Zocor) 20 mg is 706 percent more expensive than the VA price for the Zocor brand name. The lowest price for sertraline HCl (generic Zoloft) is 47 percent more expensive than the VA price for the Zoloft brand name. "
Estimating how much money could be saved if Medicare was allowed to negotiate drug prices, economist Dean Baker gave "the most conservative high cost scenario" of $ 332 billion between 2006 and 2013 (about $ 50 billion per year). Economist Joseph Stiglitz in his book The Price of Inequality estimates the "medium cost scenario" of $ 563 billion in savings "for the same budget window".
Former Congressman Billy Tauzin, R-La., Who drives the bill through the House of Representatives, soon retires and takes a $ 2 million-a-year job as president of Pharmaceutical Research and Manufacturers America (PhRMA), the industry's premier lobby group. Medicare boss Thomas Scully, who threatened to sack Medicare Chief Actuary Richard Foster if he reported how much it actually costs, is negotiating for a new job as a pharmaceutical lobbyist because the bill works through Congress. 14 congressional aides quit their jobs to work for related lobbying immediately after the bills section.
In response, the free-market think tank Manhattan Institute issued a report by professor Frank Lichtenberg saying that the VA National Formulary did not include many new drugs. Only 38% of drugs approved in the 1990s and 19% of drugs approved since 2000 were in the formulary.
In 2012, the plan requires Medicare recipients whose total drug costs reach $ 2,930 to pay 100% of the prescription fee up to $ 4,700 spent from the bag. (The actual threshold amount varies from year to year and plan per plan, and many plans offer limited coverage during this phase.) Although this coverage gap does not affect most program participants, about 25% of beneficiaries listed in the standard plan find themselves in the gap this.
Source of the article : Wikipedia
0 Comments