Medicare Part programs

Explain the variety of benefit designs in the Medicare Part D program. 

Identify sources of information about Medicare Part D programs. 

Medicare Part D has increased prescription drug access for millions of older adults. The private administration of the program has resulted in many choices among plans, which has an impact on both patients and pharmacies. MTM developed in 2007, and it has... 

Medicare Part D is in its relatively early stages of implementation. There is still much to be learned about the impact of the program on patients, pharmacists, and pharmacies and the general health care system. Fortunately, a number of program evaluations have already taken place. The results of these studies will help... 

Touchette DR, Burns AL, Bough MA, Blackburn JC. 2006. Survey of medication therapy management programs under Medicare Part D. J Am Pharm Assoc 46 683. 

Centers for Medicare and Medicaid Services (CMS). 2007d. Medicare Program—General Information, Medicare Part B. Available at www.cms.hhs.gov/Medicare GenInfo/03 Part%20B.asp accessed on May 2007. 

Again, Medicare Part D has added an additional issue to an already complex topic. While some of the problems have been improved, the difficulties for independent community pharmacy still remain (Chi and Paul, 2006). The issues of prompt payment and reimbursement rates will continue to contribute to an already complex and stressful environment, keeping everyone s focus on the continued evolution of the Medicare Part D program. 

Medicare Part D represents probably both the biggest challenge an opportunity to pharmacy practice in the last 20 years. We have added a chapter dedicated to the management implications of this program, as well as updated other chapters to describe the impact of this program on other areas of practice. 

Medicare is an entitlement program and serves all eligible beneficiaries regardless of income or medical history Like Social Securify, Medicare is based on a system of social insurance. Medicare is composed of two programs. Medicare Part A covers inpatient care in hospitals and skilled nursing facilities. It also covers hospice care and some home health care. Part A is financed by a 1.45% payroll fax paid by bofh employees and employers (2.9% for self-employed persons). Currenf employers and employees pay for the health care of current Medicare beneficiaries, wifh the expectation that when they reach age 65 they will receive the same benefits. In the U.S., when people turn 65 years of age, they are automatically eligible for Medicare s Parf A, and they do not have to pay for the hospital insurance if they, or a spouse, paid Medicare taxes when they were working. 

Both pharmacists and pharmacies use Health Care Finance Administration (HCFA) Form 855, Provider/ Supplier Enrollment Application, to request a provider number. This form may be obtained from medicare part B carriers or provided by the previously mentioned training programs. This is a cursory review of medicare policies. Training programs will provide additional details, or contact your local medicare part B carrier, HCFA regional office, or other pharmacy reimbursement publications. 

Medicare Part D which provides a Medicare prescription drug program. This program is completely voluntary and requires an affirmative action to enroll. 

Patient must be eligible for Medicare Part A and must enroll in a Medicare-approved hospice program... 

Many third parties hire pharmacy benefit managers (PBMs) to provide prescription claims processing and other services. Examples of third parties that hire PBMs are insurance companies, employers, Medicare prescription drug plans, and state Medicaid programs. PBMs establish pharmacy networks as part of their claims management services, so many pharmacy third-party contracts are with PBMs. Examples of other ser-... 

Medicare is a federal health care program, and its recipients include people over the age of 65, the disabled, and those with end-stage renal disease. Medicare is administered by the Centers for Medicare and Medicaid Services (CMS), formerly known as the Health Care Financing Administration. The Medicare program consists of two parts (parts A and B), but is funded by four different sources (1) general tax revenues, (2) beneficiaries premiums, (3) mandatory contributions from employers and employees, and (4) deducf-ibles and copayments paid by patients. ... 

Historically, a lack of public insurance programs created obstacles to health care services. For those who could not afford to pay for private insurance, the costs associated with health care were larger than most could afford. After lengthy debate, the U.S. Congress passed legislation in 1965 that established Medicare and Medicaid. Medicare covers over 95% of the elderly in the United States as well as many individuals who are disabled. Coverage for the disabled began in 1973 and is divided in two parts 1) hospital insurance and 2) supplementary medical insurance. The total disbursement for Medicare in 1997 was 213,575 billion, and there were 36,460,143 enrollees, of which 32,164,416 were elderly. 

Since 1983, Medicare has paid hospitals a fixed amount per admission for a package of services based on a patient s primary diagnosis and major treatments. Medicare will now cover attendant hospital costs for patients receiving an experimental drug if the admission was not solely for the experiment. Some observers have suggested that adjustments to hospital payments allowed by Medicare to cover costs associated with medical education also underwrite some of the patient and faculty costs associated with clinical research. Medicare contractors, the companies that administer the Medicare program under contract with HCFA, interpret these policies differently in different parts of the country (395). 

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