Many Part D plan sponsors offer multiple plans that may be viewed as analogous to commercial “good, better and best” options. 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. Plans revise their formularies every year, adding new drugs, eliminating others, and generally charging higher co-pays and co-insurance for drugs. There is an appeal process for members who need drugs that are not on their plan’s formularies.
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Within parameters established in law, plans are free to establish their own formularies. 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. 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. In order to have Part D coverage, beneficiaries must purchase a policy (i.e., enroll in a plan) offered by one of these companies. These companies are both regulated and subsidized by Medicare, pursuant to one-year, annually renewable contracts. 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. 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. 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.” 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). There, you will also find relevant legislative, statutory and CFR citation. For more detailed information on any of the topics in this section, please click on the links within the topics. This section constitutes an introduction to Part D. Recent Articles and Updates Introduction to Medicare Part D.Listen to Medicare & Health Care Stories.Join the Center for Medicare Advocacy Founder’s Circle.Career, Fellowship & Internship Opportunities.Ossen Medicare Outreach, Education and Advocacy Project.Connecticut Dually Eligible Appeals Project.The Center for Medicare Advocacy Founder’s Circle.
CMA Annual Report | Fiscal Year July 2021 – June 2022.Nursing Home / Skilled Nursing Facility Care.
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