Medicare Part D and its Salient Features

Medicare, a social insurance program which has been imbued in the health care programs, caters to the health insurance of the senior strata of America. Induced by the dominion of the U.S., Medicare is administered and regulated by CMS (Centers for Medicare and Medicaid Services).

Medicare provides assistance to a large citizenry of elderly and sick people, those who have low-incomes and to many of those who would have been unable to afford a health care themselves. Medicare ensures defined benefits to all its enrollees, irrespective of their medical history or the income that they are earning.

Medicare offers four basic modules that have been designed as per the needs of the public. They can be divided as below:

Medicare Part A

  • Deals with Hospital Insurance
  • Covers the hospital, skilled nurses, hone care for atleast 40 calender quarters

Medicare Part B

  • Deals with Medical Insurance
  • Covers doctors expenses, tests, various medical equipments, mental health care, ambulance services etc

Medicare Part C

  • Deals with everything that Parts A and B don't cover
  • These include vision and dental work and the plan often incorporates Part D

Medicare Part D

  • Deals With Presription Drug Coverage
  • Covers the expenses that are incurred on the drugs that one needs to take on a regular basis

Medicare also provides supplemental and advantage plans that are regulated by the CMS, but are sold by private companies to those who feel the need to buy them. CMS has tie-up with the private contractors already a part of health care industry and it enacts as an intermediary between the government and these private medical insurance providers.

Getting Acquainted with Medicare D:

Medicare part D is one of the sub plans that are being offered by Medicare.

The “D” stands for “Drugs”, and Medicare D is one of the prescription drug benefit plan that has been created under the Medicare Prescription Drug, Improvement and Modernization Act, 2003. Though created in 2003, it was effective from January 1, 2006.

Part D plan is known as a coverage plan for the prescribed drugs. People would want to opt for prescription drug plans as they save extra bugs, spent on buying drugs at a low premium to be paid every month.

Medicare D allows enrollees to choose from an extensive list of generic and branded drugs, but it is not necessary that all the plans would cover all prescribed drugs. So it is advised that one should be careful in choosing a plan that meets all personal requirements for drugs.

D plans are optional in nature. Part D plans allow Medicare enrollees to choose one of the following three choices:

  • Simply stick to the original Medicare plan and not support it with a prescription drug plan outlined in act
  • Stay with the original Medicare plan and opt for a prescription drug plan along with it
  • Enroll in an ubiquitous private health plan, which may lack upon some of the required benefits

Each Medicare D plan, works on a specific ‘Formulary’, which is a list of covered drugs. A plan would only cover the cost of those drugs which are covered by the formulary and at a pharmacy which is listed among the network of pharmacies.There are certain drugs that have been banned by law or not covered under the list. They can be listed as:

  • Used for losing or gaining weight
  • Used as anti-anxiety
  • Over the counter drugs except insulin and supplies related with the insulin
  • Only prenatal vitamins, products that contain fluoride and analogs of vitamin D, all other vitamins and minerals
  • Barbiturates drugs, unless combined with one or more component are excluded
  • Benzodiazepines drugs
  • Drugs used for cosmetic purposes
  • Drugs that are either denied by FDA (Food and Drug Administration) or by law of U.S
  • Drugs are related to infertility
  • Used for treating colds

A doctor can always ask for an exception to have the plan cover the drug (if you need the drug and it is not covered in the plan), if the drug has not been eliminated by law.

Getting Enrolled in Medicare D plan: Know your Rights:

Part D of Medicare

Just as every consumer has a right to know the details of the product that they are buying, so does every enrollee getting enrolled for a policy/plan have rights. They can be defined as:

  • Know your Coverage: One should have a written explanation of what would be covered, how drugs are covered, rules and conditions that are required to buy specific drugs under the plan purchased
  • Embargoed drugs from the formulary list from the administrator of the policy
  • Exceptions to remit the coverage terms and conditions, if any
  • Exceptions in co-pays, if one is on more costly tier

Medicare D and its cost determinants:

The MMA has already defined a set of benefits that are to be defined in the benefit structure and are not based on the drugs included or excluded.

Every Medicare part d plan, that is offered to enrollees would be different. It can be on the basis of the cost, benefits or drugs covered. Each plan has certain factors that affect the cost of the plan. They can be listed as below:

  • State to state (location)
  • Co-insurances, co-pays and the deductibles to be paid
  • Penalty, if any to be paid

Many elderly citizens feel that the concept is not comprehensive enough, that an extra cost should be borne for it. They have criticized that it is only adding to the cost of the drugs that senior people need to take on regular basis, which is contrary to what a Medicare D plan should do.
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Medicare is a federal program established to assist with health insurance. It applies to those aged 65+ and those who are younger but who suffer from certain health conditions that make them eligible.

If you are eligible and not enrolled automatically, you can sign up for Medicare by calling Social Security. If you are receiving social Security or certain other benefits, you may be automatically enrolled in Medicare. If you are unsure, call Social Security for assistance on 1-800-772-1213.

Basic Medicare covers those services that the government deems to be medically essential. Medicare Part A provides coverage for inpatient services in skilled nursing and hospital stays, hospices and home healthcare. Part B provides coverage for outpatient care including preventive care, doctor visits and lab tests. Part D provides coverage for most prescription drugs. Part C is privately sponsored Medicare Advantage plans that provide coverage for the gaps that Parts A, B and D don't fill.

There is various payments required by Medicare, which can include cost sharing, premiums and deductibles. There are certain government programs that assist with Medicare payments such as Low Income Subsidy payments for those with less income and fewer assets.

Some people have employer group health plans if they are actively employed. If this is the case it's possible that they will want to delay their Part B application while this plan is in effect.

If a person has creditable coverage for their prescription drugs, which is equally good if not better than regular Part D coverage, they may wish to delay Part D enrollment or forget it altogether. Creditable coverage will often be granted as part of some healthcare plans that are associate with Medicare, such as Veteran Affairs or Tricare.

Medicare can be supplemented with other useful plans such as Medigap, retiree plans and Medi-Cal (for those on a lower income or with fewer assets) which are not government sponsored, but privately issued. Other examples of private health plans include the popular Advantage plans which are comprehensive in their coverage. They include Medicare Part A and Part B but these are paid as part of the plan's premiums.

No. If your Medicare benefits are based on retirement, you must wait until age 65 to enroll. If you enter into retirement at age 62, you may have continued medical insurance from a previous employer or else you would have to purchase temporary health insurance from a private insurer while you wait to become eligible for medicare.

It is advisable to submit your Medicare application three months before your 65th birthday. You should receive your Medicare card around one month later, then coverage will start as soon as you turn 65. Those getting social security benefits will be enrolled in basic Medicare Part A and B automatically. If you don't wish to pay premiums for Part B, you may terminate your enrollment.

Termination of Part B enrollment is taken seriously and as such a form cannot be submitted online. You will be required to attend an interview with social services and may face a surcharge. To terminate enrollment, form CMS-1763 can be filled in person or over the phone and the consequences will be made clear to you.

If you are older than 65, you'll usually be required to sign up during the GEP or general enrollment period. This takes place between January 1st and March 31st and coverage commences on July 1st. There will most likely be a late enrollment penalty for those who sign up during the GEP which would mean a 10% rate increase for each month that you were eligible but did not enroll in Medicare.

If you have a low income or few assets, you may be eligible for financial assistance courtesy of the Medicare Extra Help program. This helps with monthly premiums, co-payments on Part D and annual deductible payments. Your Extra Help application also gets the ball rolling for the Medicare Savings Program, which assists with other Medicare-related costs. You will be contacted by the state with instructions to apply.