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Offers prescription drug coverage for Medicare beneficiaries.
Provided by private insurance companies who contract with Medicare.
Designed as a Cost Sharing plan meaning the cost for the medications is split between the beneficiary, the prescription drug plan, manufacturers, and Medicare.
Beneficiaries who want to receive drug benefits must enroll with a prescription drug plans.
-Stand Alone Prescription Drug Plans (PDP) -Medicare Advantage + Prescription Drug Plans (MA-PD)
PDP Plans are purchased by beneficiaries who have Original Medicare (A and/or B), or beneficiaries who enroll in a Medicare Advantage Plan can choose a plan that offers prescription drug coverage included in the benefit package.
Question: What are the types of Part D Plans?
- Stand Alone Prescription Drug Plans (PDP's)
- Medicare Advantage with Prescription Drug Plans (MA-PD's).
What are the different Plan Costs shared in PDP Plans?
Premium: Amount paid for insurance coverage.
Deductible: The pre-designated dollar amount of covered expenses that are paid by the insured individual, after which insurance coverage begins.
Copayment: A fixed fee paid by the patient at the time a medical service is rendered (e.g., when a prescription is dispensed).
Coinsurance: A percentage of the cost of an insured service (or drug) paid by the insured individual.
How do PDP Plans work?
-Medicare Part D Plans are divided into THREE Coverage Levels.
-Each level has a different cost sharing structure and drug spending requirement.
-Once a level's drug spending threshold is met, the beneficiary moves into the next level and the cost sharing will change.
-Each year the plan begins in the deductible phase, and beneficiaries will move through the three levels as each level's "spending limit" is reached.
-Since beneficiaries are enrolled in a plan for one calendar year, all drug spending is tracked and resets on a yearly basis.
-Drug spending limits are adjusted annually based on Medicare's guidance.
Drug Spending and Out of Pocket
*What is Drug Spending? -Total amount of money spent on drugs during the plan year, regardless of the payer.
-Important to ensure beneficiaries are moving through the three coverage levels accordingly.
*Out Of Pocket? -Total amount of money that the beneficiary paid on the drugs during the plan year.
-If a beneficiary switches Part D plans during a benefit year the amount will "carry" with them to the new plan.
-Includes payments made on behalf of a beneficiary by a friend, relative, most charities, and different government assistance programs.
What is NOT added to the Max Out of Pocket?
-Monthly premiums -Drugs not covered by the Part D plan -Drugs purchased outside the U.S. -Drugs purchased at an out-of-network pharmacy -Drugs not normally covered in a Part D plan -Any payments made by the plan and payments made by: *Group health plans including employer health plans *Certain insurance plans and government funded health programs such as TRICARE and the Veteran's Administration *A third-party with a legal obligation to pay for prescription costs (e.g., worker's compensation)
What are the Three Coverage Levels of PDP Plans?
Level 1 -Deductible During this stage, if your plan has a deductible, you usually pay the full cost of your covered Part D prescription drugs up to the deductible amount. If your plan does not have a Part D deductible, you will start in the Initial Coverage Stage. Once you reach the deductible amount, you enter the Initial Coverage Stage and pay a copay or coinsurance.
Level 2 -Initial Coverage During this stage, the plan pays its share of the cost and you pay a copay or coinsurance for each covered Part D prescription drug you fill until your out-of-pocket drug costs reach $2,000 for the year. Once you reach $2,000, you enter the Catastrophic Coverage Stage.
Level 3 -Catastrophic Coverage In this stage, you pay a 50 copay for each covered Part D prescription you fill
What is a payment subsidy?
A government incentive or assistance in the form of financial aid extended to an economic sector.
What payment subsidies are available for beneficiaries with limited income and resources?
-Medicaid -Extra Help - LIS (Low Income Subsidy) -SPAP/ADAP -Medicare Savings Programs
Other Cost and Payment Terms: -Deductibles -Prescription Drug Cost -Co-payments -Co-insurance costs
Who is responsible in paying the Plan Cost ?
*Beneficiary/Member -Direct Payment - monthly In voices are mailed out prior month and the customers pay directly with their preferred payment type and method.
-SSA/RRB - SSA Deduction - authorized monthly premium automatically withheld from customer's SSA check, customer's need not to pay premium as the payments are deducted from their SSA/RRB accounts.
*Subsidized Payments - Government or Church Subsidy -SPAP/ADAP - partial or full subsidy from state -Burris - partial or full subsidy from diocese ________________________________________________________________"PWHO" is the term corresponding to the source of plan payment or the entity responsible for the plan's payment.