National Bipartisan Commission On The Future Of Medicare
Following the failure of President Clinton’s health care reform proposal in 1994, Republicans captured majorities in both houses of Congress. In 1995 the main policy issue regarding Medicare was not how to improve benefits but how to restructure the program and limit the federal government’s financial liability for existing coverage. The Medicare Preservation Act, which Congress passed as part of the Balanced Budget Act of 1995 but President Clinton vetoed, included major reforms and reductions in spending in Medicare and other government programs as well as substantial tax cuts. Republican strategists miscalculated both the president’s willingness to accept the legislation and the public’s reaction . Nonetheless, reducing the budget deficit remained a high political priority, and two years later, the Balanced Budget Act of 1997 cut projected Medicare spending by $115 billion over five years and by $385 billion over ten years .
The Balanced Budget Act created a new Medicare+Choice program, which encouraged beneficiaries to choose among the traditional fee-for-service Medicare, HMOs, and preferred-provider organizations. It also created Medicare medical savings accounts, changed payment policies and formulas for providers and health plans, strengthened efforts to prevent and prosecute fraud and abuse by Medicare providers, and created the National Bipartisan Commission on the Future of Medicare.
What Drugs Are Covered By Aetna Medicare Plans
An Aetna Medicare formulary typically lists drugs grouped by the types of medical conditions they are used to treat. It also lists them in alphabetical order.
To find out which drugs are covered by Aetna® Medicare plans in your area, you can speak with a licensed insurance agent. You can reach one by calling 1-877-890-1409TTY Users: 711 24 hours a day, 7 days a week.
A licensed insurance agent can use Aetna Medicare plan formularies to help you find Aetna Medicare prescription drug coverage that fits your needs.
Will Medicare Pay For A Yearly Physical Examination
En español | Medicare does not pay for the type of comprehensive exam that most people think of as a physical. But it does cover a one-time Welcome to Medicare checkup during your first year after enrolling in Part B and, later on, an annual wellness visit that is intended to keep track of your health.
Initial visit: The Welcome to Medicare visit with your doctor aims to establish the state of your health when you enter the program and provide a plan of future care. The doctor will:
- record your vital information
- review your personal and family health history
- check risk factors that could indicate future serious illnesses
- recommend tests and screenings that could catch medical issues early and provide a checklist of preventive services to help you stay healthy
- offer you the option of discussing end-of-life issues, including information on how to prepare an advance directive naming someone to make medical decisions on your behalf if you became too ill to make them yourself
- provide counseling and referrals as appropriate
Annual visit: During an annual wellness visit, the doctor measures your height, weight, body mass and blood pressure, and may listen to your heart through your clothes. The rest is a discussion of your own and your familys medical history, any physical or mental impairments, and risk factors for diseases such as diabetes and depression.
Both services are free of charge if the following conditions are met:
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What Youll Pay For Prescriptions
In addition to Part D premiums, you may be responsible for cost-sharing, which can include deductibles, copays or coinsurance. Medicare Part D plans set their own premiums.
Part D plan deductibles vary from $0 to the maximum allowed, which in 2021 is $445 . People with high incomes will pay an extra monthly charge of $12.30 to $77.10 for Part D in 2021.
What Does A Medicare Wellness Visit Include
Routine medical care is important when youre sick or suffering from an ailment, but what about when youre feeling fine? The truth is, scheduling an annual doctors visit to assess your health, often referred to as a wellness visit, is just as important to do when youre feeling fine as it is when youre feeling under the weather. These visits provide your physician the chance to discuss any healthcare concerns you may have, and they also give you the opportunity to ask questions about any medications or supplements youre taking or about changes to your diet or exercise routine.
The Difference Between a Physical and a Wellness Visit
For many people, the terms physical and wellness visit are used interchangeably, but they are actually quite different. During a physical, your doctor carries out a physical exam of your major systems, takes measurements, documents any changes and reviews concerns. During a wellness visit, there is typically no examination that takes place other than a general inspection of the body. A wellness visit is more like checking in with your doctor while a physical is more like an in-depth examination to assess body systems and functions. During a wellness visit, you may bring up a medical concern which prompts a physical exam, and during a physical, you may discuss wellness concerns, but the two are billed as separate types of visits.
What Does a Medicare Wellness Visit Include?
Medicare Coverage Beyond Wellness Visits
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What Does It Mean If My Prescription Drug Has A Requirement Or Limit
Plans have rules that limit how and when they cover certain drugs. These rules are called requirements or limits. You need to follow the rules to avoid paying the full cost of the drug out-of-pocket. If you do not get approval from the plan for a drug with a requirement or limit before using it, you may be responsible for paying the full cost of the drug. If needed, you and your doctor can also ask the plan for an exception.
Here are the requirements and limits you may see on a drug list:
PA Prior Authorization
If a plan requires you or your doctor to get prior approval for a drug, it means the plan needs more information from your doctor to make sure the drug is being used and covered correctly by Medicare for your medical condition. Certain drugs may be covered by either Medicare Part B or Medicare Part D depending on how they are used. If you don’t get prior approval, the plan may not cover the drug.
QL Quantity Limits
The plan will cover only a certain amount of a drug for one copay or over a certain number of days.
ST Step Therapy
The plan wants you to try one or more lower-cost alternative drugs before it will cover the drug that costs more.
B/D Medicare Part B or Medicare Part D Coverage Determination
Depending on how they’re used, some drugs may be covered by either Medicare Part B or Medicare Part D . The plan needs more information about how a drug will be used to make sure it’s correctly covered by Medicare.
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How Will Part D Coverage Complement Your Medicare Supplement
Medicare Part D includes a tiered system of drug coverage. All plans cover protected medications such as HIV/AIDS and Cancer treatments. Each Part D plan sets its own formulary, or list of covered prescription drugs, offering brand-name and generic options. Medicare Part D drugs range in cost from tier one to tier three and top-tier specialty drugs .
Medicare Part D extends the drug coverage provided by original Medicare. Once recipients get expanded Medicare drug coverage through a Part C or add-on Part D option, they can enjoy savings on prescription medications, including insulin, blood-pressure regulators, and top-tier drugs.
Consider All Your Drug Coverage Choices
Before you make a decision, learn how prescription drug coverage works with your other drug coverage. For example, you may have drug coverage from an employer or union, TRICARE, the Department of Veterans Affairs , the Indian Health Service, or a Medicare Supplement Insurance policy. Compare your current coverage to Medicare drug coverage. The drug coverage you already have may change because of Medicare drug coverage, so consider all your coverage options.
If you have other types of drug coverage, read all the materials you get from your insurer or plan provider. Talk to your benefits administrator, insurer, or plan provider before you make any changes to your current coverage.
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The Long Wait For New Benefits
More than a decade passed before there was another major effort to introduce prescription drug coverage under Medicare. Even though the Democrats controlled both the legislative and executive branches of government in the wake of the Watergate scandal and the election of President Jimmy Carter in 1976, the energy crisis, a weak economy, and rising inflation precluded costly new initiatives . Inflation and growing unemployment were threatening the solvency of Social Security, and Congress responded by raising payroll taxes in 1977. Richard Himelfarb observed that
the economic troubles of this period transformed the politics of federal programs serving the elderly. Whereas the 1960s and early 1970s had been marked by significant expansion of federal aid to the aged, the late 1970s and 1980s constituted an era of scarcity in which public officials struggled to maintain the gains of an earlier era. In short, from the Carter years onward, legislators would face no more easy votes on programs affecting the elderly.
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Who Can Get Medicare Part D
All US citizens over 65 years old are eligible to receive Medicare Part D coverage through the federal government. In addition, many people under 65 with disabilities may also qualify for this program. Other individuals who need help paying their drug costssuch as low-income seniors or those suffering from long-term health conditionscan also qualify for Medicare Part D.
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References
The 2010 Medicare Part D $250 Donut Hole Rebate. Q1Group LLC, .
2020 Part D Income-Related Monthly Premium Adjustment. . .
2021 Medicare Part D Outlook.Q1Group LLC, .
2021 Part D Income-Related Monthly Premium Adjustment. . .
How Do Medicare Advantage Ppo Plans Work? Healthline Media, May 5, 2021, .
Analysis of Part D Beneficiary Access to Preferred Cost Sharing Pharmacies . . .
Announcement of Calendar Year 2021 Medicare Advantage Capitation Rates and Part C and Part D Payment Policies. . .
Assistance with Paying for Prescription Drugs. Center for Medicare Advocacy, November 30, 2015, .
How Medicare Part D Works. AARP, October 2016, .
Medicare Advantage Special Needs Plans . Healthline Media, May 3, 2021, .
Kirchhoff, Suzanne M. Medicare Coverage of End-Stage Renal Disease . . .
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Drugs That Are Used With Durable Medical Equipment
Durable medical equipment includes things like walkers, wheelchairs and other supplies used in the home and are covered by Medicare Part B. Durable medical equipment can also include things like nebulizers, infusion pumps and other equipment that pair with medication.
Medicare Part B covers drugs that are infused through durable medical equipment. That can include insulin when the use of an insulin pump is determined to be medically necessary.
The Task Force On Prescription Drugs
Soon after Medicare was implemented, unexpected increases in the program’s spending on hospital and physician services drew the attention of officials in the U.S. Department of Health, Education and Welfare and the White House. The particular policies that contributed to the early and rapid rise of Medicare expenditures were the cost-based reimbursement of hospitals and the payment of physicians based on customary, prevailing, and reasonable charges . When President Johnson was faced with proposals to expand Medicareprecisely what its original supporters had anticipatedit seems likely that he did not want to add even more to the program’s rapidly rising costs. In the fall of 1967, for example, he would not agree to support a proposal, called KiddyCare, from HEW to provide Medicare coverage for pregnant women and children .
The task force found that all out-of-hospital prescription drug use, prices, and expenditures had risen rapidly between 1950 and 1965. The number of prescriptions had climbed from 363 million in 1950 to 833 million in 1965 to 930 million in 1967. The number of prescriptions per capita had almost doubled from 2.40 to 4.75, and expenditures had risen from $736 million in 1950 to $3.25 billion in 1967. Moreover, the burden of prescription drug use fell disproportionately on the elderly, who incurred 47 percent of the total costs .
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How Do I Choose A Medicare Part D Plan
According to the Kaiser Family Foundation, the average Medicare beneficiary has 30 stand-alone Medicare Part D prescription drug plans to choose from in 2021. Its important to comparison shop to find the one thats right for you. In addition to monthly premiums and deductibles, you should definitely compare plan formularies, especially if you take daily medications.
Some plans use a pharmacy network. If you have a pharmacy you really like, make sure its part of the plans network. Look for other benefits, such as mail-order pharmacies, that can help save money out-of-pocket.
How To Get Prescription Drug Coverage With Medicare
There are different ways to get prescription drug coverage.
A person can purchase Part D plans individually, providing they already have Original Medicare, or parts A and B. Someone can also use prescription drug coverage, if they select it, alongside:
- select Private Fee-for-Service plans
- some Medical Savings Account plans
- Medicare Cost plans
Alternatively, a person can get Part D as part of a Medicare Advantage policy. Medicare Advantage typically bundles A, B, and D together in one plan. It is important to note that an individual must have Medicare parts A and B to be eligible for Medicare Advantage.
Some types of Medicare Advantage plans may not offer Part D coverage, so a person should compare plans before enrollment. In those cases, an individual may be able to add Part D coverage.
However, in this case, someone may be disenrolled from Medicare Advantage and returned to original Medicare coverage. Examples of plans that this policy could affect include:
- Health Maintenance Organization plans
- HMO Point-of-Service plans
- Preferred Provider Organization plans
A person who wishes to do this without losing their Medicare Advantage coverage can only do so in:
- private fee-for-service plans
- some employer-sponsored Medicare health plans
- registering online, either through the Medicare Plan Finder or the insurance providers website
- completing and mailing a paper enrollment form
As long as the Part D policy is active, the monthly premium will include the calculated penalty.
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D Does Not Cover Over
Medicare Part D does not pay for nonprescription drugs like antacids and cold medicines that you find at a pharmacy. Nor does it cover drugs for erectile dysfunction, hair loss or weight control, even if a doctor prescribes them.
You can use money from a health savings account tax free to pay for over-the-counter medications. You cant contribute to an HSA after you enroll in Medicare, but you can withdraw money for eligible expenses at any time without paying taxes.
Does Medicare Have Any Restrictions On Coverage
Some Medicare plans do place quantity limits on STELARA or require prior authorization. A quantity limit only allows you to fill a prescription for a limited amount of the drug at a time. Prior authorization requires your doctor to contact your plan and show that the drug is medically necessary before you can receive it.
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What Drugs Must Part D Cover
Each Medicare Part D plan has a formulary, a list of covered medications, that includes both generic and brand-name prescriptions. You generally will have higher out-of-pocket costs for brand-name drugs.
Formularies vary from plan to plan, but federal law requires that all Medicare Part D plans include at least two drugs in the most commonly prescribed categories and all medications in the following categories:
- Anticancer drugs except where covered by Part B
- Anticonvulsive treatments for seizure disorders
- Antidepressants
- Immunosuppressant drugs
Part D plans must include coverage for most commercially available vaccines, including inoculations to prevent shingles. Part B, though, covers flu, hepatitis B and pneumonia vaccinations. The government also will pay for your COVID-19 vaccinations if you are covered under any of the four parts of Medicare.
