With the increasing costs in accessing health care there has been an ever increasing need for people to come up with means and ways to meet their health needs. One such way is enrolling into a plan that will cater for some of your expenses according to some agreed on arrangement. Previously the government had enacted legislation that enabled the coming implementation of the Medicare plan. The Medicare Plans provides assistance in paying for health care and is divided into three parts namely: Part A, Part B and Part C.
But unlike Part A and Part B , Part D coverage is not within the traditional medicine program. Beneficiaries of the this program must enroll in any of the plans offered by the private companies. The en action of this plan is provided under the drug benefit Act of 2003,(MMA) whose implementation was in effect as from January 2006. Under Medicare one can enroll in a plan and change their plan, between 15th November and the last day of December. This period is referred to as the annual enrollment period. The Plan costs and benefits vary from year to year.
It is important to note that coverage begins in January but the plans can start looking for customers from as early as the 15th of November. Under the Medicare Plan D the beneficiary’s out of pocket may vary as a result in the variation of the deductibles, initial coverage limit, and changes in the annual out-of -pocket threshold. The costs vary with place and the plan as the Medicare law has not set a premium amount. Medicare Plan D The coverage is this plan is voluntary, furthermore a person can still purchase a part D plan even though he/she is enrolled in a plan A or B.
Enrollment to the plan does not require one to be enrolled in the other plans even though those enrolled in Plan A or B can still enroll in this plan. On the other hand people who have been incarcerated cannot be included in this plan and one is only allowed to enroll in a Plan D that covers his area of residence or geographical location. There is need for plans to offer benefits that are comparable to standard benefits. The standard benefit rather than being defined in terms of particular drugs is defined in terms of structure.
The benefits of the plan as at 2008 include a $275 which is deductible, after which the beneficiaries are responsible for covering the costs up to and including $2,510. Thereafter the said beneficiaries have to be deducted a ‘Donut Hole’ as they pay the full costs. After the beneficiaries have accounted for $4050 also referred to as out-of-pocket expenses, which is calculated annually, they are declared to have Catastrophic Coverage. Under catastrophic coverage, they can choose to either pay a 5% flat coinsurance or pay $2. 25 for preferred drugs and $5.
60 for others. Those who reach the limit of $4050 in a year have to start meeting the incurred costs in the next year. The Medicare Plan D Cover provides for only drugs covered by Plan D under the MMA. A Part D drug under the MMA is thus defined as a drug approved by the FDA, for which prescription and payment is required under Medicaid. There are some other drugs, which even though they don’t fit the definition, are considered as Part D drugs, an example is insulin. Generally drugs for which payment is optional are not considered as Part D drugs.
Many drugs used in nursing homes like drugs for weight, panic attacks and those that are sold over the counter are not included in Part D’s definition. Those excluded include drugs that are covered under Part A and B. It is important to note that those drugs excluded will never be covered for even if the beneficiary is only covered in Part D. There is need for each plan to come up with a mechanism to minimize cost sharing or cover for a non-formulatory drug, that is some form of custom made plan for a specif employee under her request.
Medicare’s Plan D is no exception to this rule as the plan provides a mechanism to handle exceptions. Under this plan exceptions should be certified by a prescribing doctor by confirming that no other drug in the Plan D would be effective or by proving that the use of such drugs will have adverse effects on the beneficiary. These are the main reasons under which an exception is implemented even though there are other situations that could lead to it’s implementation.
One key reason for joining a plan is to gain from it, thus there is need to join a plan from which one will maximize his/her benefits. Under the Medicare’s Plan D the deductible and out of pocket limits are determined solely by the cost of Plan D drugs included in the formulatory of the plan. True out of pocket expenses (TROOP) is a term used to refer to payments that add to the yearly out-of -pocket expenses. The plan further stipulates that only out-of-pocket costs for formulatory drugs are paid by other parties.
Thus, payments made by other parties are not included in the evaluation of the limit as they would increase the amount after which the beneficiary is obliged to partake in meeting the costs for high drug expenses. Therefore under Plan D as a medical plan the beneficiary is solely responsible for paying for non-formulatory drugs even though he no credit is awarded to him for meeting the Part D out-of-pocket expenses. There is need for one to carefully asses the options that he has before choosing a plan as the plans can be of no use to the individual if not carefully picked.
There are some key factors to be put into consideration when selecting a Plan D provider. First, financial considerations, it should be noted that the key reason as to why people ought to join Medical plans is to meet the health care expenses. Thus there is need to consider a plan that is cost effective. Some key issues to look in a plan while assessing it’s cost effectiveness include: The amount to be paid in monthly premiums, will the plan remain a low-income subsidy plan if it was one, if it is not what amount will be paid for the full extra help. Are there penalties for enrolling late?
The second key factor to be put into consideration is the content of the plan. Under this there is need to scrutinize the Plan in areas like what is the number of days covered in the prescription? what are the drugs needed by the beneficiary? There is need to question the plan on it’s policy on the usage of non-labelled drugs and room for exceptions and what are the limits? The third key area is the utilization tools in the plan. Under this the key areas to look at include: Does the formulatory contain the utilization tools and if so what are the prior authorization requirements?
What kind cost sharing mechanism the plan implement and the number of tiers involved. Some other key factors that have to be considered include: The plan sponsors and their credibility, the availability of other secondary benefits offered by the plan and the insurance status of the beneficiary. Under the design of Medicare’s Plan D the beneficiary will have less cover for prescription drug as compared to Medicaid, furthermore he will will have less avenues to seek protection from barriers to coverage.
Lastly the beneficiary is forced to pay the ever increasing Co-payments for his prescription. There is need for the beneficiaries of the Plan D medical cover to seek for other ways in which they can assure themselves of their ability to meet their drug requirements. One key way in which this can be achieved is through enrollment into programs that allow for discounts in pharmacy and retailer prescription drugs at a small monthly premium. Such a move will ease the beneficiary’s access to drugs that are not provided for by the Part D plan.
The move will also aid the access to services that are not covered by the plan for instance services that deal with health problems related to hearing, dental problems and vision. The key limiting problem in the implementation of the above mechanism is that most of the program have stringent entry requirement for instance them may require one to be of age above fifty years thus effectively locking out those below that age. There are several key advantages in enrolling for Plan D, first your medical emergencies will be taken care of in a timely manner.
Secondly, it is relatively cheap compared to the others for people who rarely need non-prescription drugs. On the other hand it’s major disadvantage lies on the fact that it covers only a specific line of drugs and medical services. Conclusion The advantages and the disadvantages of the plan highly depend on the beneficiary’s health condition as is therefore relative and applicable subject to ones assessment of his/her condition. Reference List Center for medical advocacy: Medicare Part D Prescription Drug Coverage http://www. medicareadvocacy. org/FAQ_PartD. htm as retrieved on 16 Jun 2008