The United States of America holds a reputation for being a welfare state. Its government actively seeks out ways to benefit its citizen in ways possible.
One of the most common concerns in the country, or in fact any country, is health. Many people live below the poverty line, and hence, can’t afford basic health services. The Government of United States established Medicare, a federal health care program aimed at providing insurance.
It is made accessible to the following people:
The health program is split into four categories and covers specific services:
It is run and managed by the Centers for Medicare and Medicaid Services (CMS) and funded by the Social Security Administration. Some 60 million seniors and individuals with disabilities seek to benefit from the federal program.
People who become eligible and enroll for the program can seek benefits from the Original Medicare program.
Medicare Part A is referred to as hospital insurance. It is free, meaning that an individual does not pay any premium. Medicare Part B comes with a monthly premium. It covers outpatient expenses, such as physician fees, X-rays, diagnostic tests, and medical supplies.
Medicare Part C is a premium fee-for-service plan offered by private insurance companies. These companies have contracts with Medicare. A Part C health plan covers all benefits of Part A and Part B plus additional benefits.
The one drawback to the Medicare Advantage Plan is that the individual is limited to the insurance company’s network. The full coverage extends only to its network of healthcare facilities.
Medicare Part D caters to provide price discounts on prescription drugs. Similar to the Medicare Advantage Plan, Part D is administered by private health insurance companies. Its coverage can be added to Original Medicare, Medicare cost plans, Medicare Private Fee-for-Service Plans, and Medicare Savings Account Plans. Most, if not all, Medicare Advantage Plans also include prescription drug coverage.
Each year, new changes/additions are proposed by the Government to Medicare. The Centers of Medicare and Medicaid Services (CMS) announced several proposed changes coming to Medicare for the calendar year 2019, more specifically to Medicare Advantage plans (Part C) and the prescription drug plans (Part D).
People were limited to having prescriptions written by prescribers who were contracted by Medicare. Now, prescriptions for Medicare Advantage and Part D can be written by any prescriber.
The Final Rule has also made some changes to the term “marketing.” It now defines to include only materials that motivate a beneficiary to make an enrollment decision.
For materials and activities that fall outside of the definition, CMS is implementing requirements for a new category called “communications.”
The update changes the requirement for organizations offering multiple Medicare Advantage plans in the same county. The obligation to comply with the “meaningful difference” requirements shall be eliminated.
Medicare Advantage is one of the paid plans that people can enroll in. As we mentioned earlier, it is offered through private insurers who are in contract with Medicare.
Previously, providers and suppliers of health care items or services under Medicare Advantage plan were required to enroll in Medicare by 2019. The final rule now stands free of such a requirement. According to an estimate by CMS, the provision will enable providers to save $34.4 million for the year 2019.
Instead, CMS has prepared a list of providers that are revoked from the Medicare program under 42 CFR sec. 424.535.
The new regulation prohibits Medicare Advantage plans from paying providers and suppliers whose names are in the preclusion list. Similarly, a pharmacy claim for a part D drug will be rejected if the prescription is coming from individuals placed on the list.
The list will be made available to Medicare Advantage plans and Medicare Part D prescription drug plans.
In 2019, the Medicare Donut Hole discount is set to increase to 75%. The 70% of which will be paid for by the brand-name drug manufacturer, while Medicare Part D plan provider shall cover the remaining 5%.
As an example, people who reach the Donut Hole can receive $95 credit after they pay $25 for the medication that carries a retail cost of $100.
It might allow an individual to exit the Donut Hole faster and enter Catastrophic Coverage.
People who are eligible to receive Medicare Extra Help will be able to change Part D plans. It will be accessible once per quarter during the first nine months of the year.
Starting next year, Medicare Advantage Disenrollment Period will be replaced by Medicare Advantage Open Enrollment Period. The period will run from January 1 to March 31.
CMS has established a framework in accordance with CARA that allows Part D sponsors to implement drug management programs. At-risk beneficiaries shall have limited access to coverage for frequently abused drugs.
The programs shall exclude beneficiaries who are:
Organizations providing Medicare Advantage can provide continuation of coverage once beneficiaries are eligible to receive Medicare.
Medicare Plans can reduce the cost of sharing for covered benefits. They can also offer benefits that are tailored specifically for the beneficiary, and deductibles to the ones who meet medical criteria.
Beneficiaries can be passively enrolled to another comparable plan from a non-reviewing integrated D-SNP. The enrollment shall be made after consultation with a state Medicaid agency and where continuity and quality of care conditions are met.
Revisions have been made to regulations that control the maximum out-of-pocket (MOOP) limits.
The Final Rule will enable sponsors of Medicare Advantage and Part D to provide documents via electronic means. It includes Evidence of Coverage (EOC). Additionally, the separation of delivery dates means that beneficiaries will receive the Annual Notice of Change (ANOC) first, and Evidence of Coverage (EOC) second.
Going forward, Medicare Plans will not be required to provide a notification to the appellant whose appeal has been forwarded.
Currently, the outpatient setting provides a 30-day transition supply period. With the Final Rule, long-term care will match the outpatient setting to provide a 30-day period as well.
There has been a reduction in the MLR data that Medicare Advantage and Part D sponsors are required to provide annually.
That covers nearly all Medicare 2019 changes. These will come into effect from next year, January 1, 2019.
Medicare’s services are nothing short of a maze. It is quite complicated to understand. If you’re approaching 65 years of age, then it would be best to contact a professional to work out all the details for you and receive additional information.
Please call Medicare2019.com at 844-374-1950
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