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PubMed1997

Trends in Medicare Part B mental health utilization and expenditures: 1987-92.

This article examines the impact of expanding Medicare Part B coverage of mental health services, based on analysis of 6 years of Medicare Part B claims data (1987-92). Inflation-adjusted per capita spending more than doubled (from $9.91 to $21.63) following the elimination of the annual outpatient treatment limit and extension of direct reimbursement to clinical psychologists and social workers. There was a 73-percent increase in the user rate (from 23.25 to 40.20 per 1,000 Medicare beneficiaries), and a 27-percent increase in the average number of services per user (from 8.9 to 11.3). Mental health spending increased from 1 percent to 2 percent of expenditures for Part B professional services. Ongoing monitoring of mental health utilization is desirable to ensure that recent access gains are not eroded with the increasing shift to managed care and implementation of gatekeeper mechanisms.

Ambulatory Care↗
PubMed2006

Senior enrollment in Medicare Part D.

The obvious starting point for beneficiaries to take advantage of the Medicare Part D program is to enroll in a plan that best meets their needs. Medicare beneficiaries that currently have creditable coverage (as good as Medicare Part D) should, in most situations, stay with their plan. Those without coverage should carefully assess the importance of joining a plan. Important factors to consider include being locked out of a plan from the end of the initial enrollment period, May 15, 2006, until the next open enrollment period, Nov. 15, 2006, through Dec. 31, 2006, with the new plan becoming effective Jan. 1, 2007; the late enrollment penalty of a 1 percent increase in premium for every month without coverage; and the lost opportunity in not taking advantage of having coverage, especially for those eligible for the low-income subsidy.

Aged↗
PubMed2006

The transition to Medicare Part D and the new senior care landscape.

The landscape of coverage for prescription drugs for Medicare beneficiaries has dramatically changed as a result of Medicare Part D. As regulations were drafted to govern this program, the federal government's fear was that because pharmacy benefit managers had never gone at risk for the management of medications, plans would be reluctant to enter the new arena of Medicare drug coverage. Of course, that has not happened as hundreds of various plans have entered this market, including a new form of managed care plan referred to as a "special needs plan". The landscape of health care has changed and will continue to change as Medicare Part D changes, both as the result of competitive market forces and regulatory actions.

Economic Competition↗
PubMed2006

Medicare Part D: who wins, who loses?

The Medicare Part D prescription drug benefit aims to relieve the burden of out-of-pocket prescription drug costs for persons older than 65 years, but its effects will vary. Persons with low income and those without prior prescription coverage are projected to save the most, whereas those who lose employer-based coverage are predicted to pay more for their existing regimens.

Drug Costs↗
PubMed2006

Medicare Part D: early findings on enrollment and choices for rural beneficiaries.

On January 1, 2006, the Medicare program began offering prescription drug coverage (Medicare Part D) to over 42 million Medicare beneficiaries. This policy brief provides a first snapshot of enrollment in rural and urban areas across the United States and outlines the early findings from an analysis of plans available to rural persons under Medicare's Part D program. The data in this brief will be updated as new data are available from the Centers for Medicare and Medicaid Services (CMS). Key Findings As of March 18, 2006 (date of release by CMS), (1) 59% of rural beneficiaries and 67% of urban beneficiaries have creditable drug coverage. (2) 21% of rural beneficiaries were enrolled in stand-alone prescription drug plans (PDPs), compared to 13% of urban beneficiaries. (3) 3% of rural beneficiaries were enrolled in Medicare Advantage prescription drug (MA-PD) plans, compared to 16% of urban beneficiaries. (4) In non-adjacent rural areas, 22% of rural beneficiaries were enrolled in stand-alone PDPs, and 2% were enrolled in MA-PD plans. (5) All beneficiaries, including those in rural areas, can choose a PDP option that covers 91% of the top 100 formulary drugs. (6) Average monthly premiums and other plan characteristics for MA-PD plans vary significantly across states-for example (excluding Maine), 2 premiums vary from $6 in urban New Hampshire to $53 in rural Hawaii.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2005

Medicare Part D subsidies. Final rules.

We are adding to our regulations a new part to contain rules that we will apply when we evaluate applications for premium and cost-sharing subsidies under the Medicare program. We are including a new subpart, Medicare Part D Subsidies, to this part. This new subpart contains the rules that we use to determine eligibility for premium and cost-sharing subsidies under the Medicare Part D program, which was added by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Medicare Modernization Act or MMA). These final rules describe: What the new subpart is about; how we determine whether you are eligible for premium and cost-sharing subsidies; how we redetermine your eligibility for a subsidy; how you apply for a subsidy; how we evaluate your income and resources; when your eligibility for premium and cost-sharing subsidies terminates; how you may report changes in your circumstances; and how you can appeal a determination we make under the Part D subsidy program.

Cost Sharing↗
PubMed1998

Medicaid program; state allotments for payment of Medicare Part B premiums for qualifying individuals: federal fiscal year 1998--HCFA. Notice with comment period.

Section 4732 of the Balanced Budget Act of 1997 (Public Law 105-33) amended the Social Security Act to provide for two additional eligibility groups of low-income Medicare beneficiaries for whom Medicaid payment can be made for Medicare Part B premiums during the period beginning January 1998 and ending December 2002. This notice announces the Federal fiscal year 1998 State allotments that are available to pay Medicare Part B premiums for these two new eligibility groups and describes the methodology used to determine each State's allotment.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2005

Medicare program; application of inherent reasonableness payment policy to Medicare Part B services (other than physician services). Final rule.

This final rule finalizes the process that was set forth in an interim final rule published on December 13, 2002, for establishing a realistic and equitable payment amount for Medicare Part B services (other than physicians' services) when the existing payment amounts are inherently unreasonable because they are either grossly excessive or grossly deficient. This process does not apply to services paid under a prospective payment system, such as outpatient hospital services or home health services. The December 2002 interim final rule also described the factors we (or our carriers) will consider and the procedures we will follow in establishing realistic and equitable payment amounts for Medicare Part B services. In addition, this final rule responds to public comments we received on two provisions in the December 13, 2002 interim final rule relating to how we define grossly excessive or deficient payment amounts and to the criteria for using valid and reliable data in applying the inherent reasonableness authority.

Centers for Medicare and Medicaid Services, U.S.↗
PubMedDate not supplied

Access to cancer drugs in Medicare Part D: formulary placement and beneficiary cost sharing in 2006.

The Medicare Part D benefit expands the universe of cancer drugs and biologics that Medicare may cover. Individual Part D plans have discretion to determine their formularies and cost sharing for drugs within federal guidelines. This paper analyzes differences in coverage and cost sharing for cancer drugs among these plans. We find that many cancer drugs, including brand-name products, are covered by almost all plans, although prior authorization might limit access to some. In addition, many plans charge a relatively low copayment for most cancer drugs. These findings suggest that Part D could greatly expand beneficiaries' access to cancer treatments.

Biological Products↗
PubMedDate not supplied

A new Medicare Part B wound care policy.

Skin and wound care specialists should design an assessment tool that includes all the documentation required to prove medical necessity for the initial and continued use of NPWT, when appropriate for patients who are managing their wounds at home. In addition, specialists should supply the physician with the order form that is provided by the NPWT pump supplier. Finally, personnel should be trained to appropriately assess and document the need for NPWT. Once a Medicare Part B-covered patient at home qualifies for a NPWT pump and supplies, the supplier will deliver the equipment and supplies and will bill Medicare Part B directly. Payment will be 80% of the DMERC Fee Schedule. The patient will be charged 20% of the Medicare allowable fee.

Aged↗
PubMed1992

Estimating the effect of new technology on Medicare Part B expenditure and volume growth: do related procedures matter?

The new Medicare Part B physician reimbursement system requires the Health Care Financing Administration to consider how medical technology contributes to growth in service volume. One estimate of this effect has been made by the Physician Payment Review Commission (PPRC), which estimated how individual new technologies have influenced volume growth. This paper extends the PPRC analysis to include both new technology services and those services that are complementary, or related to, the new technology services. The results show that adjusting for related procedures can increase the estimated cost of new technology by as much as 50 percent. In addition, related procedures can increase the estimated share of volume growth attributable to new technology by as much as 42 percent. This implies that both new and related procedures should be used when implementing physician payment reforms.

Diagnostic Imaging↗
PubMed1995

Agreement between physicians' office records and Medicare Part B claims data.

This article tests agreement between demographic, diagnostic, and procedural information from primary-care physicians' office records and Medicare Part B claims for Maryland Medicare beneficiaries. The extent of agreement depended on the category of information being compared. Demographics matched poorly, probably due to incomplete record samples. Important diagnoses were often missing from the medical record. When claims indicated presence of disease, the patient was likely to have the disease, but claims did not capture all people who have the disease. Additionally, many laboratory tests and procedures were missing from the primary-care record. The appropriate use of either of these data sources depends on the specific research question that is being asked.

Demography↗
PubMedDate not supplied

Survey of medication therapy management programs under Medicare part D.

OBJECTIVE: To describe and summarize the enrollment criteria and benefit designs for medication therapy management (MTM) programs offered throughout the United States during the first year of the Medicare Part D benefit. DESIGN: Cross-sectional survey. SETTING: United States between November 1, 2005, and June 30, 2006. PARTICIPANTS: MTM benefit plan managers of major health insurance companies nationwide selected nonrandomly by the investigators from lists provided by the Centers for Medicare & Medicaid Services. INTERVENTION: Telephone interview and/or e-mail 12-item survey with mostly open-ended questions. MAIN OUTCOME MEASURES: Characteristics required for a patient to be enrolled in MTM programs and types of services provided along with modes of delivery. RESULTS: Interviews were completed or surveys returned from 21 distinct MTM programs representing 70 health insurance plans covering 12.1 million Medicare enrollees. Of the MTM programs offered, 90.5% restricted their enrollment based on number of diseases, with a median of 3 (range, 2-5) diseases required; 57.1% restricted enrollment based on the type of chronic condition; and 95.2% had requirements for the number of medications (median, 6; range, 2-24) necessary for enrollment in the program. The most frequently provided MTM services were patient education (75.0% of programs),patient adherence (70.0%), and medication review (60.0%). The median number of different service types provided by MTM programs was 3 (range, 2-7). MTM program services included the use of mailed interventions (76.1%) and inhouse call centers (90.4%). While only 4 of the 21 MTM programscontracted with pharmacies to provide some or all of their MTM services, these plans covered a large number of beneficiaries (7.5 million lives). CONCLUSION: MTM programs offered by prescription drug plans and Medicare Advantage plans were highly variable during the first year of the Medicare Part D benefit. Definitive evidence supporting the effectiveness of many of the most common interventions is lacking.

Cross-Sectional Studies↗
PubMed2006

Who failed to enroll in Medicare Part D, and why? Early results.

Early results on the Medicare Part D prescription drug program, from a survey of people age sixty-five and older who were interviewed just before enrollment started and just after it ended, indicate that Medicare has met its target of 90 percent coverage. Enrollment rates in vulnerable subpopulations-poor health, low income, or cognitive impairment-are almost high enough to offset lower rates of other coverage. However, sizable numbers of elderly people remain uncovered, contrary to their self-interest. Seniors give Part D mixed reviews, and majorities are less satisfied with Medicare and with the government as a result of their experience with this program.

Aged↗
PubMed1992

Medicare Part B spending.

In its continuing effort to identify and examine the trends in Medicare spending for surgical services, the College obtained copies of the Medicare procedure code files for the years 1986 through 1989. The results from analysis of these data files were presented in a report entitled Trends in Medicare Part B Spending 1986-1989, issued by the College in September 1991. This article describes the federal activity that prompted the College to commission the report, and presents some of the significant results of the analysis.

Data Interpretation, Statistical↗
PubMed2006

Medicare Part D: exceptions and appeals process.

Once enrolled in a Medicare Part D prescription plan, the focus changes to access to medically necessary medications through the prescription plan. In many situations, this will involve the exceptions and appeals process. Each Medicare plan has its own drug formulary and differentiates itself through various parameters within those formularies. The federal government has rules in place for what may or may not be covered in a formulary, and has specified parameters for an exceptions and appeals process. It is the responsibility of the patient, along with his or her physician, to learn about and take advantage of mechanisms built into the system to ensure access to medically necessary medications. As physician reimbursement moves to an outcome-based through pay-for-performance system, physicians will have a financial incentive for assuring that their patients receive the necessary medications.

Gatekeeping↗
PubMed2006

Narrative review: the U.S. Pharmacopeia and model guidelines for Medicare Part D formularies.

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 includes a provision directing the Secretary of the U.S. Department of Health and Human Services to request that the U.S. Pharmacopeia (USP) develop a list of categories and classes (the USP Model Guidelines) that can be used by prescription drug plans in developing their formularies for the Part D prescription drug benefit. The Centers for Medicare & Medicaid Services (CMS) used the Model Guidelines and USP's related listing, termed the Formulary Key Drug Types, to evaluate prescription drug plan formularies submitted by prescription drug plan sponsors intending to provide the new Part D benefit. This article recounts how USP's all-volunteer Model Guidelines Expert Committee developed the USP Model Guidelines and Formulary Key Drug Types, working under a cooperative agreement with CMS in response to the Secretary's request. The Model Guidelines and Formulary Key Drug Types are updated annually to reflect advances in evidence-based medicine, thereby offering timely guidance to CMS and to prescription drug plans based on USP's demonstrated expertise in setting standards.

Drug Prescriptions↗