In general, Part D provides insurance coverage for beneficiaries’ prescription drugs. Those who are enrolled in the program (either voluntarily through private insurance companies, or if they do not select a program, CMS will enroll them in a PDP, as required by the MMA) will pay a monthly premium ranging from only a few dollar to over 100 dollars, with the prescription costs varying depending on the particular drug plan selected (Medicare-PartD. com, 2007). This thesis will tackle two basic issues with regard to Medicare Part D:
1) the CMS enrollment process is complicated and takes time, thus creating difficulties for some dual eligible beneficiaries under the program; and 2) although CMS made drug coverage retroactive, it failed to inform beneficiaries of their right to reimbursement. Beneficiaries of the Part D program can obtain their benefit through two types of private plans: one, they can join a PDP for drug coverage only, or two, they can opt to join a Medicare Advantage plan (MA) which covers both medical services and prescription drugs (Center for Medicare Advocacy, Inc., 2007).
In the US, there are already 34 PDP regions and 26 MA regions, with the drug plans controlling drug costs through a system of tiered formularies wherein lower cost drugs are assigned to lower tiers, making them easier to prescribe. Medicare beneficiaries thus have to affirmatively choose and enroll in the plan, except in the case of dual eligible beneficiaries who, if already enrolled in an MA-only plan, are then automatically removed from the MA plan upon enrollment to a PDP plan (Wikipedia, The Free Encyclopedia, 2007).
Since the past 40 years when Medicare was first established, there has never been any prescription drug benefit included in the program until Part D was created. Prior to Part D, federal governments would subsidize about half of the Medicaid drug costs. The passage of the MMA allows any Medicare beneficiary to voluntarily enroll into a prescription drug benefit plan (Stebbins, 2006). Unfortunately, the Part D roll-out encountered many glitches, and these problems primarily arose from the case of the program’s dual eligible beneficiaries.
As of December 31, 2005, dual eligible beneficiaries ceased to receive their Medicaid drug coverage, since they were randomly and automatically assigned to one of eight plans in Medicare even prior to January 1, 2006. Unfortunately, in many of these instances, the dual eligible beneficiaries did not receive any eligibility information with regard to any of the eight plans they were automatically assigned to.
This means that the assigned dual eligible beneficiaries have not always been recognized as members. Worse, Medicare and the plans did not receive correct information on those who were deemed as dual eligibles under the program (Stebbins, 2006). With the roll-out of Part D, dual eligible beneficiaries, enrolled in both Medicare and Medicaid coverage, were supposed to have their drug costs covered by Part D, and no longer by the state Medicaid programs (U.
S. General Accounting Office, 2007). As earlier mentioned in this thesis, for dual eligible beneficiaries to continue receiving the drug benefit, they must affirmatively enroll in a Part D plan offered by private companies (Center for Medicare Advocacy, Inc. , 2007), with the MMA requiring that the CMS must assist dual eligible beneficiaries by enrolling them in a private PDP if they do not select a plan of their own (U. S. General Accounting Office, 2007).
Unfortunately, the complicated enrollment process of CMS has caused much problems for dual eligibles, not only with providing information to Medicare and the plans as to who were considered dual eligibles, but also in failing to inform these beneficiaries of their right to reimbursement. In examining these two central issues (the enrollment process for dual eligibles and their right to reimbursement), the thesis proponent hopes to shed some light to the reader in order to assist him or her in understanding the Medicare Part D maze.
This thesis also aims to provide information to insurance companies and employers offering health benefits to their employees, of the possible issues and pitfalls of Part D inherently as a system, and how they can act internally within their organizations to remedy the loopholes to the system. In sum, the significance of this thesis is that it aims to make the system of receiving health benefits more effective for the beneficiaries, by highlighting the joint responsibility of both the receivers and the providers of such benefits.