This paper is final guidance on how CMS will review Medicare prescription drug benefit plans to assure that beneficiaries receive clinically appropriate medications at the lowest possible cost. Two key requirements in the Medicare Modernization Act (MMA) are to assure that drug plans provide access to medically necessary treatments for all and do not discriminate against any particular types of beneficiaries, and to encourage and support the use of approaches to drug benefit management that are proven and in widespread use in prescription drug plans today. The goal is for plans to provide high-quality cost-effective drug benefits by negotiating the best possible prices and using effective drug utilization management techniques. This goal can be achieved through a CMS drug benefit review strategy that facilitates appropriate beneficiary access to all medically necessary Part D covered drugs along with plan flexibility to develop efficient benefit designs, thus bringing drug benefit strategies that are already providing effective coverage to millions of seniors and people with a disability to the Medicare population. Our formulary review process focuses on three areas:
What is the Medicare Modernization Act?
The Medicare Prescription Drug, Improvement, and Modernization Act, also called the Medicare Modernization Act or MMA, is a federal law of the United States, enacted in 2003. It produced the largest overhaul of Medicare in the public health program's 38-year history.
What is the legislative history of Medicare?
Legislative history. The Medicare Prescription Drug, Improvement, and Modernization Act, also called the Medicare Modernization Act or MMA, is a federal law of the United States, enacted in 2003.
What happened in 2003 in the US Medicare?
In 2003, a near-decade of intensive efforts to move beneficiaries out of traditional Medicare had led to ____. Medicare's architects created a tension between Medicare's short-term goals and its long-term aspirations.
What is Medicare and how does it work?
Medicare was established by Congress in 1996 to provide financial assistance with medical expenses to. People older than 65. Medicare requires its beneficiaries to pay premiums, deductibles, and coinsurance, which is referred to as.
What did the Medicare Modernization Act of 2003 do?
The 2003 Medicare Modernization Act (MMA) is considered one of the biggest overhauls of the Medicare program. It established prescription drug coverage and the modern Medicare Advantage program, among other provisions. It also created premium adjustments for low-income and wealthy beneficiaries.
What was the impact of the Medicare prescription drug and Improvement Act of 2003 quizlet?
The Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003 was signed into law in December of 2003. It added outpatient prescription drug coverage to Medicare beginning in January of 2006.
What came out of the Medicare Prescription Drug Improvement and Modernization Act?
This new law amended section 1144 of the Social Security Act to require the Commissioner of Social Security to conduct additional outreach efforts to identify individuals entitled to benefits, or enrolled under the Medicare program under Title XVIII, who may be eligible for transitional assistance under the Medicare ...
Why was Medicare Prescription Drug Improvement and Modernization Act passed?
In an attempt to relieve patients of some of the financial burden of prescription drugs, the government has enacted a law that provides new prescription drug coverage under Medicare: the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003.
What was the impact of the Medicare Prescription Drug Improvement and Modernization Act quizlet?
What was the impact of the Medicare Prescription Drug Improvement and Modernization Act? The Act created Medicare Part D, the drug prescription program.
Which part of the Medicare program was created under the Medicare Modernization Act of 2003 MMA )? Quizlet?
The Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA) made the biggest changes to the Medicare in the program in 38 years. Under the MMA, private health plans approved by Medicare became known as Medicare Advantage Plans.
Which of the following is not a condition for drugs covered under Part D?
Drugs not covered under Medicare Part D However, plans usually do not cover: Weight loss or weight gain drugs. Drugs for cosmetic purposes or hair growth. Fertility drugs.
When did Part D become mandatory?
January 1, 2006The benefit went into effect on January 1, 2006. A decade later nearly forty-two million people are enrolled in Part D, and the program pays for almost two billion prescriptions annually, representing nearly $90 billion in spending.
What was the purpose of the prescription drug Marketing Act of 1987?
Prescription Drug Marketing Act of 1987 - Amends the Federal Food, Drug, and Cosmetic Act to permit only the U.S. manufacturer of a drug to reimport such drug into the United States, except for emergency medical care. Prohibits the selling, purchasing, or trading of prescription drug samples or coupons.
What are Medicare Part A benefits?
Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. coverage if you or your spouse paid Medicare taxes for a certain amount of time while working. This is sometimes called "premium-free Part A." Most people get premium-free Part A.
Why did Medicare Part D pass?
Medicare Part D dramatically lowered the number of beneficiaries spending more than one-fifth of their income on prescription drugs from 14% in 2003 to 7% in 2010. Part D coverage has made seniors' finances more stable and less prone to bankruptcy due to drug costs.
Which medical expense is covered by Medicare quizlet?
Medicare covers all medical costs but only if you are at least 65 years of age. Skilled nursing care is approved and covered by Medicare. Medicare covers routine checkups, dental care, most immunizations, cosmetic surgery, routine foot care, eyeglasses, and hearing aids.
What items were reduced in the 2005 Medicare payment?
Provides that for 2005 the payment amount for certain items, oxygen and oxygen equipment, standard wheelchairs, nebulizers, diabetic lancets and testing strips, hospital beds and air mattresses, will be reduced.
What is SSA Title 3?
Title III: Combatting Waste, Fraud, and Abuse - (Sec. 301) Amends SSA title XVIII to allow the Secretary to make a conditional Medicare payment if a primary plan has not made or cannot reasonably be expected to make prompt payment. Requires the payment to be contingent on reimbursement by the primary plan to the appropriate Medicare trust fund. Requires a primary plan as well as an entity that receives payment from a primary plan to reimburse the Medicare Trust Funds for any payment made by the Secretary if the primary plan was obligated to make payment. Makes other changes with regard to Medicare as a secondary payer to address the Secretary's authority to recover payment from any and all responsible entities and to bring action, including the collection of double damages, to recover payment under the Medicare secondary payer provisions.
What are the beneficiary protection requirements for a PDP?
Establishes beneficiary protection requirements for qualified prescription drug plans, such as requiring each PDP sponsor offering a prescription drug plan to: (1) have a mechanism for providing specific information on a timely basis to enrollees upon request ; (2) have in place with respect to covered part D drugs a cost-effective drug utilization management program and a medication therapy management program ; and (3) provide that each pharmacy that dispenses a covered part D drug shall inform an enrollee of any differential between the price of the drug to the enrollee and the price of the lowest priced generic covered part D drug under the plan that is therapeutically equivalent and bioequivalent and available at such pharmacy.
Which title directs the Secretary to request the Institute of Medicine of the National Academy of Sciences to conduct an evaluation of the?
Directs the Secretary to request the Institute of Medicine of the National Academy of Sciences to conduct an evaluation of the peer review program under SSA title XI.
How many summaries are there for H.R.1?
There are 3 summaries for H.R.1.
When did the CCA program begin?
241) Directs the Secretary to establish a program for the application of comparative cost adjustment in CCA areas, to begin January 1, 2010, and last six years, and to test whether direct competition between private plans and the original Medicare fee-for-service program will enhance competition in Medicare.
Who conducts a study for a report to the Congress on the extent to which drug utilization and access to covered?
Requires the Comptroller General to conduct a study for a report to the Congress on the extent to which drug utilization and access to covered part D drugs by subsidy eligible individuals differs from such utilization and access for individuals who would qualify as such subsidy eligible individuals except for application of the assets test.
When was Medicare Modernization Act enacted?
Signed into law by President George W. Bush on December 8, 2003. The Medicare Prescription Drug, Improvement, and Modernization Act, also called the Medicare Modernization Act or MMA, is a federal law of the United States, enacted in 2003. It produced the largest overhaul of Medicare in the public health program's 38-year history.
When did Medicare Advantage start?
Medicare Advantage plans. With the passage of the Balanced Budget Act of 1997, Medicare beneficiaries were given the option to receive their Medicare benefits through private health insurance plans, instead of through the Original Medicare plan (Parts A and B).
What is Medicare Part D?
Main article: Medicare Part D. The MMA's most touted feature is the introduction of an entitlement benefit for prescription drugs, through tax breaks and subsidies. In the years since Medicare's creation in 1965, the role of prescription drugs in patient care has significantly increased.
What is the "donut hole" in Medicare?
The "donut hole" provision of the Patient Protection and Affordable Care Act was an attempt to correct the issue.
How many votes did the Senate have to override the conference report?
However, a budget point of order was raised by Tom Daschle, and voted on. As 60 votes were necessary to override it, the challenge was actually considered to have a credible chance of passing.
How many Americans were enrolled in HSAs in the first 10 years?
After the first 10 years over 12 million Americans were enrolled in HSAs (AHIP;EBRI).
When was the H.R. 1 bill introduced?
The bill was introduced in the House of Representatives early on June 25, 2003 as H.R. 1, sponsored by Speaker Dennis Hastert. All that day and the next the bill was debated, and it was apparent that the bill would be very divisive. In the early morning of June 27, a floor vote was taken. After the initial electronic vote, the count stood at 214 yeas, 218 nays.
What is the Medicare Modernization Act?
This article also probes whether or not the bill has been successful in meeting the needs of the elderly population to gain secure access to affordable prescription medicine as well as helping the federal government lower its spending. Based on available literature, the Modernization Act has a limited advantage to the people it seeks to serve, while giving private companies more money and business. The Medicare Modernization Act fails to answer the needs of the elderly population to have better access to prescription drug because. While it offers more services and benefits, the MMA does not answer the problem on cost related to medication.
Does Medicare cover disabled people?
The program also covers people under 65 years old who are disabled and are not capable of holding employment. Traditionally, the Medicare provides hospitalization and medical insurance to the elderly [1]. Later amendments allowed an individual to enhance the services by integrating a private health plan into Medicare for an additional cost.
Is Medicare Modernization Act a failure?
Those who believe that the Medicare Modernization Act is a failure have based their arguments on some points. For one, Medicare users can’t avail of the drug prescription benefit without getting involved with private health insurers and paying for monthly premiums. While this is not an issue for some, there are elderly people whose monthly stipends are meager. They could not afford the premiums. Although the MMA provides that this type of people can be accommodated and given prescription drugs for free, the question would lie on what type of drugs would they get, given that they are not paying for them? This would also imply that the MMA becomes discriminatory based on income. Those who can afford to pay get more, while those who cannot get less. This beats the very essence of Medicare being a social program.
When was Medicare established?
Medicare was established by Congress in 1996 to provide financial assistance with medical expenses to. People older than 65. Medicare requires its beneficiaries to pay premiums, deductibles, and coinsurance, which is referred to as. Cost sharing. Medicare Part A, the hospital insurance part of Medicare, is funded through.
What is Medicare Part A?
Medicare Part A, the hospital insurance part of Medicare, is funded through. Taxes paid by employers and taxes withheld from employee's wages. Coverage requirements under Medicare, state that for a service to be covered, it must be considered. Medically necessary.
How long is a SNF allowed?
Benefit period. This duration of time begins the day an individual is admitted to a hospital or SNF and ends when the beneficiary has not received care in a hospital or SNF for. 60 days in a row.
What is a dual eligible program?
Dual Eligible. The program that provides community based acute and long term care services to Medicare beneficiaries is called. PACE- Programs of All Inclusive Care for the Elderly. A health insurance plan sold by private insurance companies to help pay for healthcare expenses not covered by Medicare is called a.
What is Medicare Part D?
Medicare Part D helps the elderly, and others, afford prescriptions. Use medicare.gov to help the patient pick an appropriate plan. Financial help is available for patients if needed. The donut hole is challenging for patients and providers. Pharmacists are a great resource - utilize them.
When is open enrollment for Medicare Part D?
Medicare Part D: Enrollment. Open Enrollment Period occurs from October 15th through December 7th. -Individuals who sign up late may be penalized.
What is the late enrollment penalty for Medicare Part D?
Late enrollment penalty (also called the "LEP" or "penalty") -Added to the person's monthly Part D premium for as long as he or she has Medicare prescription drug coverage.
What is the role of Social Security Administration?
Determines eligibility for Medicare A, B, and low income subsidy (SSI) Centers for Medicare and Medicaid Services (CMS) Policies and procedures. Oversees Medicare and Medicaid plans, billing and rules.
Does Medicare Advantage Plan include a prescription drug?
Medicare Advantage Plan (like an HMO) -Must provide all of Part A and Part B, but could provide more benefits. --> Most include a prescription drug benefit that substitutes for part D. Medicare Part D. Prescription Drug Plan. -Covers prescription medications.
Is every drug covered by Medicare Part D?
Medicare Part D: Coverage. Prescription drugs covered by the plan can vary plan to plan. Every therapeutic category of prescription drugs will be covered under the Medicare Part D prescription drug plan. -Not EVERY drug in a therapeutic class.
Overview
The Medicare Prescription Drug, Improvement, and Modernization Act, also called the Medicare Modernization Act or MMA, is a federal law of the United States, enacted in 2003. It produced the largest overhaul of Medicare in the public health program's 38-year history.
The MMA was signed by President George W. Bush on December 8, 2003, after …
Prescription drug benefits
The MMA's most touted feature is the introduction of an entitlement benefit for prescription drugs, through tax breaks and subsidies.
In the years since Medicare's creation in 1965, the role of prescription drugs in patient care has significantly increased. As new and expensive drugs have come into use, patients, particularly senior citizens at whom Medicare was targeted, have found prescriptions harder to afford. The …
Medicare Advantage plans
With the passage of the Balanced Budget Act of 1997, Medicare beneficiaries were given the option to receive their Medicare benefits through private health insurance plans, instead of through the Original Medicare plan (Parts A and B). These programs were known as "Medicare+Choice" or "Part C" plans. Pursuant to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the compensation and business practices for insurers that offer these plans changed, a…
Health savings accounts
The MMA created a new Health Savings Account statute that replaced and expanded the previous Medical Savings Account law by expanding allowable contributions and employer participation. After the first 10 years over 12 million Americans were enrolled in HSAs (AHIP;EBRI).
Other provisions
While nearly all agreed that some form of prescription drug benefit would be included, other provisions were the subject of prolonged debate in Congress. The complex legislation also changed Medicare in the following ways:
• it mandated a six-city trial of a partly privatized Medicare system (by 2010)
• it gave an extra $25 billion to rural hospitals (at the request of congressional representatives in the rural West)
Legislative history
According to the New York Times December 17, 2004 editorial W.J."Billy" Tauzin, the Louisiana Republican who chaired the Energy and Commerce Committee from 2001 until February 4, 2004 was one of the chief architects of the new Medicare law. In 2004 Tauzin was appointed as chief lobbyist for the Pharmaceutical Research and Manufacturers of America (PhRMA), the trade association and lobby group for the drug industry with a "rumored salary of $2 million a year," dr…
Costs
Initially, the net cost of the program was projected at $400 billion for the ten-year period between 2004 and 2013. Administration official Thomas Scully instructed analyst Richard Foster not to tell Congress of Foster's finding that the cost would actually be over $500 billion. One month after passage, the administration estimated that the net cost of the program over the period between 2006 (the first year the program started paying benefits) and 2015 would be $534 billion. As of F…
Bar to negotiation of prescription drug prices
Since the enactment of Medicare Prescription Drug, Improvement, and Modernization Act in 2003, only insurance companies administering Medicare prescription drug program, not Medicare, have the legal right to negotiate drug prices directly from drug manufacturers. The Medicare Prescription Drug Act expressly prohibited Medicare from negotiating bulk prescription drug prices. The "donut hole" provision of the Patient Protection and Affordable Care Act was an attem…