Sixth Week

During Week 6, I studied how Medicare payment plans work. Medicare is a health insurance program for people 65 years and older, people under the age of 65 with certain disabilities, and people with End-Stage Renal Disease (permanent kidney failure). Medicare offers three different payment plans: Part A Hospital Insurance, Part B Medical Insurance, and Prescription Drug Coverage. Part A Hospital Insurance allows the patients to pay no premiums because they are usually paid through their payroll taxes. This insurance pays for inpatient care in hospitals, critical access hospitals, and skilled nursing facilities. Part B Medical Insurance patients usually pay a monthly premium. This insurance covers doctors’ services that are medically necessary or preventive. Medicare’s prescription drug coverage also has additional monthly premiums. Prescription drug coverage is also available for everyone with Medicare. However, there are a few drug coverage rules. The drug must have prior authorization meaning clinics must contact the drug plan and may need to show that the drug is medically necessary. There may also be quantity limits on the drug. Medicare can also require step therapy where the patient must try one or more similar, lower cost drugs before the plan will cover the prescribed drug.  In 2015, there were 55.3 million total Medicare beneficiaries with 46.3 million people 65 years and older and 9 million disabled patients.

Next week, I will study and research The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) which is the law that repealed the Sustainable Growth Rate (SGR) formula and created the Quality Payment Program (QPP) to stabilize Medicare payments and potentially reward providers, hospitals and medical practices for providing quality, high-value care to Medicare patients.



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