Medicare drug program enrollment

Doctor and hospital choice: Original Medicare allows you to see any doctor or hospital that takes Medicare, anywhere in the U. Some plans offer non-emergency coverage out of network but at higher cost. You may need to get a referral to see a specialist. Cost: For Part B-covered services, Original Medicare usually requires you to pay 20 percent of the Medicare-approved amount after you meet your deductible; this is called your co-insurance.

You pay a premium monthly payment for Part B. There is no yearly limit to what you pay out of pocket unless you have supplemental coverage such as Medicare Supplement Insurance Medigap. With Medicare Advantage, out-of-pocket costs vary; plans have different costs for certain services. Plans may have zero premium and may help pay all or part of your Part B premium.

Most plans include Medicare drug coverage Part D. Plans have a yearly limit on what you pay out of pocket for services that Medicare Part A and Part B covers. You should have prescription drug coverage as soon as you are eligible for Medicare — if not through an employer or some other source, such as a union or the Department of Veterans Affairs, you may want to consider purchasing either a Part D drug plan if you are on Original Medicare or a Medicare Advantage plan that covers drugs.

Seventy percent of the discount will be paid by the brand-name drug manufacturer and 5 percent will be paid by the Medicare Part D plan. Not all enrollees will reach the donut hole, but those who do will pay a maximum 25 percent co-pay on generic drugs purchased while in the coverage gap — in other words, receiving a 75 percent discount.

To find out if you qualify and to apply, call the Social Security Administration toll-free at , apply online at socialsecurity. The federal government offers Medicare Savings Programs to help low-income seniors and adults with disabilities with Medicare premiums. To see if you qualify and learn how to apply, call the Social Security Administration toll-free at or visit this medicare.

Visit floridashine. CMS tested such materials with beneficiaries to maximize readability and understanding. Through the FAI, we have shown it is possible to create a successful framework for joint State and CMS oversight and contract management.

CMTs regularly meet with State ombudsman organizations, State-convened advisory groups, and may also meet with local stakeholders, such as beneficiary advocates, enabling more rapid problem-solving and real-time feedback on plan performance and beneficiary experience. Based on feedback from States and MMPs and our own experiences for the last eight years, we believe these joint oversight processes, along with having performance data specific to the local MMPs, have improved communications and driven performance improvement.

The capitated model demonstrations have shown it is possible to effectively incentivize innovation and investment for better serving the dually eligible population. This is similar to how States generally approach Medicaid managed care contracts and quality reporting. In contrast, a D-SNP may be one of many plan benefit packages under a single MA contract, making it difficult to get a true picture of a particular MA plan's performance.

From to , MMPs as a group improved performance on measures related to care coordination like Care for Older Adults by an average of 17 percent across three separate measures and Medication Reconciliation Post-Discharge by 54 percent , and on key outcome measures like Controlling High Blood Pressure by 16 percent and Plan All-Cause Readmissions 17 percent reduction for beneficiaries age 65 and over.

MA plans as a group improved by an average of 5 percent across the Care for Older Adults measures although only D-SNPs report those measures and by 32 percent on the Medication Reconciliation Post-Discharge measure, while the Plan All-Cause Readmissions measure had a 16 percent reduction for beneficiaries age 65 and over. The MMP experience has shown that we can create a competitive market among MMPs with multiple choices for beneficiaries in the same service area and maintain high expectations for plans around care coordination and cost effectiveness.

However, it has also shown the potential for beneficiary confusion and disruption in markets where MMPs are competing with other products targeting dually eligible individuals, including D-SNPs and, more recently, D-SNP look-alikes. True integration of Medicare and Medicaid requires long-term State participation.

However, interest and capacity in pursuing integrated care for dually eligible individuals varies considerably from State to State, and sometimes from year to year. One of the many lessons from the MMP experience has been that standing up a demonstration of this scope requires significant State resources. However, even outside of MMPs, many of the features of integration also require significant State effort. States that have successfully utilized D-SNP contracts to integrate or align Medicare and Medicaid programmatic and administrative elements outside of the FAI have also invested in building State capacity, including establishing dedicated staff or contractors with Medicare knowledge and expertise, building technical capacity to integrate Medicare and Medicaid data, and creating analytic resources to support ongoing program operations and oversight.

State investment in establishing enrollment and assignment processes to enable alignment of Medicare and Medicaid enrollment require upfront and ongoing monitoring resources. Kruse and M. Herman Soper. Center for Health Care Strategies, Inc. Since the outset of the FAI, our shared goal with State partners has been to develop models that promote greater Medicare-Medicaid integration that, if successful, could be implemented on a broader scale.

Below we propose to incorporate into the broader MA program many of the MMP practices that successfully improved experiences for dually eligible individuals. We describe those proposals in greater detail in this section of this proposed rule.

Table 1 summarizes how our proposals relate to MMP policies. CMS believes managed care plans derive significant value from engaging enrollees in defining, designing, participating in, and assessing their care systems. One of the ways managed care plans can engage dually eligible individuals is by including enrollees in plan governance, such as establishing enrollee advisory committees and placing enrollees on governing boards.

Engaging enrollees in these ways seeks to keep enrollee and caregiver voices front and center in plan operations and can help plans achieve high-quality, comprehensive, and coordinated care. We describe these requirements later in this section. These enrollee advisory committees provide a mechanism for MMPs to solicit feedback directly from enrollees, assisting MMPs in identifying and resolving emerging issues, and ensuring they meet the needs of dually eligible individuals.

While three-way contract terms differ by State, all three-way contracts require the enrollee advisory committees to meet at least quarterly, be comprised of enrollees, family members, and other caregivers that reflect the diversity of the demonstration population, and provide regular feedback to the MMP's governing board.

MMPs have flexibility in conducting these meetings, including determining how to recruit and train enrollees, number of participants, discussion topics, and how feedback is disseminated and used.

CMS's contractor Resources for Integrated Care partnered with Community Catalyst, a non-profit advocacy organization, to offer a series of webinars and other written technical assistance to help enhance MMPs' operationalization of these committees. These include MMP efforts to In late , Federal and State officials led conversations with MMPs to gain a better understanding of the enrollee advisory committees, promising practices, challenges, and how plans are using the feedback received from enrollees and caregivers.

A significant number of MMPs reported value from having an advisory committee and that the committee contributes to operational improvements through: 1 Understanding challenges with community resources and potential gaps in services; 2 improving enrollee communications, including printed materials and the website enhancements; 3 identifying barriers to medication adherence and what adherence tools might be most useful to enrollees; and 4 improving delivery of non-emergency transportation, dental, vision, and over-the-counter benefits.

A few MMPs reported a neutral value of the advisory committee meetings, citing benefits from enrollee feedback but also challenges in enrollee participation and willingness to engage on issues beyond their personal circumstances.

Overall, though, the MMPs reported the committees provided a valuable perspective that shapes the plan's approach to recovery, wellness, and overall access to health care as well as prioritize areas where additional assistance is needed for enrollees. More recently, MMPs have utilized enrollee advisory committees to gain insight into the effectiveness of specific enrollee materials. For example, some MMPs have shared redacted care plans with enrollee advisory committees for enrollee feedback.

Other MMPs have shared draft influenza vaccination outreach materials with their enrollee advisory committees and used the quarterly meetings to discuss influenza prevention. We have had the opportunity to observe some of these meetings and found the dialogue between enrollees and their caregivers and the MMPs to be open and constructive, with all parties interested in sharing information, listening, and identifying solutions. Other programs overseen by CMS include similar committees or mechanisms for beneficiaries to provide feedback and have a role in plan administration.

The majority of the 51, PACE participants are dually eligible individuals. The November IFC noted that consumer participation through advisory committees is a "well accepted community organization vehicle to maximize the involvement of consumers in a program designed to serve them" and that through the use of a consumer advisory committee consumers are also "likely to feel a greater stake in the operation of the program" 64 FR The original regulation, codified at SEC We also clarified in the preamble that the final rule was not specifying the size of the participant advisory committee but that we expected each committee to be representative of the size and population of the PACE organization's participants.

The requirements at SEC Per SEC These participant representatives act in part as a liaison of the participant advisory committee to the PACE organization governing body and the participant advisory committee, presenting issues from the participant advisory committee to the governing body. The link between the participant advisory committee and the governing body helps to elevate issues raised by participants to PACE organization leadership.

Medicaid managed care plans that cover long-term services and supports LTSS are also required to solicit active member and other stakeholder input through the use of a member advisory committee. Recognizing that stakeholder engagement is an important member protection and is critical to the success of Medicaid managed LTSS programs, CMS requires certain Medicaid managed care plans providing LTSS to establish and maintain a member advisory committee.

Per 42 CFR The committee must include at least a reasonably representative sample of the LTSS population, or other individuals representing those members, covered under the contract with the Medicaid managed care plan. CMS designed this requirement in a way that gives managed care plans covering LTSS flexibility to work with their stakeholder communities to establish the most effective member engagement process.

We believe that the establishment and maintenance of an enrollee advisory committee is a valuable beneficiary protection to ensure that enrollee feedback is heard by D-SNPs and to help identify and address barriers to high-quality, coordinated care for dually eligible individuals. Therefore, we propose at SEC We also propose at SEC We propose to establish the new paragraph at SEC We believe that a requirement for an MA organization offering one or more D-SNPs to establish one or more enrollee advisory committees is not inconsistent with either the Part C statute or administration of the MA program.

While current law does not impose such a requirement, our experience with existing requirements for MMPs and PACE demonstrates that the use of advisory committees improves plans' ability to meet their enrollees' needs by providing plans with a deeper understanding of the communities the plans serve and the challenges and barriers their enrollees face, as well as serving as a convenient mechanism to obtain enrollee input on plan policy and operational matters.

Our experience also suggests that advisory committees complement other mechanisms for enrollee feedback--such as surveys, focus groups, and complaints--with most advisory committees featuring longer-term participation by enrollees who can share their lived experiences while also learning how to best advocate over time for broader improvements for all enrollees.

We believe the performance of all D-SNPs would benefit from this new requirement. Further, this requirement would be consistent with the existing requirement at SEC While we describe the proposed advisory committee at SEC We believe that D-SNPs should work with enrollees and their representatives to establish the most effective and efficient process for enrollee engagement.

We expect the evolution and adoption of telecommunications technology, including as experienced during the COVID public health emergency, will mean that the most effective modalities for enrollee input may change over time. Therefore, we choose not to propose Federal requirements as to the specific frequency, location, format, participant recruiting and training methods, or other parameters for these committees beyond certain minimum requirements. Further, our proposal includes flexibility for MA organizations in how they structure their enrollee advisory committee s.

Under our proposed rule, an MA organization would be able to choose between establishing one single enrollee advisory committee for one or multiple D-SNPs in that State or by establishing more than one committee in that State to meet proposed SEC Second, we propose that the advisory committee must have a reasonably representative sample of enrollees of the population enrolled in the dual eligible special needs plan or plans, or other individuals representing those enrollees.

By using the phrase "representative sample" in the regulation text, we intend D-SNPs to incorporate multiple characteristics of the total enrollee population of the D-SNP s served by the enrollee committee, including but not limited to geography and service area, and demographic characteristics. An MA organization that offers separate D-SNPs in multiple counties in a State could decide to convene one enrollee advisory committee to solicit feedback across the membership of all these D-SNP plans as long as that committee's participants reasonably represent the totality of the D-SNP membership.

The MA organization could also choose to implement a combination of the aforementioned approaches, such as establishing an enrollee advisory committee that solicits enrollees from a D-SNP offered in one county and establishing an enrollee advisory committee with enrollees representing D-SNPs offered in more than one county. For example, a MA organization that offers separate D-SNPs in Broward , Hillsborough , and Orange counties in Florida could establish one enrollee advisory committee that convenes membership representative of these distinct regions of Florida via virtual communications methods, or it could establish separate enrollee advisory committees in each county, or it could implement some combination of these approaches.

Similarly, for MA organizations that offer separate D-SNPs serving full-benefit dually eligible individuals and partial-benefit dually eligible individuals in the same State, proposed SEC Ensuring that the enrollee advisory committee is representative of the covered population of the D-SNP s that are served by the committee is key to achieving the goals of requiring an enrollee advisory committee. Finally, we propose that the advisory committee must, at a minimum, solicit input on ways to improve access to covered services, coordination of services, and health equity among underserved populations, which is a CMS priority aligned with Executive Order on Advancing Racial Equity and Support for Underserved Communities Through the Federal Government January 20, Section The proposed regulation permits an organization that operates a D-SNP that is affiliated with a Medicaid managed care plan to use one enrollee advisory committee to meet both the requirement under SEC In other circumstances, it may not be feasible for an organization to operate a single enrollee advisory committee that meets the requirements of our proposal and SEC Those organizations would need to operate multiple enrollee advisory committees.

Our experience with MMPs establishing and maintaining enrollee advisory committees demonstrates that these plans have found the committees useful and carefully consider feedback provided by enrollees to inform plan decisions without prescriptive Federal requirements for the committees. As a result, we are not proposing specific prescriptive requirements for how D-SNPs must interact with and use these enrollee committees.

However, we solicit comments on our proposal, including whether we should include more prescriptive requirements on how D-SNPs select enrollee advisory committee participants, training processes on creating and running a successful committee, the responsibilities of the enrollee advisory committees, and additional topics for enrollee input, and whether we should limit the enrollee advisory committee proposed at SEC We also solicit comments on whether our approach to allow MA organizations to meet the requirements in proposed [Sec.

As we learn about the implementation experiences of these committees, if proposed SEC Section f 5 A ii I of the Act requires each SNP to conduct an initial assessment and an annual reassessment of the individual's physical, psychosocial, and functional needs using a comprehensive risk assessment tool that CMS may review during oversight activities, and ensure that the results from the initial assessment and annual reassessment conducted for each individual enrolled in the plan are addressed in the individual's individualized care plan.

The following are examples of actions that CMS has taken since to address social risk through the identification and standardization of screening for risk factors:. Specifically, CMS encouraged the use of elements that identify the medical, functional, cognitive, psychosocial and mental health care needs of enrollees.

Section B b 1 of the Act requires, in part, that the Secretary require certain post-acute care PAC providers to submit standardized patient assessment data with respect to certain categories of data.

CMS finalized several standardized patient assessment data requirements, including on social determinants of health. The AHC Model, which is being tested under section A of the Act, tests whether systematically screening for health-related social needs and referrals to community-based organizations to resolve identified unmet needs will improve healthcare utilization and reduce costs.

Over a five-year period, organizations implementing the AHC Model, known as Bridge Organizations, are screening community-dwelling Medicare and Medicaid beneficiaries to identify their health-related social needs and providing navigation assistance to connect those beneficiaries with community services.

The tool asks 10 standardized questions that identify a patient's HRSNs in five core domains: Housing instability, food insecurity, transportation problems, utility help needs, and interpersonal safety. Food insecurity was the most commonly reported social risk factor. Many dually eligible individuals contend with multiple social risk factors such as food insecurity, homelessness, lack of access to transportation, and low levels of health literacy.

We believe requiring SNPs to include standardized questions about social risk factors is appropriate in light of the impact these factors may have on health care and outcomes for the enrollees in these plans and that access to this information will better enable SNPs to design and implement effective models of care. We propose to amend SEC These questions will help SNPs gather the necessary information in order to conduct a comprehensive risk assessment of each individual's physical, psychosocial, and functional needs as required at SEC Rather than include the specific questions in regulation text, we propose that the questions be specified in sub-regulatory guidance.

This would afford us some flexibility to modify questions to maintain consistency with standardized questions that are developed for other programs while still providing MA organizations with clear requirements; we intend to provide ample notice to MA organizations of any changes in the questions over time. While we are proposing that the regulation text specify that the wording of individual questions would be established through sub-regulatory guidance, we provide here examples of the questions on these topics used in other Medicare contexts to provide better context on the proposed requirement and to solicit public comment.

Some people have made the following statements about their food situation. Within the past 12 months, you worried that your food would run out before you got money to buy more. Pediatrics, 1 , Within the past 12 months, the food you bought just didn't last and you didn't have money to get more.

Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living? Our proposal would result in SNPs having a more complete picture for each enrollee of the risk factors that may inhibit accessing care and achieving optimal health outcomes and independence.

We believe that these questions are sufficiently related to and provide information on enrollees' physical, psychosocial, and functional needs to be appropriate to include the HRA. Having knowledge of this information for each enrollee would better equip MA organizations to develop an effective plan of care for each enrollee that identifies goals and objectives as well as specific services and benefits to be provided.

Our proposal would also equip SNPs with person-level information that would help them better connect enrollees to covered services for example, non-emergency medical transportation, when capitated by Medicaid or covered as a supplemental benefit and to social service organizations and public programs that can help resolve housing instability, food insecurity, transportation needs, or other challenges.

Coordinating care along these lines is consistent with the obligations under SEC We are not explicitly proposing that SNPs be accountable for resolving all risks identified in these assessment questions, but SEC Results of the HRAs do not require SNPs to provide housing or food insecurity supports, but having the results means that SNPs would need to consult with enrollees about their unmet social needs, which may include homelessness and housing instability, for example, in developing each enrollee's care plan.

For example, a SNP may make a referral to an appropriate community partner, consistent with the individual's goals and preferences, to assist in meeting these needs.

The SNP may also adapt communication methods to fit the individual's circumstances and take steps to maximize access to covered services that may meet the individual's needs and preferences, especially for supplemental benefits that may help with housing instability, food insecurity, or transportation. By standardizing certain data elements, our proposal would make those data elements available for collection by CMS from the SNPs for all enrollees. While we continue to consider whether, how, and when we would have the SNPs actually report data to CMS, we believe having such information could help us to better understand the prevalence and trends in certain social risk factors across SNPs and further consider ways to support SNPs in promoting better outcomes for their enrollees.

We believe standardizing these data elements could also eventually facilitate better data exchange among SNPs such as when an individual changes SNPs. We understand that some States may separately require that Medicaid managed care plans collect similar information, potentially creating inefficiencies and added assessment burden on dually eligible individuals who are asked similar, but not identical information, in multiple HRAs.

We believe that the benefit gained by all SNPs having standardized information about these social risk factors outweighs this potential risk. These questions build on other work across CMS.

Where States are interested in requiring assessment questions, we recommend that States consider conforming to the standardized questions we implement for use under this proposed rule and, for integrated care programs, ensuring that plans do not need to ask the same enrollees similar or redundant questions. However, we also seek input from States about what questions they are using and how we can best minimize assessment burden while ensuring that SNPs and States are capturing actionable information on social risk factors.

We are considering several alternatives to our proposal. We believe these would provide valuable insight but are not proposing to require HRAs to include standardized questions in these areas out of parsimony. We focused on the proposed areas since there is a large evidence base suggesting they have a particularly significant influence on the physical, psychosocial, and functional needs of the enrollees.

Our proposal would not preclude SNPs from asking additional questions related to these areas as long as the minimum standardized questions specified in CMS sub-regulatory guidance pursuant to the regulation are included as part of the HRA.

Housing instability and food insecurity as barriers to health care among low-income Americans. J Gen Intern Med. Submit it to Medicare using the online complaint form. Get information on how to file an appeal for a coverage or payment decision. Learn where and how to report suspected Medicare fraud, errors, or abuse.

For questions about billing or other information, contact Medicare by phone or mail. Review this chart showing Medicare costs for If you do not enroll in Medicare Part B when you're first eligible and decide to enroll later, you'll pay a penalty for as long as you're enrolled in Part B. You do not need to sign up for Medicare each year. But each year, you will have a chance to review your coverage and change plans.

Learn more about your plan and benefits by creating a myMedicare. Part D of Medicare is an insurance coverage plan for prescription medication. Five-star ratings Five-star ratings are one way to determine if a Medicare plan is right for you. Ratings are based on several factors like quality, overall performance, customer service, and more. Each plan is ranked 1 to 5, with 5 being the highest score. Medicare plan compare tool The Medicare plan compare tool is another great tool that allows you to browse plans in your area.

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