Medicare Part D is the prescription drug benefit added to Medicare
in 2006. It was created through the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) and provides elderly and disabled people on Medicare access to prescription drug coverage from private prescription drug plans. As of June 2011, approximately 1.5 million rural Medicare beneficiaries were enrolled in Medicare Advantage. Rural Medicare Advantage enrollment was composed of 46% in PPO plans, while private fee-for-service enrollment fell to just over 16% of the market.
Sources
June 2011: Rural Medicare Advantage Enrollment Update, September 2011, RUPRI Center for Rural Health Policy Analysis
Related Guides
Frequently Asked Questions
Tools
2012 Medicare Health and Drug Plans by State
Web site
Presents a page for each state containing fast facts, important dates, number of plans, and data regarding plan costs and coverage.
CMS Pharmaceutical, Pharmacy, & Device Manufacturers Open Door Forums
Technical assistance
Provides information on a series of CMS forums addressing pharmacy issues. Includes call-in instructions, how to register for the mailing list, and links to pharmacy-related fact sheets.
Extra Help With Medicare Prescription Drug Plan Costs
Web site
Provides resources for Medicare beneficiaries who may qualify for the Medicare Prescription Drug Plan Extra Help program.
Medicare Advantage: National and State Enrollment Tables and Maps
Web site
A listing of tables and maps identifying enrollment in Medicare Advantage and other prepaid plans by state. Tables 3, 4, and 5 show rural by state.
Medicare Health and Prescription Drug Plan Tracker
Web site
Consists of an interactive tool which provides information about private plans participating in the Medicare Advantage program and the Medicare prescription drug program. Includes national statistics specific to rural areas.
Medicare Plan Finder
Web site
Online tool for identifying and enrolling in Medicare drug and health plans. Includes information about plans available in each state. Text also available in Spanish.
Medicare Prescription Drug Coverage - General Information
Web site
Provides links to information on the Medicare prescription drug benefit. Includes prescription drug benefit pharmacy training information.
Medicare State Health Facts
Web site
Provides current data about states' aged and disabled Medicare beneficiaries, Medicare Prescription Drug Plans, and Medicare Advantage such as enrollment, demographics (such as age, gender, race/ethnicity), spending, other sources of health coverage, managed care participation, and use of services.
Medicare.gov (English)
Database
Provides a searchable website on a host of Medicare related resources: The four parts of Medicare, Medicare basics, applying online for Medicare, enrolling in a prescription drug plan, ordering a Medicare replacement card, finding a doctor, and comparing hospitals and nursing homes.
Medicare: Part D Prescription Drugs
Web site
Includes a summary as well as documents on Medicare Part D and Medicare Advantage.
MedlinePlus: Medicare Prescription Drug Plan
Web site
Presents links to resources, tools, and news related to the Medicare Prescription Drug Plan (Part D).
Number of Medicare Prescription Drug Plans (PDPs), 2012
Web site
Presents the number of Medicare Prescription Drug Plans by state or region from 2006-2012.
Rural Health Research: Medicare Part D
Web site
Provides summaries of current and completed rural health research projects and related publications addressing the topic of Medicare Part D, produced by the Office of Rural Health Policy's funded rural health research centers.
Regulations, Forms & Other Useful Documents
2013 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter
Sponsoring organization: Centers for Medicare and Medicaid Services
Provides information for health plans regarding how to implement CMS policies and procedures and comply with critical program requirements for the 2013 contract year. Includes detailed information on the Medicare Advantage (Part C) and prescription drug (Part D) programs.
Date: 04 / 2012
Basics: Medicare Drug Benefit (Part D)
Author(s): Mary Ellen Stahlman
Sponsoring organization: National Health Policy Forum
Provides an overview of the Medicare Drug Benefit (Part D).
Date: 01 / 2011
Basics: Medicare Drug Benefit Coverage Gap
Author(s): Mary Ellen Stahlman
Sponsoring organization: National Health Policy Forum
Describes the coverage gap within the Medicare prescription drug benefit (Part D), known as the "donut hole," and its impact on beneficiaries. Describes the provisions in the Patient Protection and Affordable Care Act of 2010 (PPACA) that will fill in this gap in coverage by 2020.
Date: 02 / 2011
Effect of Medicare Part D Plan Switching and Formulary Changes on Sole Community Pharmacies and the Patients They Serve
Author(s): Michelle Lampman, Andrea Radford, Anh Nguyen
Sponsoring organization: North Carolina Rural Health Research and Policy Analysis Center
Presents findings from a 2008 survey of 401 pharmacist-owners of sole community independent pharmacies.
Date: 03 / 2010
Eligible But Not Enrolled? Potential for Targeting Over a Half-Million Rural Medicare Beneficiaries for Enrollment in the Low-Income Subsidy Prescription Drug Program (Policy Brief)
Author(s): Timothy D. McBride, Keith J. Mueller
Sponsoring organization: RUPRI Center for Rural Health Policy Analysis
Discusses the Medicare Part D low-income supplement (LIS), which is designed to help low-income persons access the prescription drug benefit with reduced premiums and lower out-of-pocket costs.
Date: 12 / 2008
Explaining Health Care Reform: Key Changes to the Medicare Part D Drug Benefit Coverage Gap
Sponsoring organization: Kaiser Commission on Medicaid and the Uninsured
Discusses several key changes to the Medicare Part D drug benefit as a result of the health reform law to reduce Part D enrollees’ out-of-pocket liability when they reach the coverage gap, known as the “doughnut hole”.
Date: 03 / 2010
Fact Sheet: The Medicare Prescription Drug Benefit
Sponsoring organization: Kaiser Family Foundation
Provides information and data about the Medicare Drug Benefit, including 2012 plan information, a breakdown of the standard benefit, updates on additional low-income assistance, and enrollment data.
Date: 11 / 2011
February 2010: A Dramatic Shift Away from Private Fee-for-Service Plans in Rural Medicare Advantage Enrollment
Author(s): Leah Kemper, Timothy D. McBride, M. Katherine Stone, Keith Mueller
Sponsoring organization: RUPRI Center for Rural Health Policy Analysis
Discusses the 2010 decline in private fee-for-service (PFFS) enrollment in rural areas and as a result, Medicare Advantage (MA) enrollment in those areas (excluding other prepaid plans) fell slightly in early 2010 for the first time in years.
Date: 03 / 2010
Information Partners Can Use On: Medicare Drug Coverage under Medicare Part A, Part B, and Part D
Sponsoring organization: Centers for Medicare and Medicaid Services
Provides an overview of drug coverage under Medicare Part A (Hospital Insurance), Medicare Part B (Medical Insurance), and Medicare Part D (Medicare prescription drug coverage).
Date: 01 / 2011
June 2011: Rural Medicare Advantage Enrollment Update
Author(s): Leah Kemper, Lisa Pollack, Abigail Barker, Timothy D. McBride, Keith J. Mueller
Sponsoring organization: RUPRI Center for Rural Health Policy Analysis
Shows increases in enrollment into Medicare Advantage plans in rural America. The enrollment is concentrated in plans offered by three firms, especially in the types of plans with high rural enrollment which are preferred provider organizations and private fee-for-service plans.
Date: 09 / 2011
Medicare & You: 2012
Sponsoring organization: Centers for Medicare and Medicaid Services
Highlights what's new, what's covered, health plans, prescription drug plans, and consumer rights.
Date: 12 / 2011
Medicare Advantage 2011 Data Spotlight: Plan Availability and Premiums
Sponsoring organization: Kaiser Family Foundation
Presents an overview of changes made to the Medicare Advantage program and trends affecting both rural and urban populations in plan participation, premiums and certain benefits.
Date: 10 / 2010
Medicare Advantage: Fact Sheet
Sponsoring organization: Kaiser Family Foundation
Provides an overview of the Medicare Advantage program, describes program changes made by the health reform law in plan participation and beneficiary enrollment, presents data on benefits and premiums, and explains changes in Medicare payments to participating plans.
Date: 11 / 2011
Medicare Beneficiaries’ Access to Pharmacy Services in Small Rural Towns: Implications of Contracting Patterns of Sole Community Pharmacies with Part D Plans
Author(s): Victoria A Freeman, Indira Richardson, Rebecca T. Slifkin
Sponsoring organization: North Carolina Rural Health Research and Policy Analysis Center
Describes pharmacy Prescription Drug Plan (PDP) contract patterns of sole rural pharmacies. Addresses PDP enrollment choices of Medicare Part D enrollees.
Date: 01 / 2009
Medicare Part D Data Spotlight: A First Look at Part D Plan Offerings in 2012
Author(s): Jack Hoadley, Juliette Cubanski, Elizabeth Hargrave, Laura Summer, Jennifer Huang
Sponsoring organization: Kaiser Family Foundation
Examines the stand-alone Part D drug plan options available to Medicare beneficiaries in 2012. The first in a series of planned reports examining the private plan choices available to Medicare beneficiaries.
Date: 10 / 2011
Medicare Part D Prescription Drug Plan (PDP) Availability in 2012
Sponsoring organization: Kaiser Family Foundation
Contains 2012 state-specific summary data about available Medicare drug benefit options, including premium ranges, and the number of plans available at no cost to qualifying beneficiaries.
Date: 10 / 2011
Medicare Payment Basics: Medicare Advantage Program Payment System
Sponsoring organization: Medicare Payment Advisory Commission
Presents an overview of Medicare payments to Medicare Advantage (MA) plans. Includes information on Medicare Advantage regions.
Date: 10 / 2011
Medicare Payment Basics: Part D Payment System
Sponsoring organization: Medicare Payment Advisory Commission
Presents an overview of the Medicare Part D prescription drug benefit. Includes information on Medicare subsidies, Medicare payments to plans, and the calculation of enrollee premiums.
Date: 10 / 2011
MedPAC A Data Book: Medicare Part D Program, 2010
Sponsoring organization: Medicare Payment Advisory Commission
Uses charts and maps to present 2007 data on the characteristics of Medicare Part D enrollees and beneficiaries, participating pharmacies, and prescriptions dispensed. Some data is compared based on CBSA (core-based statistical area): metropolitan, micropolitan or rural.
Date: 03 / 2010
MedPAC Report to the Congress: Medicare Payment Policy, 2012
Sponsoring organization: Medicare Payment Advisory Commission
Annual review of Medicare payment policies, with recommendations to Congress. Discussions of rural aspects of Medicare payment policies are included throughout the report.
Date: 03 / 2012
MedPAC Report to the Congress: Medicare Payment Policy: Status Report on Part D: Chapter 13
Sponsoring organization: Medicare Payment Advisory Commission
Chapter 13 of the March 2011 MedPAC report. Provides a status report on Medicare Part D including Part D enrollees' access to prescription drug benefits in 2010, costs, measuring plan performance, and policy issues.
Date: 03 / 2011
One Year In: Sole Community Rural Independent Pharmacies and Medicare Part D (Final Report)
Author(s): Andrea Radford, Michelle Mason, Indira Richardson, Stephan Rutledge, Stephanie Poley, Keith Mueller, Rebecca Slifkin
Describes the experiences of 51 rural independently-owned pharmacies that are the sole providers of pharmacy services in their community one year after implementation of the Medicare Part D prescription drug benefit. Findings Brief
Date: 09 / 2007
Rural Enrollment in Medicare Advantage: Growth Slows in 2008
Author(s): Leah Kemper, Timothy D. McBride, Keith Mueller
Sponsoring organization: RUPRI Center for Rural Health Policy Analysis
Reports that rate of growth of rural enrollment in the Medicare Advantage program decreased significantly in 2008, compared to previous years. In addition, the growth rate in preferred provider organization plans in rural areas now exceeds that in private fee-for-service plans.
Date: 03 / 2009
Rural Enrollment in Medicare Part D is Growing Slowly
Author(s): Timothy D. McBride, Leah Kemper, Keith Mueller
Sponsoring organization: RUPRI Center for Rural Health Policy Analysis
Reports that rural beneficiaries are more likely to enroll in stand-alone prescription drug plans (PDPs), while urban beneficiaries are much more likely to enroll in Medicare Advantage (MA) plans that offer prescription drug coverage (MA-PD plans).
Date: 03 / 2009
Rural Medicare Advantage 2011: Enrollment Trends and Plan Characteristics
Author(s): Leah Kemper, Lisa Pollack, Abigail Barker, Timothy D. McBride, Keith J. Mueller
Sponsoring organization: RUPRI Center for Rural Health Policy Analysis
Addresses the current and future plan, characteristics, and enrollment trends of the Medicare Advantage program specific to rural America.
Date: 10 / 2011
Organizations
Centers for Medicare and Medicaid Services (CMS)
Federal government
Operates the Medicare and Medicaid programs - two national health care programs that benefit millions of Americans. Part of the U.S. Department of Health and Human Services. Website includes access to research, statistics, and data related to their programs.
Terms & Acronyms
CMS (Centers for Medicare and Medicaid Services) Federal agency responsible for the Medicare and Medicaid programs. Part of the U.S. Department of Health & Human Services.
Enrollment Period For Medicare Part D, those already on Medicare can enroll in the drug benefit between November 15 and December 31, and coverage would be effective on January 1 of the new year. If you were first eligible to enroll before May 15, 2006 but did not sign up, you may need to pay a late enrollment penalty.
Medicare Advantage Prescription Drug Plan (MAPD) Plans that cover both drugs and other Medicare benefits, such as HMO's.
Medicare Donut Hole Also known as the Medicare Part D coverage gap, this is the difference of the initial coverage limit and the catastrophic coverage threshold. After a Medicare beneficiary surpasses the prescription drug coverage limit, the Medicare beneficiary is financially responsible for the entire cost of prescription drugs until the expense reaches the catastrophic coverage threshold.
Medicare Part A (Hospital Insurance Program) Hospital insurance that helps pay for inpatient hospital care, limited skilled nursing care, hospice care, and some home health care. Most people get Medicare Part A automatically when they turn 65.
Medicare Part B (Supplementary Medical Insurance Program) Medical insurance that helps pay for doctors' services, outpatient hospital care, and some other medical services that Part A does not cover (like some home health care). Part B helps pay for these covered services and supplies when they are medically necessary. A monthly premium must be paid to receive Part B.
Medicare Part C (Medicare Advantage) (MA) Covers Part A and B services and most prescription drugs for beneficiaries who enroll in private health insurance plans such as health maintenance organization (HMO), preferred provider organization (PPO), or private fee-for-service (PFFS) plan. These plans receive payments from Medicare to provide Medicare-covered benefits, including hospital and physician services, and in some cases, prescription drug benefits. These plans offer combined coverage of Part A, Part B, and in some cases, Part D (prescription drug) benefits.
Medicare Part D (Prescription Drug Plans) (PDPs) Provides outpatient prescription drug coverage that is delivered through private plans that contract with Medicare. The benefit includes additional assistance with plan premiums and cost-sharing amounts for low-income beneficiaries. People enrolled in Medicare drug plans pay a monthly premium. Prescription drug benefit added to Medicare in 2006. Created by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA).
Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) Legislation passed in 2003 that included significant Medicare reforms including a prescription drug benefit for Medicare beneficiaries and reimbursement improvements for rural healthcare facilities.
Medigap A Medicare supplement insurance policy sold by private insurance companies to fill gaps in Original Medicare Plan coverage.
Patient Protection and Affordable Care Act (PPACA) Is a Federal statute, signed into law on March 23, 2010. This Act, along with the Health Care and Education Reconciliation Act of 2010 (signed into law on March 30, 2010) make up the health care reform of 2010. The laws focus on reform of the private health insurance market, provide better coverage for those with pre-existing conditions, improve prescription drug coverage in Medicare, and extend the life of the Medicare Trust fund by at least 12 years.
True Out-of-Pocket Costs (TrOOP) Drug costs paid by a Medicare enrollee, or on behalf of an enrollee by a family member, charitable organization, or State Pharmacy Assistance Program.
Version D.O This is the new version of the National Council for Prescription Drug Programs (NCPDP) standards for pharmacy transactions that replaces version 5.1. Mandatory compliance date is January 1, 2012.
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