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  1. Public Part C Medicare health plans, the most popular of which are branded Medicare Advantage, are another way for Original Medicare (Part A and B) beneficiaries to receive their Part A, B and D benefits; simply, Part C is capitated fee and Original Medicare is fee for service. All Medicare benefits are subject to medical necessity.

  2. › wiki › MedicaidMedicaid - Wikipedia

    • Features
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    Beginning in the 1980s, many states received waivers from the federal government to create Medicaid managed care programs. Under managed care, Medicaid recipients are enrolled in a private health plan, which receives a fixed monthly premium from the state. The health plan is then responsible for providing for all or most of the recipient's healthcare needs. Today, all but a few states use managed care to provide coverage to a significant proportion of Medicaid enrollees. As of 2014, 26 states have contracts with managed care organizations (MCOs) to deliver long-term care for the elderly and individuals with disabilities. The states pay a monthly capitated rate per member to the MCOs, which in turn provide comprehensive care and accept the risk of managing total costs. Nationwide, roughly 80% of Medicaid enrollees are enrolled in managed care plans. Core eligibility groups of low-income families are most likely to be enrolled in managed care, while the "aged" and "disabled" eligibili...

    The Social Security Amendments of 1965 created Medicaid by adding Title XIX to the Social Security Act, 42 U.S.C. §§ 1396 et seq. Under the program, the federal government provided matching funds to states to enable them to provide Medical Assistance to residents who met certain eligibility requirements. The objective was to help states assist residents whose income and resources were insufficient to pay the costs of traditional commercial health insurance plans. The Medicaid Drug Rebate Program and the Health Insurance Premium Payment Program (HIPP) were created by the Omnibus Budget Reconciliation Act of 1990(OBRA-90). This act helped to add Section 1927 to the Social Security Act of 1935 and became effective on January 1, 1991. This program was formed due to the costs that Medicaid programs were paying for discount price outpatient drugs. The Omnibus Budget Reconciliation Act of 1993 (OBRA-93) amended Section 1927 of the Act, bringing changes to the Medicaid Drug Rebate Program....

    States may bundle together the administration of Medicaid with other programs such as the Children's Health Insurance Program(CHIP), so the same organization that handles Medicaid in a state may also manage the additional programs. Separate programs may also exist in some localities that are funded by the states or their political subdivisions to provide health coverage for indigents and minors. State participation in Medicaid is voluntary; however, all states have participated since 1982 when Arizona formed its Arizona Health Care Cost Containment System (AHCCCS) program. In some states Medicaid is subcontracted to private health insurance companies, while other states pay providers (i.e., doctors, clinics and hospitals) directly. There are many services that can fall under Medicaid and some states support more services than other states. The most provided services are intermediate care for mentally handicapped, prescription drugs and nursing facility care for under 21-year-olds. T...

    According to CMS, the Medicaid program provided health care services to more than 46.0 million people in 2001. In 2002, Medicaid enrollees numbered 39.9 million Americans, with the largest group being children (18.4 million or 46%). From 2000 to 2012, the proportion of hospital stays for children paid by Medicaid increased by 33% and the proportion paid by private insurance decreased by 21%. Some 43 million Americans were enrolled in 2004 (19.7 million of them children) at a total cost of $295 billion. In 2008, Medicaid provided health coverage and services to approximately 49 million low-income children, pregnant women, elderly people, and disabled people. In 2009, 62.9 million Americans were enrolled in Medicaid for at least one month, with an average enrollment of 50.1 million. In California, about 23% of the population was enrolled in Medi-Cal for at least 1 month in 2009–10.As of 2017, the total annual cost of Medicaid was just over $600 billion, of which the federal government...

    Unlike Medicaid, Medicare is a social insurance program funded at the federal level and focuses primarily on the older population. As stated in the CMS website, Medicare is a health insurance program for people age 65 or older, people under age 65 with certain disabilities, and (through the End Stage Renal Disease Program) people of all ages with end-stage renal disease. The Medicare Program provides a Medicare part A covering hospital bills, Medicare Part B covering medical insurance coverage, and Medicare Part D covering purchase of prescription drugs. Medicaid is a program that is not solely funded at the federal level. States provide up to half of the funding for Medicaid. In some states, counties also contribute funds. Unlike Medicare, Medicaid is a means-tested, needs-based social welfare or social protection program rather than a social insuranceprogram. Eligibility is determined largely by income. The main criterion for Medicaid eligibility is limited income and financial re...

    There are two general types of Medicaid coverage. "Community Medicaid" helps people who have little or no medical insurance. Medicaid nursing homecoverage helps pay for the cost of living in a nursing home for those who are eligible; the recipient also pays most of his/her income toward the nursing home costs, usually keeping only $66.00 a month for expenses other than the nursing home. Some states operate a program known as the Health Insurance Premium Payment Program(HIPP). This program allows a Medicaid recipient to have private health insurance paid for by Medicaid. As of 2008 relatively few states had premium assistance programs and enrollment was relatively low. Interest in this approach remained high, however. Included in the Social Security program under Medicaid are dental services. Registration for dental services is optional for people older than 21 years but required for people eligible for Medicaid and younger than 21. Minimum services include pain relief, restoration o...

    While Congress and the Centers for Medicare and Medicaid Services(CMS) set out the general rules under which Medicaid operates, each state runs its own program. Under certain circumstances, an applicant may be denied coverage. As a result, the eligibility rules differ significantly from state to state, although all states must follow the same basic framework. As of 2013, Medicaid is a program intended for those with low income, but a low income is not the only requirement to enroll in the program. Eligibility is categorical—that is, to enroll one must be a member of a category defined by statute; some of these categories are: low-income children below a certain wage, pregnant women, parents of Medicaid-eligible children who meet certain income requirements, low-income disabled people who receive Supplemental Security Income (SSI) and/or Social Security Disability(SSD), and low-income seniors 65 and older. The details of how each category is defined vary from state to state.

    During 2003–2012, the share of hospital stays billed to Medicaid increased by 2.5%, or 0.8 million stays.As of 2019, Medicaid paid for half of all births in the United States. Medicaid super utilizers (defined as Medicaid patients with four or more admissions in one year) account for more hospital stays (5.9 vs.1.3 stays), longer lengths of stay (6.1 vs. 4.5 days), and higher hospital costs per stay ($11,766 vs. $9,032). Medicaid super-utilizers were more likely than other Medicaid patients to be male and to be aged 45–64 years. Common conditions among super-utilizers include mood disorders and psychiatric disorders, as well as diabetes, cancer treatment, sickle cell anemia, sepsis, congestive heart failure, chronic obstructive pulmonary disease, and complications of devices, implants, and grafts.

    Unlike Medicare, which is solely a federal program, Medicaid is a joint federal-state program. Each state administers its own Medicaid system that must conform to federal guidelines for the state to receive Federal matching funds. Financing of Medicaid in the American Samoa, Puerto Rico, Guam, and the U.S. Virgin Islands is instead implemented through a block grant. The Federal government matches state funding according to the Federal Medical Assistance Percentages.The wealthiest states only receive a federal match of 50% while poorer states receive a larger match. Medicaid funding has become a major budgetary issue for many states over the last few years, with states, on average, spending 16.8% of state general funds on the program. If the federal match expenditure is also counted, the program, on average, takes up 22% of each state's budget. Some 43 million Americans were enrolled in 2004 (19.7 million of them children) at a total cost of $295 billion. In 2008, Medicaid provided h...

    A 2019 review by Kaiser Family Foundation of 324 studies on Medicaid expansion concluded that "expansion is linked to gains in coverage; improvements in access, financial security, and some measures of health status/outcomes; and economic benefits for states and providers." A 2021 study found that Medicaid expansion as part of the Affordable Care Act led to a substantial reduction in mortality, primarily driven by reductions in disease-related deaths. A 2018 study in the Journal of Political Economy found that upon its introduction, Medicaid reduced infant and child mortality in the 1960s and 1970s. The decline in the mortality rate for nonwhite children was particularly steep. A 2018 study in the American Journal of Public Health found that the infant mortality rate declined in states that had Medicaid expansions (as part of the Affordable Care Act) whereas the rate rose in states that declined Medicaid expansion. A 2020 JAMA study found that Medicaid expansion under the ACA was as...

  3. › wiki › MedigapMedigap - Wikipedia

    A person must be enrolled in both Part A and B of Medicare before they can enroll in a Medigap plan. Upon enrollment, Medicare enrollees become eligible for Medigap Open Enrollment. This period starts on the first day of the month one turns 65 & enrolled in Medicare Part B and lasts for 6 months.

  4. Medicare Part D, also called the Medicare prescription drug benefit, is an optional United States federal-government program to help Medicare beneficiaries pay for self-administered prescription drugs. Part D was enacted as part of the Medicare Modernization Act of 2003 and went into effect on January 1, 2006.

    • 商業模式
    • 處方集
    • 歷史
    • 市場與競爭
    • 爭議和訴訟

    在美國,醫療保險公司通常僱用第三方的管理者,協助處理藥物價格談判、保險理賠、和處方藥的配送。會運用到這種管理者的機構包括商業醫療保險計劃、雇主自辦保險計劃、聯播按醫療保險D部分計劃、聯邦僱員醫療福利計劃、和州政府僱員醫療福利計劃。PBM被設計成利用登記加入者的醫療保險計劃,把他們的集體購買力匯集,讓前述保險計劃贊助者以及個人能夠利用較低的價格獲得處方藥。PBM從零售藥房取得價格折扣,從藥廠以及郵遞藥房取得回扣,郵購藥房可在患者無須與藥劑師面對面諮詢的情況下,把處方藥品交付到患者住處。 藥物福利管理公司可從幾種途徑獲得收入。首先,他們從原始醫療保險計劃收取管理費和服務費。他們還可從藥廠那裡收取回扣。傳統的PBM不會披露處方藥的議定淨價格,他們得以使用高於淨價的公開標價(也稱為標籤價格(sticker price))出售藥品。這種做法被稱為"價差定價"。價差數字被視為商業秘密。PBM通常禁止藥房和保險公司公開談論費用和報銷金額。這種作法導致的結果是缺乏價格透明度。

    PBM為它們的客戶提供有關"架構藥物福利"的建議,並根據各種價格提供複雜的選擇給患者。這是透過構建醫療計劃涵蓋的"處方集"或特定藥物清單來達成。處方集通常分為幾個偏好的"階級",階級越低的有較高的共付額,以激勵消費者購買自己偏好階級的藥品。如果藥品沒列在處方集上,就表示消費者必須支付價目表的全額價錢來購買。為了讓藥物能夠被列入處方集裡面,藥廠通常需要向PBM支付回扣,這就會把藥品的淨價降低,但是在價目表上的標價仍保持不變。 製藥產業中的藥廠表示,為了彌補這些回扣的成本,他們被迫提高藥品價格。例如,禮來公司的總裁聲稱折扣,再加上回扣的成本,佔他們公司胰島素定價的75%。像快捷藥方之類的PBM聲稱回扣是藥廠對標價上漲的回應,而不是漲價的原因。 處方集的複雜定價結構可能會生出意想不到的後果。當保險理賠被提出的時候,患者支付的共付額是根據公開標價計算,而不是根據秘密議定後的淨價。大約有四分之一的機會,患者根據標價計算出的共付額,會比直接以現金購買的藥品總價高。然後,PBM可通過稱為"撈回(英语:clawback)"的做法把差價放進自己的口袋。消費者可選擇用現金購買藥物,但PBM在與藥房簽訂的合同中,除非消費者自己直接向藥劑師提出要求,否則禁止藥劑師主動告知消費者不用申請保險理賠,而可用較低的價格購得藥物。自2017年以來,美國已有六個州通過立法,將此類"噤聲條款(gag clauses)"視為非法。隨後,聯邦政府於2018年10月禁止私人保險設有噤聲條款,聯邦醫療保險(Medicare)也設下這種禁令,從2020年1月1日生效。

    1968年,Pharmaceutical Card System Inc.(這家公司後來更名為AdvancePCS Inc.(英语:AdvancePCS))發明塑膠藥品福利卡,成立第一家PBM。到 "1970年代,他們擔任財務中介,用書面的方式作處方藥理賠的裁定,然後到1980年代,改用電子的方式來作裁定"。:34 到1980年代後期,"隨著醫療衛生和處方藥的成本不斷的攀升",PBM已成為市場裡面一股重要的勢力。多元化藥物服務(英语:Diversified Pharmaceutical Services)(DPS)是PBM最早的營運模式之一,最早由一家名為United HealthCare(現在稱為聯合健康集團)的全國性健康維護組織所創立。:304在葛蘭素史克的前身SmithKline Beecham公司於1994年從United Healthcare購入DPS之後,這個部門在SmithKline Beecham的營運發揮出關鍵的作用,到1999年,這個DPS在美國多元化藥物服務所有的會員中,佔比達到44%。快捷藥方於1999年4月收購這個DPS,並將集團本身整合成為管理式醫療護理組織的產業中一家領先的PBM。 2002年8月,《華爾街日報》寫道,雖然PBM在1992年至2002年間"引導醫生開立便宜的藥物,尤其是大型藥廠生產的廉價學名藥",但他們也"靜悄悄地轉向" 銷售昂貴的品牌藥。 2007年,當CVS藥局收購Caremark這家公司的時候,PBM的功能"從單純地處理處方箋工作,轉到管理醫療保險計劃的藥物福利",:34 "與藥廠談判藥品的折扣",:34並提供"藥物利用審查和疾病管理"。:34PBM還建立一種處方集,用來鼓勵甚至要求"醫療計劃參與者使用處方集中首選的藥物來治療疾病"。:34到2012年,快捷藥方和CVS Caremark已從原來的分級處方集,轉變成只在處方集中單純標明排除不用的特定藥物。

    截至2004年,聯邦貿易委員會發現PBM是在一個競爭異常激烈的市場中運作。在美國,截至2013年,大部分管理式醫療護理機構的處方藥福利支出,是經由大約60個PBM處理。少有PBM是獨立組成和運營。PBM在綜合醫療系統(例如凱撒醫院或退伍軍人醫療管理局)內部運作、為零售藥房系統的一部分(例如CVS藥局,或是來愛德)、或者是保險公司的一部分(例如聯合健康集團)。但是到2016年,在美國屬於這個類別的大型PBM公司只剩不到30家,其中三家最大的PBM(快捷藥方、CVS藥局、和聯合健康集團中的OptumRx),它們共同的市場佔有率是78%,為1.8億登記加入者提供藥品保險覆蓋。。 在2015年,最大的三個上市PBM是快捷藥方,CVS藥局(以前稱為CVS Caremark)和聯合健康集團所屬的OptumRx/Catamaran。截至2018年,美國三家最大的PBM控制著超過80%的市場。

    1998年,美國司法部聯邦檢察官詹姆斯·希恩(James Sheehan)對PBM展開調查,針對這個產業是否能有效降低處方藥成本和節省客戶費用方面,提出質疑。
    2004年,訴訟事件為PBM的作為增加不確定性。 2015年,針對PBM所涉及的詐欺、騙術、或反托拉斯法行為,共有七項法律訴訟被提出。
    州立法機關一直使用"透明度"、"信任"、和"披露"條款來改進PBM的商業做法。在2011年,密西西比州藥房委員會(Mississippi Board of Pharmacy)成立一個藥物福利管理者的新部門,任務是核准以及規範PBM。
    2013年,聯邦醫療保險和聯邦醫療補助服務中心(英语:Centers for Medicare & Medicaid Services)(CMS)所做的一項研究發現,郵購藥房與PBM的議定價格比社區藥房的議定價格高出83%。
    在2014年的ERISA(《1974年僱員退休所得安全法(英语:Employee Retirement Income Security Act of 1974)》)一項聽證會中指出,垂直整合後的PBM有構成利益衝突的可能,並且PBM的醫療保險計劃贊助人(例如藥廠)"在…確定是否遵守PBM合同(包括直接和間接補償條款)的時候,碰到極大的困難。"。
  5. Aug 29, 2021 · Dewonkify – Medicare Part B. The National Law Review. 2013-11-05. ^ Medicare: Part A & B (页面存档备份,存于互联网档案馆), University of Iowa Hospitals and Clinics, 2005. ^ content ^ What is Medicare Part C?. ^ Pope, Christopher. Supplemental Benefits Under Medicare Advantage. Health Affairs. [2016-01-25].

  6. The Medicare Part D coverage gap (informally known as the Medicare doughnut hole) is a period of consumer payment for prescription medication costs which lies between the initial coverage limit and the catastrophic-coverage threshold, when the consumer is a member of a Medicare Part D prescription-drug program administered by the United States federal government.

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    Need More Coverage? We Can Help. See Your Medicare Part C Options! Top Medicare Part C Plans At Affordable Prices. Get the Coverage You Deserve. Call Now!

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