Beginning January 1, 2006, upon voluntary enrollment in either a stand-alone PDP or an integrated Medicare Advantage plan that offers Part D coverage in its benefit, subsidized prescription drug coverage. Most FDA-approved drugs and biologicals are covered. However, plans may set up formularies for their drug coverage, subject to certain statutory standards. (Drugs currently covered in Parts A and B remain covered there.) Part D coverage can consist of either standard coverage or an alternative design that provides the same actuarial value. (For an additional premium, plans may also offer supplemental coverage exceeding the value of basic coverage.) Standard Part D coverage is defined for 2006 as having a $250 deductible, with 25 percent coinsurance (or other actuarially equivalent amounts) for drug costs above the deductible and below the initial coverage limit of $2,250. The beneficiary is then responsible for all costs until the $3,600 out-of-pocket limit (which is equivalent to total drug costs of $5,100) is reached. For higher costs, there is catastrophic coverage; it requires enrollees to pay the greater of 5 percent coinsurance or a small copay ($2 for generic or preferred multisource brand and $5 for other drugs). After 2006, these benefit parameters are indexed to the growth in per capita Part D spending (see Table 2.C1). In determining out-of-pocket costs, only those amounts actually paid by the enrollee or another individual (and not reimbursed through insurance) are counted; the exception is cost-sharing assistance from Medicare’s low-income subsidies (certain beneficiaries with low incomes and modest assets will be eligible for certain subsidies that eliminate or reduce their Part D premiums, cost-sharing, or both) and from State Pharmacy Assistance Programs. A beneficiary premium, representing 25.5 percent of the cost of basic coverage on average, is required (except for certain low-income beneficiaries, as previously mentioned, who may pay a reduced or no premium). For PDPs and the drug portion of Medicare Advantage plans, the premium will be determined by a bid process; each plan’s premium will be 25.5 percent of the national weighted average plus or minus the difference between the plan’s bid and the average. To help them gain experience with the Medicare population, plans will be protected by a system of risk corridors, which allow Part D to assist with unexpected costs and to share in unexpected savings; after 2007, the risk corridors became less protective. To encourage employer and union plans to continue prescription drug coverage to Medicare retirees, subsidies to these plans are authorized; the plan must meet or exceed the value of standard Part D coverage, and the subsidy pays 28 percent of the allowable costs associated with enrollee prescription drug costs between a specified cost threshold ($250 in 2006, indexed thereafter) and a specified cost limit ($5,000 in 2006, indexed thereafter).
How to Reform Medicare: First Stage to Fix the Current Program
The significant differences in official long-term projections, including projections of the program’s unfunded liability, reflect the differences in agency assumptions, particularly about the likelihood of the continuation of current law. The Medicare Trustees and the Congressional Budget Office (CBO) are required to make projections under current law, which assumes, for example, that the large Medicare Part A payment reductions are sustainable and that the projected 29.4 percent reduction in Medicare physician payment will be implemented in 2012. The Office of the Actuary in the Centers for Medicare and Medicaid Services (CMS) makes projections based on the premise that key elements of current law are simply “unworkable.” See John D. Shatto and M. Kent Clemens, “Projected Medicare Expenditures Under an Illustrative Scenario with Alternative Payment Updates to Medicare Providers,” Centers for Medicare and Medicaid Services, Office of the Actuary, May 13, 2011, at https://www.cms.gov/ReportsTrustFunds/downloads/2010TRAlternativeScenario.pdf (September 19, 2011).
F & J Deductible Announcements
Medicare supplemental (Medigap) Plan F can be sold with a high deductible option. Before June 1, 2010, Medigap Plan J could also be sold with a high deductible. Effective January 1, 2016, the annual deductible amount for these two plans is $2180, the same amount as for 2015. The deductible amount for the high deductible version of plans F and J represents the annual out-of-pocket expenses (excluding premiums) that a beneficiary must pay before these policies begin paying benefits. CMS updates the deductible amount for plans F and J each year, after release of the August Consumer Price Index for all Urban Consumers (CPI-U) figures by the Bureau of Labor Statistics, which generally occurs in mid-to late September.
What’s in Store for Medicare’s Part B Premiums and Deductible in 2016, and Why?
The absence of a COLA affects the amount of the Medicare Part B premium charged to enrollees because it triggers the broader application of a provision in the Social Security law known as the hold-harmless provision. In a year where the Social Security COLA is insufficient to cover the amount of the Medicare Part B premium increase for an individual, the law prohibits an increase in the Part B premium that would result in a reduction in that individual’s monthly Social Security benefits from one year to the next. (For an example of how the hold-harmless provision works in a typical year with a Social Security COLA, see Appendix B.) The hold-harmless provision affects a different number of beneficiaries each year, depending on the level of their Social Security benefits, the size of the COLA, and the increase in the Medicare Part B premium. In years with no COLA, a majority of beneficiaries are protected by the hold-harmless provision.
Medicare Fee, Payment , Reimbursement Procedure code, ICD, Denial: October 2011
Eligible professionals do not have to enroll or file an intent to participate in the eRx Incentive Program. Professionals who choose to participate by reporting the eRx measure through claims can simply report the G-code on service lines of Medicare Part B Physician Fee Schedule (PFS) professional-services claims. Beginning with the 2010 eRx Incentive program year, eligible professionals may also qualify to earn an eRx incentive by reporting the eRx measure to a qualified registry. Professionals participating in a registry that self-nominates and qualifies to submit data on behalf of eligible professionals for a particular program year should expect to receive more information from the registry on how to participate. Only registries qualified for the Physician Quality Reporting System are eligible to become qualified for purposes of submitting data on the eRx measure on behalf of eligible professionals. In addition to the claims-based reporting mechanism and the registry-based reporting mechanism, CMS tested electronic health record (EHR) data submission, in cooperation with EHR vendors. After successful completion of the 2009 Physician Quality Reporting System EHR Testing Program and a determination that there was at least one “qualified” EHR vendor, an eligible professional may potentially be able to earn an eRx incentive payment through the EHR-based reporting mechanism beginning with the 2010 eRx Incentive Program (if the eligible professional is using one of the EHR products that CMS “qualified” in its 2009 Physician Quality Reporting System EHR Testing Program). Only an EHR vendor that is qualified for the Physician Quality Reporting System is eligible to become qualified for purposes of an eligible professional being able to earn an eRx incentive through submission of eRx measure data extracted from a qualified EHR product. NEW! CMS Is Now Accepting Public Comment on Proposed 2012 Physician Quality Reporting System EHR Measure Specifications The Centers for Medicare & Medicaid Services (CMS) is now accepting public comment on proposed Electronic Health Record (EHR) Measure Specifications under consideration for possible inclusion in the 2012 eRx Incentive Program for future program years. 2010 eRx Incentive Program As described in the 2010 Medicare PFS final rule (to view the rule, click on the “Statute/Regulations” link at left), CMS retains the claims-based reporting mechanism. In addition, CMS will accept eRx measure data submitted by a qualified registry on behalf of an eligible professional or eRx measure data extracted from a qualified EHR product. Since only EHR products that are qualified for the Physician Quality Reporting System are eligible to become qualified for the eRx Incentive Program, this was contingent upon the successful completion of our 2009 Physician Quality Reporting System EHR Testing Program, a determination that one or more EHR vendors participating in the 2009 Physician Quality Reporting System EHR Testing Program was “qualified,” and one or more qualified Physician Quality Reporting System EHR vendors notified us of their desire to have one or more of their products qualified for purposes of the 2010 eRx Incentive Program. Registry-Based Submission for 2010 Incentive To qualify to submit eRx measure data on behalf of eligible professionals seeking eRx incentive payments for 2010, registries must be qualified to submit 2010 Physician Quality Reporting System data on behalf of eligible professionals. To become qualified to submit 2010 Physician Quality Reporting System data on behalf of eligible professionals, and thus, be eligible to become qualified to submit 2010 eRx measure data on behalf of eligible professionals, registries are required to go through a self-nomination and vetting process if they are new to Physician Quality Reporting System registry reporting, or to notify CMS of their desire to continue Physician Quality Reporting System data submission in 2010 if they were qualified in 2009 and successfully submitted their users’ quality data. To become qualified, registries must meet certain technical and other requirements specified by CMS. The document “Registry Requirements for Submission of 2010 Physician Quality Reporting System Data on Behalf of Eligible Professionals” describes the high-level requirements for a registry to qualify to submit under the registry-based reporting alternatives for the 2010 Physician Quality Reporting System. This document also outlines how a registry can become qualified for 2010 Physician Quality Reporting System data submission. Any registry that wants to report the eRx measure for the 2010 eRx Incentive Program also will have to follow the requirements contained in this document. This document provides the data submission specifications for registry-based reporting to be utilized by the qualified registries. An updated list of registries that have become “qualified” to submit quality data to CMS on behalf of their eligible professionals for 2010 Physician Quality Reporting System. This list consists of qualified registries for the 2008 and 2009 Physician Quality Reporting System that have successfully submitted 2008 Physician Quality Reporting System data on behalf of eligible professionals to us and that have notified us of their desire to submit 2010 eRx measure data on behalf of eligible professionals. Additional registries were added to the list of qualified registries for the 2010 eRx Incentive Program upon completion of the 2010 registry self-nomination process. The self-nomination process to qualify additional registries for the 2010 eRx Incentive Program was completed during summer 2010. EHR-Based Submission for 2010 Incentive To qualify to submit eRx measure data on behalf of eligible professionals or group practices seeking eRx incentive payments for 2010, EHR vendors must be qualified to report 2010 Physician Quality Reporting System EHR measures. In early 2010, CMS finished vetting EHR vendors that self-nominated to participate in the 2009 EHR Testing Program. EHR vendors that successfully completed the 2009 EHR Testing Program are qualified to report 2010 Physician Quality Reporting System EHR measures and may potentially be qualified to report the 2010 eRx measure. A list of qualified EHR vendors for the 2010 eRx Incentive Program is posted here. Qualified Electronic Health Record (EHR) Vendors for 2010 Physician Quality Reporting System and Electronic Prescribing Incentive Programs An updated list of EHR vendors and their programs that have become “qualified” to submit quality data to CMS by eligible professionals 2010 Physician Quality Reporting System reporting. Each of these EHR vendors has gone through a thorough vetting process for the product and version listed including checking their capability to provide the required Physician Quality Reporting System data elements for 10 Physician Quality Reporting System measures. Some EHRs are also capable of reporting the electronic prescribing measure. In addition to capturing the required data elements for the measure calculation, these “qualified” EHR products can also transmit the required information in the requested file format. While the listed EHR vendors and their EHR products have successfully completed the vetting process, CMS cannot guarantee that any other product or version of software from the listed vendors will be compatible for EHR based submission for Physician Quality Reporting System. Additional 2010 EHR products that passed “qualification” were posted by mid-January 2010. 2011 eRx Incentive Program EHR-Based Submission for 2011 Incentive To qualify to report the eRx measure for 2011, EHR vendors will need to be qualified to report 2011 Physician Quality Reporting System EHR measures. EHR vendors who wish to qualify to participate in the 2011 Physician Quality Reporting System EHR program must have submitted a self-nomination letter requesting inclusion in the 2011 Physician Quality Reporting System Testing Process in 2010 by no later than January 31, 2010. The 2011 Physician Quality Reporting System EHR vendor qualification process and requirements for the 2011 Physician Quality Reporting System EHR Testing Process are described in the “Requirements for EHR Vendors to Participate in the 2011 Physician Quality Reporting System EHR Program”. Any EHR vendor that wants to report the eRx measure for the 2011 eRx Incentive Program also will need to have followed the requirements contained in this document.