Talk:Medicare Part D

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medicareadvocacy.org links

The http://www.medicareadvocacy.org/ links are all broken.

What is a formulary?

  • EOM
  • The best article currently on wikipedia explaining a formulary is British National Formulary, which is not that great and obviously is specific to England. A formulary is a list of drugs that one specific plan through a specific provider will cover. Medicare D has a formulary and then the different providers can cover a percentage of that - usually about the low 70% range on the very low end all the way up to 100% (with restrictions of course) in the case of certain plans available through Humana and AARP-United and a few others. Does that answer your question?--Hraefen 17:44, 21 February 2006 (UTC)[reply]
Part D does not have a formulary. A formulary includes an explicit schema detailing exactly what drugs are covered, and under what conditions, including such things as cost sharing level (copay). Part D coverage instead has interpretative exclusionary regulations, based in US law, which some have mistakenly described as a formulary. As an example of efforts to make clear that there is no formulary legally authorized for Part D, the legislation recently passed by the US House as "H.R. 4 - Requiring Medicare to Negotiate Lower Prescription Drug Prices" as part of the Speaker Nancy Pelosi's 100-Hour Plan explicitly states that the bill does not authorize HHS to establish or require a particular formulary.[1] There would be no need for this wording if a formulary currently existed. However the individual plans do establish their own formularies, within certain restrictions governed by CMS. -- 12.106.111.10 23:23, 1 February 2007 (UTC)[reply]

I wonder about the neutrality of this page

Although there is an entire section dedicated to the implementation issues of Medicare Part D, there is no section reporting on the progress it has made or the possible advantages it may have (projected costs, although initially higher, have been estimated to be lower as of late, impacting possible clawback rates). Of course, state-sponsored dogma such as Secretary Leavitt's frequent Part D updates is undesirable, but the future of the plan is very much in question and there are arguments for how it may outperform other nations' prescription drug benefits (as well as those mentioned in this article for how it may ultimately fail). In the next few weeks, I will endeavor to unfold some of these arguments, but if anybody is an expert in the area, they could help flesh out this description. Poa02003 16:40, 11 July 2006 (UTC)[reply]

The total number of participants does not add up. "31.8 million in Medicare, 5.4 million other sources." The total number is supposed to add up to 38.2 million. But my math says that 31.8 + 5.4 = 37.2. My knowledge in health care is not as good as my math knowledge so can someone find the correct numbers and make proper adjustments please. Thank you. Goadhatesmyspace 00:27, 13 February 2007 (UTC)[reply]

From Plans Available: "It is also important to note that relatively few people as a percent of the total number of people on Medicare are ever financially affected by either the donut hole or catastrophic phases of spending." Not only is this not sourced but it's nonsense. The donut hole badly affects about five million (https://www.kff.org/medicare/issue-brief/closing-the-medicare-part-d-coverage-gap-trends-recent-changes-and-whats-ahead/) out of the 44 million on Medicare, which is why there have been efforts to close the hole, and nobody gets badly financially affected by the catastrophic phase because at that phase you pay the smallest amount. This is biased nonsense. 154.3.44.73 (talk) 18:14, 18 January 2021 (UTC)[reply]

Dual Eligible

Can anyone direct me to info that claims duals can move plans monthly? This has not been my experience as I handle Part D for a fortune 500 company.EmDeeEm 23:49, 12 September 2006 (UTC)[reply]

I can't find a citation unfortunately, but our Part D enrollment director tells me that fully subsidized individuals can can plans as often as once a month with no real limitations. LIS folks who are not fully subsidized can only change once a year. Again, apologies for the lack of a cite, but she forwarded on some examples that emperically showed that it can happen. (Though given what we've seen from CMS, this could be a quirk rather than policy...) Jargent 13:49, 21 November 2006 (UTC)[reply]

I work for a Medicare Health Benefit provider as a work contect specialist. Individuals who are dual elegible recieve a Special Election Period, that allows them to change services as often as they like for as long as they are dual eligible, see this excerpt:

Medicare Managed Care Manual Chapter 2 - Medicare Advantage Enrollment and Disenrollment 30.4.4 - SEPs for Exceptional Conditions (Rev. 66, Issued: 08-05-05, Effective: 08-05-05)

5. SEP for Dual-eligible Individuals or Individuals Who Lose Their Dual-eligibility - There is an SEP for individuals who are entitled to Medicare Part A and Part B and receive any type of assistance from the Title XIX (Medicaid) program including full-benefit dual eligible individuals, as well as those eligible only for the Medicare Savings Programs (QMB-only , SLMB-only, and QI). This SEP lasts from the time the individual becomes dually-eligible and exists as long as they receive Medicaid benefits. The effective date of an election made using this SEP would be dependent upon the situation. In addition, MA-eligible individuals who are no longer eligible for Title XIX benefits have a 3-month period after the date it is determined they are no longer eligible to make an election. Rick (Humana)

Donut hole

Medicare spells it "donut hole" here. Perhaps we might be consistent with the name the government is using? --Chrispounds 20:22, 17 November 2006 (UTC)[reply]

I love to ignore the term in most cases as replace it with "coverage gap", which Chrispounds has done. It needs to be in there somewhere so people can find it while searching, but do(ugh?)nut hole is one of those terms that CMS only reluctantly uses. (You'll only find one other donut reference on the medicare site, while Coverage Gap appears 500+ times.) As for which one is "correct", the two are interchangable, and both valid. You could probably make an argument for using both so the article will pop up on either search term. In all, I don't think it matters much. -- Jargent 13:44, 20 November 2006 (UTC)[reply]

Also, FYI, I've created a Donut Hole (Medicare) stub page. I can see arguments for keeping/merging that info into the main Medicare page, but I think it's a term with enough life to get a page of its own. The link is also on the Doughnut (disambiguation) page. Have fun with that one.  ;) Jargent 14:14, 20 November 2006 (UTC)[reply]

Missinformation?

Perhaps it's against my better judgement, but I'd like to mention that I work for Aetna Inc. The literature we've been trained on states that medicare maintains a formulary list and that legally all part d carriers must conform to this list. Several of the customers I’ve spoken to disagree with this & so does this article. Looking at the reference cited (ref 13) I can’t find any place where it’s directly stated otherwise, though the wording seems to suggest it indirectly. Does anyone have a more direct reference for this piece of information?

Try the CMS part D PDP finder. Search for a few common drugs and look at a few of the plans links, it will tell you if they cover the drug or not. for most drugs, some will, others will not. does that answer your question? Pdbailey (talk) 03:31, 9 April 2008 (UTC)[reply]

Losing encyclopedic tone?

I think some of the recent (April 7-9, 2007) edits by Nbauman contain some interesting information, but I think they also turn the Wikipedia entry into an Anti-Medicare Part D propaganda piece. For instance, the first line of the Program Specifics heading is now a quote about how confusing the options are. I have no issue with putting attributed quotes about problems with Medicare in the Criticisms section, but the latest additions compromise NPOV. I'm going to tag the article as such for now until we get a better edit.

Let me be clear, I support keeping a lot of the added information in the article, but would prefer a more objective reading in the body, limiting criticisms to the criticisms section. Another example: The number of members enrolled in Medicare Part D is fairly objective. The fact that the vast majority of those members did not enroll voluntarily is relevant, but I feel it should be in a separate section. Happy to challenged here. Jargent 16:37, 11 April 2007 (UTC)[reply]

Medicare Advantage Perscription Plan

While they are certainly related sounding plans, medicare part D is different than the perscription plans provided under the medicare advantage plans. 75.132.36.150 15:15, 12 August 2007 (UTC)[reply]

Other resources

I want to discuss this in Talk first before deleting those links again.

King Vegita said, "partial rv. I checked those two sites desparately to find them selling something, both are offering free advice. There is no justification to delete them.)"

First, if you check Patient's Digest more carefully, you'll see that they have advertising. There was an ad for Lipitor on the home page when I last looked at it.

Second, more generally, there are thousands of web sites that offer help with Medicare Part D. Why should we recommend those two? In Wikipedia terms, I would ask, why is this source of information WP:NOTABLE? Neither of these 2 web sites is notable -- certainly not in comparison to the Kaiser Foundation and all the others.

I use the http://www.hon.ch/HONcode/Conduct.html principles. One of the principles is full financial disclosure -- the web site has to tell you where they get their money from. Many web sites are run by drug companies, or other medical companies that are trying to promote their products and services. If they don't at least disclose that, they're unethical, and I will delete the links.

In particular I look at the About Us box, to see who's running the web site and why. For example, http://www.patientsdigest.com/content/about.php shows that they're run by a pharmaceutical communications company. Drug companies are entitled to promote their products, but you can't expect a salesman to be objective.

Same with http://www.medicaresaver.com/home/index.htm. Who are these guys? They don't even say. They violate the HON principles by not disclosing their funding sources, among other things.

How do you know they're objective? How do you know they're reliable? You don't.

Basically it comes down to WP:NOTABLE. They're two sites that are not distinguished in any way, that have nothing objective to recommend them, and are less notable than every other site on that list. Do you know anything about them that I don't know?

Is that a good enough reason for you? Unless somebody has further objections, I'm going to delete them again. Nbauman (talk) 17:47, 22 March 2008 (UTC)[reply]

Both appeared to be run by pharmacies, who seemed interested enough in making sure that the seniors get a good deal, because they make money if the right drugs are covered. They did not seem to support any specific company or set of companies, and certainly would be better than the Kaiser foundation, which would have its own plan..... There are ads on the page for the second one, but not for their own product. That's no different than linking CNN or Google or just about any website out there unfortunately. We don't know if these two sites specifically are notable, but they would be about as notable as the CVS site, and anything other than a SHIP or Medicare's website. Since we're including those others, it doesn't seem sensical to delete the others that aren't specifically promoting. When you removed them, you called them obvious spam, whereas I did not see that they were spam, but rather some site I never heard of that seemed to meet the criteria enough that I didn't delete it when I was looking for something to delete. Now, I don't care if they stay or go, but if they go, there should be an illustrated difference between them and other sites like that or we stick to the SHIP and Medicare's site for finding plans. You may be able to do that easily, but I'm going off of what I can and cannot see without in depth research into every link listed.KV(Talk) 18:45, 22 March 2008 (UTC)[reply]
Why not do a simple search on these websites? The 10 Google resullts on medicaresaver and 22 for patientsdigest will tell you all you need to know why they don't meet WP:EL. Another way to determine notability is to check to see if notable news sources are quoting the websites or its significant contributors/owners, or if the only mentions (or highly ranked results) are junk websites or press releases picked up from PR distribution services. Flowanda | Talk 00:42, 23 March 2008 (UTC)[reply]
Point of fact: The Kaiser Family Foundation is no longer associated with Kaiser Permanente health plan, as its WP entry notes. I'm not sure about CVS, because I didn't examine it enough to know whether it's useful, but if somebody does I'd tend to go along with their judgment.
I think we need an affirmative reason to include an entry in external links. It's not enough to say, "I found this on the Internet and it looks good." It has to provide something particularly useful that we can't get anywhere else. I don't think those links meet the test. Do we have consensus? I think so. Nbauman (talk) 04:57, 23 March 2008 (UTC)[reply]

I've again removed the nn links discussed above, plus the cvs link, since it seems like basically a sales prospecting tool (at least that's what I got when I filled out the online form). I also added some modifiers to some of the other links that included commercial sponsorship (such as the Dole site). The Aging-sponsored site should also be updated to include drug company sponsorship as well. I don't particularly think these links should be removed, but just be more clear about their associations. Flowanda | Talk 17:04, 26 March 2008 (UTC)[reply]

Cost of Medicare prescription drug insurance has risen 756% in 3 years!! It is a major bait-and-switch scam.

I am an 86 year old WWII veteran (100th Infantry Division). In January 2006, my wife and I signed up for the basic Medicare Prescription Drug Insurance from Humana (one of the providers of that insurance) at a cost of $5.41 per month per person.

By January 2009, the monthly cost has risen to $41.90 per person. That is a 756 percent increase in 3 years!! That is not "free market capitalism" ... it is outright "highway robbery" !! We seniors are being abused by such despicable bait-and-switch tactics.

I believe it would be appropriate to include a discussion of the exorbitant price increase as a new section of this article. Not to do so would be a sad omission. mbeychok (talk) 21:21, 4 March 2009 (UTC)[reply]

I cannot speak to the specifics of the Humana PDP. However, the premium cost increases cited above may be due to the leveraging effect of medical inflation compared to lower or no increases in subsubsidies. For instance, assume the full cost of a drug program is $100 per month and the subsidy from the Federal Government is $95 (example only). If prescription drug inflation (including increases to utilization) is 10% increasing the cost to $110, and the subsidy increases at only 4% (example only) increasing the subsidy to $98.80, then the cost increase to the participant goes up 124% from $5 to $11.20.Jmhager (talk) 12:17, 9 February 2011 (UTC)[reply]

The total cost of the program cited here is way off from what I can see and way old

I may be wrong so please let me know but in the total cost of the program section the article states:

"In August 2008, CMS estimated that the 10-year cost of the program would be $395 billion, down from the original estimate of $634 billion."

First- the link cited (15) is dead.

Second- The number of $395 billion appears to be from the CBO projected estimate of Nov 2003 not August 2008 as the article states.

Please see this link http://www.medicalnewstoday.com/articles/28942.php

It states:

"When the law was enacted in November 2003, the Congressional Budget Office projected the 10-year cost at $395 billion."

Third- Here are other estimates from the Heritage Foundation at http://www.heritage.org/research/healthcare/bg1849.cfm

"When Congress enacted the Medicare Moderniza­tion Act (MMA) in November 2003, it relied on cost estimates by the Congressional Budget Office (CBO). The CBO estimated the 10-year cost of the drug pro­visions at $394 billion for the period 2004 to 2013.

The Centers for Medicare and Medicaid Services (CMS), the agency that runs the Medicare program, gen­erated its own estimate in 2003 and has continued to do so every year since the bill’s enactment. Though not made public until 2004, the CMS’s 2003 estimate was $534 billion for the period 2004 to 2013. In CMS’s February 2005 estimate, the 10-year price tag of the drug provision is $724 billion for the period 2006 to 2015."

Forth- The latest estimates from: BOARDS OF TRUSTEES OF THE FEDERAL HOSPITAL INSURANCE AND FEDERAL SUPPLEMENTARY MEDICAL INSURANCE TRUST FUNDS, Washington, D.C., May 12, 2009

located at: http://www.cms.hhs.gov/ReportsTrustFunds/downloads/tr2009.pdf

gives these nummbers (billions) for the projected, intermediate cost range, total expenditures for 2009 to 2018 respectively: 

    63     
    66.2     
    72.7     
    79.8     
    86.7     
    94.8     
    104.8     
    114.6     
    127.2     
    140.8

The total cost of the program from what I can see for these 10 years is $999.90 billion based on the INTERMEDIATE cost numbers.

The ten year cost went from:

2003 $395 billion 2004 $394 billion *made public in 2004 2005 $724 billion 2008 $999.9 billion *call it an even trillion over 10 years (remind you of another cost estimate)

I know this is a sliding 10 year window but there is a serious error from what I can see and the latest numbers should at least be updated.

I have never done this so any advice would be highly appreciated...

Markdart (talk) 19:10, 22 January 2010 (UTC) 1/22/10[reply]

You're using the wrong numbers to reach that result - the numbers you've cited are the total expenditures, not the amount of money coming out of general revenues. If you subtract premium payments and transfers from states, you get the actual net cost of the program, which is what all the other numbers you've cited were referring to. According to the Trustees, those numbers are:

48.5 50.7 55.5 60.8 66.1 72.4 79.9 88.2 97.4 107.8

That adds up to $727.3b over the 2009-2018 period. Leuchars (talk) 18:25, 9 February 2010 (UTC)[reply]

Proposed change to "Program costs" section

Current "Program costs" Section is:

As of January 2006, the expected per capita drug spending, reported by the Department of Health and Human services, was $2,250, making the total cost of the program $42.75 Billion.[6] This budget compares with revenues of $54 Billion for Pfizer and $48.6 Billion for Johnson & Johnson, the two largest pharmaceutical companies. Kaiser Family Foundation, estimates the 2006 costs at $37.4 billion.[2] Total costs through 2015 are estimated to be $724 billion. Some of these revenues will be provided by "clawback" of revenues currently provided to the states for Medicaid. The "clawback" is a mechanism by which federal expenditures that benefit states (specifically regarding dual eligibles) are reimbursed back to the federal government. This reimbursement starts at 90%, but then falls to 75% in 2015. Figures also depend on per capita estimates of dual eligible expenditures and the number of dual eligibles that receive benefits.

As of January 2008, total Medicare spending for prescription drug benefits was projected to drop from $40.5 billion in 2007 to $36 billion in 2008. One factor contributing to lower costs is the increased use of generic drugs.[4] Shortly after the release of the 2008 Medicare Trustees' Report,[25] the Chief Actuary testified that the 10-year cost of Medicare drug benefit is 37% lower than originally projected in 2003, and 17% percent lower than last year's projections.[26]

In August 2008, CMS estimated that the 10-year cost of the program would be $395 billion, down from the original estimate of $634 billion.[15] (note: This link is dead.) In late October 2008, USA Today reported that costs were down by $6 billion, or 12%, for the fiscal year ended September 30. Costs for the program were approximately one third less than originally predicted.[27]

Proposed New "Program costs" Section:

As of the end of year 2008, the average annual per beneficiary cost spending for Part D, reported by the Department of Health and Human Services, was $1,517 [44], making the total expenditures of the program for 2008 $49.3 (billions). Total intermediate, projected expenditures from 2009 through 2018 are estimated to be $999.9 (billions). [45]

New "Program costs" References:

44. ^ 2009 ANNUAL REPORT OF THE BOARDS OF TRUSTEES OF THE FEDERAL HOSPITAL INSURANCE AND FEDERAL SUPPLEMENTARY MEDICAL INSURANCE TRUST FUNDS, Table II.B1.—Medicare Data for Calendar Year 2008, Page 5 (Page 11 in pdf)

45. ^ 2009 ANNUAL REPORT OF THE BOARDS OF TRUSTEES OF THE FEDERAL HOSPITAL INSURANCE AND FEDERAL SUPPLEMENTARY MEDICAL INSURANCE TRUST FUNDS, Table III.C19.—Operations of the Part D Account in the SMI Trust Fund (Cash Basis) during Calendar Years 2004-2018, Page 120 (Page 126 in pdf)

Notes for Talk section viewers:

- There are many links that are dead in this article. The data is also very old.

- I will try to update the article one section at a time starting with the program cost section. If there are no objections or requested additions I will update the "Program costs" section on 2/1

- The hyperlink for reference 44 is http://www.cms.hhs.gov/ReportsTrustFunds/downloads/tr2009.pdf

- The hyperlink for refernce 45 is also http://www.cms.hhs.gov/ReportsTrustFunds/downloads/tr2009.pdf

- Any comments or feedback is highly welcome...

Markdart (talk) 21:09, 25 January 2010 (UTC) 1/25/10[reply]

Bad Citation

The citation link in "criticisms" about drug costs compared to VA coverage is bad. It is number 32. Dude6935 (talk) 00:30, 2 February 2010 (UTC)[reply]

2010 Updated info

There is updated 2010 info on plan premiums, as well as updated stats on average costs. I don't have time to go through and make them all but much is available through Kaiser's Medicare Primer. Zach99998 (talk) 18:30, 14 June 2010 (UTC)[reply]

Don't link to Kaiser in the main article. I've updated the LIS cost chart with the 2010 info. There's no specialty copay level for LIS beneficiaries anymore; that all comes up as brand now. Annorax (talk) 05:08, 4 July 2010 (UTC)[reply]
Why not link to Kaiser in the main article? Also, where did you find the LIS 2010 information? Zach99998 (talk) 02:45, 26 July 2010 (UTC)[reply]

I've further updated the page, down to the low-income subsidies section. Zach99998 (talk) 02:48, 26 July 2010 (UTC)[reply]

Trouble archiving links on the article

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Getting on new drug plan

I’m from Ohio never been on drug plan I have Medicare can I still get on it Sissyboothmk (talk) 16:06, 10 January 2018 (UTC)[reply]

Article is outdated

In spite of updated/fixed links, the article as a whole is woefully outdated -- and necessarily so, because the Medicare rules change every year! Keeping up with annual changes like this (the tax code is, of course, another example) is a huge challenge. Suggest restructuring the article into: (1) historical background, (2) a current year baseline (pick a year), and (3) a new section each year thereafter, that describes whatever significant changes in that year. G41rn8 (talk) 19:32, 19 January 2018 (UTC)[reply]

The History section of this article is blatantly an opinion piece

The entire section consists almost exclusively of subjective claims, rather than facts, and provides sources for neither.

I agree that the history section had some serious problems. I rewrote it to try to be more fact-based and to include a broader historical context for the program. --Burritosol (talk) 18:40, 19 July 2021 (UTC)[reply]

Wiki Education assignment: Research Process and Methodology - FA23 - Sect 202 - Thu

This article was the subject of a Wiki Education Foundation-supported course assignment, between 6 September 2023 and 14 December 2023. Further details are available on the course page. Student editor(s): ChrisMisu (article contribs).

— Assignment last updated by ChrisMisu (talk) 18:26, 1 December 2023 (UTC)[reply]

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