State and federal laws and regulations Essay Example for Free

State and federal laws and regulations Essay Beginning from January 1, 2006, individuals with incomes up to 150% of the federal state poverty level and with limited resources would be eligible for the subsidy. Unfortunately, the MMA also eliminated all Medicaid drug coverage for more than 6 million individuals who are dually-eligible for both Medicare and Medicaid, and required states to pay back to the federal government – through a mechanism known as the â€Å"clawback† – most of the savings that they would otherwise realize from the state. As a result of the legal mandate, states have attempted to respond by implementing their own State Pharmaceutical Assistance Programs (SPAP) to provide cost-sharing and supplemental drug coverage for dual eligibles and other low-income residents. The SPAP makes payments on behalf of a Part D beneficiary, with such payments being counted toward to the beneficiary – true out-of-pocket costs which count toward meeting the astronomical threshold which leads to reduced or eliminated beneficiary cost-sharing (Center for Medicare Advocacy, Inc., 2007). Despite such efforts by the states, however, the Center for Medicare Advocacy (2007) reports that dual eligibles will nevertheless find themselves with less prescription drug coverage under Part D than they had under Medicaid, and with far less protection to challenge denials, and other barriers to coverage. In addition to making co-payments for their prescriptions, dual eligibles also have to deal with predicted yearly increase of these co-payment amounts (Center for Medicare Advocacy, Inc., 2007). As a result of Part D, the stop-gap emergency actions taken by numerous states was estimate to have cost between $500,000 to several million dollars, as it varies per state, and puts those states budgets at risk (Champlin, 2006). Unfortunately, by law, the federal government cannot reimburse the states for the costs they spent in order to fix the problem. Based on the data presented and analyzed in the previous sections, the thesis concludes with the following recommendations to minimize issues identified – the complicated CMS enrollment process, and the lack of information as to the dual eligible beneficiaries right to reimbursement – to the different parties involved, or affected, by Medicare Part D: The Business Environment †¢ Non-insurance companies, regardless of whether in the US or anywhere else in the world, and regardless of type of industry, should run their health care program like other parts of their business. Health care management should be deemed as a key business function as equally important as the other key business functions of the company such as marketing, sales, or operations (Watson Wyatt Worldwide, n. d. ) †¢ Private insurance companies offering Part D should make sure there is exhaustive communication with Medicare representatives in terms of eligibility information, and with companies and beneficiaries themselves. With regard to beneficiaries, private insurance companies should make sure there is full disclosure, and knowledge, as to the plans available to them, and as to the prescription drugs available in the plans they selected. Insurance companies need to work closely with physicians to ensure that the required drugs their beneficiaries need are included in each beneficiarys formulary. There may be a need to develop a formulary which is more flexible in incorporating the individual medication needs of each patient. Private insurance companies should also not bombard their prospective clients with too much plan options, and should perhaps start with what their clients need, instead of presenting them with a set of options, in order to help the beneficiaries determine which plan is most appropriate for their needs. †¢ Physicians and pharmacies should participate in keeping an eye on how private insurance companies implement Part D plans and regulations. Since these are the two parties or sectors which deal directly with the beneficiaries – either on how they get their medicine upon purchase, and in determining what medication they need – physician associations and pharmacies should lobby or solutions to the glaring loopholes of the Part D program. The Employer †¢ Employers have to emphasize employee productivity and overall health as key goals. Not only should they aim for longer-lasting and more efficient health care strategy planning cycles, but they must also engage their employees in health care decision-making (Watson Wyatt Worldwide, n. d. ) For instance, employers can help by including employee self-service features in their health care program, and should empower their employees to take responsibility for health benefits without the employees feeling that they are left on their own. The employer should provide assistance and information in helping their employees to select the best plans they need. To do so, employers should themselves be careful in their selection if the medical vendor they decide to tie up with, or have been tied up with, in providing employee health benefits. The employer has the responsibility to ensure that the insurance company is effectively transmitting eligibility information to Medicare. In other words, the employer should be vigilant for their employees sake †¢ The employer can also make use of information and technology investments to administer benefits and distribute health information to their employee. The Employee †¢ The employee should do his or her research on Medicare, and study carefully the plans available. The employee should figure out how much he or she can afford to spend, and a make a list of the drugs currently taken. For questions, the employee can turn to the Medicare website or call their 1-800 hotline. Some state assistance programs can also help them enroll, and articles and reports, featured online or in newspapers, which investigate the choices available in their local areas may also provide useful information. Should the beneficiary be taking a large number of prescription drugs, he or she should look for a plan that does not have a doughnut hole or get multiple plans to cover the gap, if they can afford it. Lastly, the employee could also try talking to his or her pharmacist, who fills prescriptions every day and may be able to name plans that provide the best coverage (McWhinney, 2006). †¢ The above recommendations are applicable to retirees or plan-holders who may want to shift to another plan. To beneficiaries however who have not yet retired and are still currently enrolled, they should then strive to take a more active part in taking responsibility for their health care. Understanding the ins and outs of their companys health care program is a first step, as is availing of seminars, and other information dissemination campaigns that their organization may offer. In other words, employees should not be merely passive recipients, but should participate as engaged and informed consumers in making cost-effective decisions with their employers about the type and amount of health care that they need (Watson Wyatt Worldwide, n. d. ) The Government †¢ CMS should require PDPs to notify beneficiaries about their right to reimbursement, and monitor implementation of its retroactive payment policy (U. S. General Accounting Office, 2007). CMS should work with state governments in determining where the deficits arise, and in assisting state-sponsored programs to subsidize low-income beneficiaries by reimbursing at least a percentage of what states spend to make up for what Medicare was unable to provide. This may perhaps require an amendment to the actual MMA law, to encourage states to participate more actively in prescription drug subsidies for their low-income constitutions without the fear of depleting their state coffers. CMS should also require PDPs to transmit eligibility information to Medicare within a prescribed period, with a penalty imposed should such information not be communicated, or be wrongly communicated. In the same vein, CMS must ensure that the assignment of dual eligibles into appropriate plans involves communicating to the PDPs of these beneficiaries dual eligibility. The point is that beneficiaries should not be turned away at pharmacies simply because they were not identified or classified correctly by their PDPs. Otherwise, the MMA would not be serving the original objective of the law: to provide prescription drug benefits, and ultimately, to improve the quality of health care in the country. Part IX: References Camillus, J. C. (November 1999). Putting Strategy to work. Praxi, Business Line’s Journal of Management. Vol. 2, No. 4. Center for Medicare Advocacy, Inc. (2007). Medicare Part D. Retrieved May 10, 2007 from: http://www.medicareadvocacy. org/FAQ_PartD. htm Champlin, Leslie. (January 13, 2006). Family Physicians Grapple with Medicare Part D Glitches. American Academy of Family Physicians. Retrieved May 12, 2007 from: http://www. aafp. org/online/en/home/publications/news/news-now/archive/medicarepartd. html Employee Benefit Research Institute. (July 2004). Health Care Expenses in Retirement and the Use of Health Savings Accounts and Appendix. EBRI Issue Brief # 271. Retrieved May 10, 2007 from: http://www. ebri. org/publications/ib/index. cfm? fa=ibPrintcontent_id=3502 McWhinney, Jim.(January 9, 2006). Getting Through The Medicare Part D Maze. Investopedia. Retrieved May 10, 2007 from: http://www. investopedia. com/articles/06/MedicarePartD. asp Medicare-PartD. com. (April 1, 2007). The Background and Basics of Medicare Part D. Retrieved May 10, 2007 from: http://www. medicare-partd. com/PartD-History-MedicarePartD-ProgramPDP. php Rovner, Julie. (January 11, 2006). Problems Plague Rollout of New Medicare Drug Plan. National Public Radio. Retrieved May 10, 2007 from: http://www. npr. org/templates/story/story. php? storyId=5148817 Slaughter, Louise M.(June 1, 2006). Medicare Part D – The Product of a Broken Process. The New England Journal of Medicine, Vol. 354: 2314-2315, No. 22. Retrieved May 10, 2007 from: http://content. nejm. org/cgi/content/full/354/22/2314 Stebbins, Marilyn. (January 20, 2006). Confused by Medicare Part D? UCSF Expert Offers Advice. University of California, San Francisco. UCSF School of Pharmacy. Retrieved May 10, 2007 from: http://pub. ucsf. edu/today/cache/news/200601203. html Watson Wyatt Worldwide. (No date). New Rules for Managing Health Costs – Seventh Annual WBGH/Watson Wyatt Survey Report. Retrieved May 10, 2007 from: http://www. watsonwyatt. com/research/resrender. asp? id=W-532page=1 Wikipedia, The Free Encyclopedia. (2007). Medicare Part D. Retrieved May 10, 2007 from: http://en. wikipedia. org/wiki/Medicare_Part_D U. S. Government Accountability Office. MEDICARE PART D – Enrolling New Dual-Eligible Beneficiaries in Prescription Drug Plans. Testimony by Kathleen M. King, Director, Health Care, before the Committee on Finance, U. S. Senate, May 8, 2007. Retrieved May 12, 2007 from BenefitsLink. com Website at: http://www. gao. gov/new. items/d07824t. pdf.