What does PD mean in health insurance plans?
Medicare members can use the prescription drug benefit in Medicare Part D in two ways: a standalone prescription plan, or as an option in a Medicare Advantage plan. Members must enroll in Medicare Parts A and B in order to use the standalone Part D plans.
To include a prescription benefit in a comprehensive plan, members must choose Medicare Advantage and not Original Medicare.
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Getting Part D: Prescription Drug Coverage
Part D coverage is a valuable part of the Medicare system. Millions of consumers get treatment and maintain their health through prescription medications. Part D coverage can control the costs of needed medications.
The best time to sign up for Part D benefits is during the initial enrollment period. After that opportunity passes, many members will pay a late enrollment fee.
Medicare is a Comprehensive Healthcare System
The Congress authorized Medicare as part of the safety net for older Americans. With Social Security, Medicare provided health coverage during the often difficult later years.
The Original Medicare is a government run program. The Congress later added Part C to provide the comprehensive services of the Original Medicare but with private insurance methods. The below-listed items describe the major parts of Medicare.
Part B – Medical Insurance
Part C – Medicare Advantage
Part D – Prescription Drug benefits
Medicare Supplement – Medigap insurance
Health Care Network
A plan network consists of health professionals, hospitals, and related facilities under an agreement. All the managed care networks have a mission of providing top quality care to their subscribers. Most have a mission of satisfying customer needs so that they do not use resources outside the network.
Some people go outside of the network because they cannot find the services they require. Others may go outside for a preference for a particular doctor, facility, or type of treatment.
The subscriber has the burden of making sure the plan has resources that he or she requires. The subscriber has the further duty to decide when to spend more for health care; going outside the network increases costs.
In or Out-of-Network
One of the more important determinations of costs is whether one uses in-network resources. Using outside resources means that the spending will not count towards the deductible, and it will not count towards the out-of-pocket maximum.
Medicare Advantage Forms of Managed Care
Medicare Advantage offers private plans to perform the functions of Original Medicare. The private plans use many types of managed care to achieve an appealing balance of benefits and prices for consumers.
HMO stands for “health maintenance organization.” This type of managed care grew from earlier efforts aimed at increasing prevention and wellness benefits to avoid more severe diseases.
The HMO uses a primary care physician to direct treatment and make referrals to network specialists. They do not use outside resources nor do they cover them with insurance.
PPO stands for “preferred provider organization.” This type of managed care grew to attract customers that sought re freedom than the HMO model offered.
The PPO does not use a primary care physician to control care and issue referrals.
Users are free to go to any network resource. Users can also go outside of the network and get a much lower rate of costs sharing, no credit towards the deductible, and no credit towards the out of pocket maximum.
EPO stands for is ”exclusive provider organization.” This type of managed care does not use a primary care physician, and users can have free access to network resources.
This model does not pay anything towards outside resources. Customers must pay their own insurance costs when using outside specialists.
HMOPOS stands for ”health maintenance organization with a point of sale option.” The HMO uses a primary care physician to oversee treatment and issue referrals for using network resources.
The point of sale option permits the primary care physician to issue referrals to outside resources. The insurance plan covers the outside referrals at a lower rate of cost sharing than with network resources.
PFFS stands for ”private fixed-fee-for services model.” This type of insurance can exist by itself or in connection with a regional or local plan. PFFS matches well with HMO or PPO type plans to provide a regional network of plan members.
This is an arrangement used by the office of personnel management for federal employee health benefits.
A savings account that is used to pay pay out of pocket expense before a deductible threshold passes. This account goes with high deductible Part C Medicare Advantage plans.
Standalone Prescription Benefit Plans
Part D plans are standalone plans and do not provide health insurance as contained in Original Medicare, or Parts A and B. These Part D plans only cover prescription drug benefits.
They offer formularies to determine if they supply the needed prescription drugs. The consumer can get the price, copay, and deductibles when deciding among the private insurance plans.
Medicare Advantage Prescription Benefit Plans
The popularity of all-in-one plans is understandable. Consumers can get all their needs from a single source and cut down on the need to track of many separate things.
Medicare Advantage comes with or without the drug benefit. The system will detect the existence of two drug benefits for a single user. In this event, the system will cancel the MA-PD and send the user back to Original Medicare.
Employer-Sponsored Prescription Benefit Plan
Employer plans provide drug benefits and, if credible, can excuse the late enrollment in Part D. Employees or a covered spouse can avoid the late enrollment fee for Part D if they can show prior coverage by an employer plan. The employer plan coverage must meet a minimum standard. It must e creditable coverage.
PD is the Path to Great Outcomes
Inpatient and outpatient uses of prescription drugs are an important part of medical care. The prescription drug benefits of Parts C and D make drugs more affordable for users. The donut hole has improved with the Affordable Care Act, and fair pricing trends continue.
Comparison shopping is an excellent method for finding the right prescription drug benefits.
Whether part of Medicare Advantage Plan or a standalone prescription benefit plan, comparison shopping can help consumers find the best match for their needs and preferences.
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