Los Angeles counsel Paul Gelb co-authored “Reimbursement to Medicare Part D Prescription Drug Plans” for American Health Lawyers Association, Member Briefing. Medicare Part D subsidizes prescription drug coverage pursuant to the Medicare Prescription Drug Benefit, Improvement and Modernization Act of 2003. Part D allows consumers to enroll in plans offered by qualified insurance providers with substantially lower premiums than would otherwise be possible without the subsidy. Insurance providers are reimbursed for offering these lower cost plans by the Centers for Medicare & Medicaid Services (CMS). The article explains how CMS reimburses insurance providers for sponsoring Part D plans. First, the article describes how CMS sets the premium that plan sponsors can charge beneficiaries enrolled in their plan. Second, the article explains how CMS reimburses plan sponsors offering the most basic type of plan know as the Defined Standard Benefit. In addition, the article explains how CMS reimburses plan sponsors offering other available plans. Finally, the article discusses how plan sponsors can administratively appeal CMS’ payment determinations.
Click on the PDF link above to view the full article.