Medicare Part D Made Some Incorrect Payments to Community Insurance Inc. for Institutional Beneficiaries in 2008.

摘要

The Balanced Budget Act (BBA) of 1997, P.L. No. 105-33 established Medicare Part C to offer beneficiaries managed care options through the Medicare+Choice program. Section 201 of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, P.L. No. 108-173, revised Medicare Part C and renamed the program the Medicare Advantage (MA) program. The Centers for Medicare & Medicaid Services (CMS), which administers the Medicare program, makes monthly capitated payments to MA organizations for enrolled beneficiaries. MA organizations provide health care services to Medicare enrollees, including all medically necessary services that are allowable in the traditional Medicare fee-for-service program. Title I of the MMA of 2003 amended Title XVIII of the Social Security Act by establishing the Medicare Part D voluntary prescription drug benefit for enrolled individuals. CMS contracts with prescription drug sponsors to provide the Part D benefit as a stand-alone drug plan. MA organizations provide this prescription drug coverage as part of an individual or group managed care plan, known as a Medicare Advantage Prescription Drug Plan (MA-PD). CMS provides a monthly prospective payment equal to the Part D plans standardized bid, risk adjusted for health status, minus the monthly beneficiary premium. Part D excludes drugs covered under traditional Medicare, including drugs for beneficiaries in skilled nursing facilities (SNF) or in the case of a MA-PD, drugs already covered by the MA organizations plan benefits. Medicare Part D requires that for every prescription filled, drug sponsors must submit an electronic summary record, called the prescription drug event (PDE), to CMS. The PDE record contains information that CMS uses to reconcile monthly subsidy payments made to drug sponsors with actual program cost data. Within the PDE record, the gross drug cost and other payment data enable CMS to make payments to drug sponsors and administer the Part D benefit. PDE records are then stored in the Integrated Data Repository that also accumulates summary data used in payment reconciliation. While enrolled in a Medicare Part D prescription drug plan, most beneficiaries are responsible for certain costs which may include a monthly premium, an annual deductible, and coinsurance or copayments.