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Statements (208)
| Predicate | Object |
|---|---|
| gptkbp:instanceOf |
gptkb:government_agency
gptkb:insurance health insurance plan healthcare payment system |
| gptkbp:administeredBy |
gptkb:Centers_for_Medicare_&_Medicaid_Services
private insurance companies |
| gptkbp:alsoKnownAs |
gptkb:Medicare_Part_C
gptkb:Hospital_Insurance |
| gptkbp:alternativeName |
Medicare_Advantage
Medicare_Advantage_Plan Medicare_Advantage_plan Medicare_Part_A Medicare_payment_system |
| gptkbp:annualDeductible |
yes
|
| gptkbp:annualEnrollmentPeriod |
October 15 to December 7
|
| gptkbp:annualReview |
yes
|
| gptkbp:appealsProcess |
yes
|
| gptkbp:appliesTo |
gptkb:Medicare_Part_C
gptkb:Medicare_Part_B Medicare Part D |
| gptkbp:approvedBy |
gptkb:Balanced_Budget_Act_of_1997
|
| gptkbp:availableOn |
gptkb:United_States
Medicare beneficiaries |
| gptkbp:basisOfPayment |
fee-for-service
bundled payments capitation value-based payments |
| gptkbp:beneficiaryCostSharing |
coinsurance
copayments deductibles premiums |
| gptkbp:catastrophicCoverage |
yes
|
| gptkbp:coinsurance |
yes
|
| gptkbp:country |
gptkb:United_States
|
| gptkbp:coverageGap |
yes
|
| gptkbp:coverageGapKnownAs |
donut hole
|
| gptkbp:covers |
outpatient services
prescription drugs home health care medically necessary services outpatient prescription drugs hospice care medical services inpatient hospital care physician services vision care dental care hearing care hospital services skilled nursing facility care |
| gptkbp:deductible |
yes
|
| gptkbp:eligibility |
gptkb:Annual_Election_Period
gptkb:Open_Enrollment_Period gptkb:Special_Enrollment_Period Medicare beneficiaries certain disabilities age 65 and older end-stage renal disease |
| gptkbp:enrollment |
voluntary
automatic for most people at age 65 over 30 million in 2023 |
| gptkbp:enrollmentIn2023 |
over 30 million people
|
| gptkbp:established |
1983
|
| gptkbp:establishedBy |
gptkb:Balanced_Budget_Act_of_1997
gptkb:Medicare_Prescription_Drug,_Improvement,_and_Modernization_Act |
| gptkbp:excludes |
over-the-counter drugs
cosmetic drugs drugs for weight loss or gain drugs not approved by FDA erectile dysfunction drugs (with some exceptions) fertility drugs vitamins and minerals (with some exceptions) hospice care (covered by Original Medicare) |
| gptkbp:fundedBy |
gptkb:government
beneficiary premiums federal government payments to private insurers state payments payroll taxes |
| gptkbp:includes |
gptkb:Diagnosis-Related_Group
gptkb:Inpatient_Prospective_Payment_System gptkb:Outpatient_Prospective_Payment_System Resource-Based Relative Value Scale End-Stage Renal Disease Prospective Payment System Home Health Prospective Payment System Prospective Payment System Skilled Nursing Facility Prospective Payment System |
| gptkbp:influenced |
private insurance payment models
|
| gptkbp:limitation |
provider choice
|
| gptkbp:lowIncomeAssistance |
Extra Help
|
| gptkbp:marketShare2023 |
about 50% of Medicare beneficiaries
|
| gptkbp:mayInclude |
gptkb:Health_Maintenance_Organization_plans
gptkb:Medical_Savings_Account_plans gptkb:Preferred_Provider_Organization_plans gptkb:Private_Fee-for-Service_plans gptkb:Special_Needs_Plans gptkb:HMO_plans gptkb:PPO_plans gptkb:Part_D_prescription_drug_coverage telehealth services annual changes in benefits and costs care coordination services chronic care management different cost-sharing than Original Medicare fitness benefits high-deductible plan home health care meal delivery services network restrictions out-of-pocket maximum over-the-counter drug benefits prior authorization requirements transportation benefits zero-premium plan disease management programs different copayments different deductibles different drug formularies different premiums different provider networks drug formularies extra benefits limited service area limited service areas provider networks |
| gptkbp:mustCover |
all services covered by Original Medicare
|
| gptkbp:offeredBy |
private insurance companies
|
| gptkbp:offers |
gptkb:Medical_Savings_Account_plans
gptkb:Private_Fee-for-Service_plans gptkb:Special_Needs_Plans gptkb:HMO_plans gptkb:PPO_plans telehealth services chronic care management extra benefits not covered by Original Medicare fitness benefits transportation benefits wellness programs over-the-counter allowances |
| gptkbp:openEnrollmentPeriod |
October 15 to December 7
|
| gptkbp:partOf |
gptkb:Medicare
|
| gptkbp:penalty |
yes
|
| gptkbp:penaltyForLateEnrollment |
yes
|
| gptkbp:planVariation |
cost-sharing structures
formularies pharmacy networks prior authorization requirements quantity limits step therapy requirements |
| gptkbp:policy |
gptkb:Medicare_Advantage_Prescription_Drug_plans
stand-alone prescription drug plans |
| gptkbp:premium |
usually free for most people
|
| gptkbp:prohibits |
federal government from negotiating drug prices directly
|
| gptkbp:provides |
Medicare Part A benefits
Medicare Part B benefits Medicare Part D benefits additional premiums coinsurance copayments dental coverage hearing coverage prescription drug coverage vision coverage wellness programs monthly premium |
| gptkbp:purpose |
control healthcare costs
standardize payments |
| gptkbp:regulates |
gptkb:United_States_federal_law
gptkb:Centers_for_Medicare_&_Medicaid_Services private insurance companies hospital reimbursement physician reimbursement post-acute care reimbursement provider reimbursement |
| gptkbp:relatedTo |
gptkb:Social_Security_Act
gptkb:Affordable_Care_Act Medicaid payment system |
| gptkbp:replacedBy |
gptkb:Medicare+Choice
gptkb:Medicare+Choice_plan |
| gptkbp:requires |
enrollment in Medicare Part A and Part B
network restrictions prior authorization for some services referrals for specialists primary care physician prior authorization for services |
| gptkbp:requiresEnrollmentIn |
gptkb:Medicare_Part_B
Medicare Part D |
| gptkbp:startDate |
1966
2006 |
| gptkbp:subject |
federal regulations
annual changes in benefits and costs annual enrollment periods star ratings by CMS state regulations Medicare rules and regulations annual plan changes annual contract renewal star ratings system |
| gptkbp:targetAudience |
seniors
Medicare beneficiaries people with disabilities |
| gptkbp:updated |
gptkb:legislation
CMS rulemaking |
| gptkbp:usedBy |
gptkb:Medicare_(United_States)
|
| gptkbp:website |
https://www.medicare.gov/drug-coverage-part-d
|
| gptkbp:bfsParent |
gptkb:Centene_Corporation
gptkb:Express_Scripts gptkb:Medicare |
| gptkbp:bfsLayer |
4
|