Medicare can play an important role for Elders and other eligible patients in obtaining necessary health care services. However, due to premiums and out-of-pocket costs, many Medicare-eligible patients are not able to access critical services covered under the various components of the Medicare program. While Medicare beneficiaries generally pay no premiums for Medicare Part A, enrollment in Part B and/or Part D requires payment of premiums prompting some individuals to be unable or unwilling to enroll.
Starting in October, the Prairie Band Potawatomi Nation offers the Medicare Part D Tribal Premium Sponsorship Program (MTSP). The MTSP pays Medicare Part D premiums on behalf of eligible Tribal members. Participating in the MTSP will provide eligible Elders with wider prescription drug coverage while allowing for increased Medicare reimbursement for the Prairie Band Potawatomi Health Center.
What is Medicare and Medicare Part D?
Medicare is a federal health insurance program which began in 1965. Medicare is not free for the members (called beneficiaries) who benefit from the program. It was designed so that beneficiaries would share the total cost of health care with the federal government through premiums, deductibles, coinsurance charges, and payments for non-covered services. Medicare eligibility is open to people regardless of income and is not based on financial need (though there are some assistance programs). In that respect, Medicare differs greatly from Medicaid, the state-sponsored health insurance program for low-income older Americans and others.
Eligibility for Medicare is available to three groups: (1) those who are over 65, (2) people with disabilities, and (3) people with end stage renal disease.
Medicare A covers inpatient hospital, skilled nursing facility, home health, and hospice care services. Most eligible beneficiaries receive Part A automatically (with no premiums) because they paid a Medicare tax through FICA payroll deductions during their working career.
Medicare B benefits include outpatient hospital, home health, ambulance, and preventive services, along with medical equipment, supplies, and other services and items. Unlike Part A, people must elect to enroll in Part B and pay a monthly premium.
Medicare C is a system for delivering Medicare benefits to beneficiaries who enroll in plans offered by private health insurance plans.
Medicare D provides prescription drug coverage to Medicare beneficiaries through private insurance companies. Enrollment in Part D requires payment of a monthly premium.
Who is eligible for the MTSP?
Eligibility for Medicare is available to three groups: (1) those who are over 65, (2) people with disabilities, and (3) people with end stage renal disease. In addition to meeting Medicare requirements, in order to be eligible for the MTSP individuals must meet the following criteria:
- Be an enrolled Tribal Member or a spouse or dependent of a PBPN enrolled Tribal Member. (The spouse or dependent must be a member or descendant of a Federally Recognized Tribe.) The eligible spouse and/or dependent must also otherwise meet Medicare and MTSP requirements.
- Be eligible to qualify for Medicare A or B, or both. Eligibility qualifications for Medicare is: those who are 65 and older, or, people with Medicare approved disability, or people with end stage renal disease.
- Be a registered active patient at Prairie Band Potawatomi Health Center.
- Sign an individual Memorandum of Understanding agreeing to use the PBPN Health Center and pharmacy except in cases of emergency or other extenuating circumstances.
- There is no geographic component to sponsorship eligibility; however, the sponsored tribal member (and/or eligible spouse, and/or dependent) must be able to otherwise meet the eligibility criteria listed above.
Tribal Council Resolution 2019-223 established the Medicare part D Tribal Sponsorship Program and policy. The intent of this new program is to increase the number of Elders enrolled in Medicare Part D and to increase the resources available to Tribal health care programs. When patients with Medicare Part D use tribal health care facilities for their medications, the pharmacy can then be reimbursed through Medicare insurance. The Affordable Care Act provides an opportunity for any Tribe to establish a Tribally-Sponsored program to purchase health insurance coverage for their Tribal members. A number of Tribes have initiated sponsorship of Medicare Part D plans in order to increase the coverage available to their members while also stimulating increased reimbursement for their Tribally-owned Health Care facilities. The value of the services paid for under Medicare Part D typically exceeds the amount of the premium payment and as such, sponsorship of Medicare Part D adds value to both the patient (in the form of expanded coverage) and the Tribal facility (as increased 3rd party pharmacy reimbursement).
The Prairie Band Potawatomi Health Center has Patient Benefit Coordinators ready to assist members with determining eligibility and navigating the enrollment process. For more information about the MTSP, please call 785-966-8211 or 785-966-8208; or email MTSP@pbpnation.org.