Medicare Part D Sample Clauses

Medicare Part D. The Medicare prescription drug program authorized under the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA), effective January 1, 2006, and the regulations issued pursuant thereto or as thereafter amended.
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Medicare Part D a. The Medicare Part D baseline for the Part D Direct Subsidy will be set at the Part D national average monthly bid amount (NAMBA) for the calendar year. CMS will estimate an average monthly prospective payment amount for the low income cost-sharing subsidy and Federal reinsurance amounts; these payments will be reconciled after the end of each payment year in the same manner as for all Part D sponsors. The CY 2013 Part D NAMBA is $79.64.
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Medicare Part D. In order for POs to continue to meet the statutory requirement of providing prescription drug coverage to their enrollees, and to ensure that they receive adequate payment for the provision of Part D drugs, beginning January 1, 2006, POs began to offer qualified prescription drug coverage to their enrollees who are Part D eligible individuals. The MMA did not impact the manner, in which POs are paid for the provision of outpatient prescription drugs to non-part D eligible PACE participants. POs are required to annually submit two Part D bids: one for a Plan Benefit Package (PBP) for dually eligible enrollees and one for a PBP for Medicare-only enrollees. The Part D payment to POs comprises several pieces, including the risk adjusted direct subsidy, reinsurance payments, and risk sharing. With a few exceptions, Part D payments are made to POs in the same manner as to MA-PD and standalone PDP plans. The direct subsidy is risk adjusted. Payments for eligible enrollees of either PBP will include a low-income premium subsidy and a low-income cost- sharing subsidy for basic Part D benefits. Payments for dually eligible enrollees will also include an additional amount to cover nominal cost sharing amounts (“2% capitation”), and an additional premium payment in situations where the PO’s basic Part D beneficiary premium is greater than the regional low-income premium subsidy amount. Description of Rate (ex. Dual Eligible, Medicaid Only)Amount of Rate (LTC + Acute care = Total) Dual Eligible $3,956.32 Medicaid Only $5,825.03 APPENDIX N: STATE ENROLLMENT/DISENROLLMENT RECONCILIATION METHODOLOGY A description of the State's procedures for the enrollment and disenrollment of participants into the state system, including procedures for any adjustment to account for the difference between the estimated number of participants on which the prospective monthly payment was based and the actual number of participants in that month as required at 42 CFR §460.182(d). Oregon’s PACE payment is prospective, based on actual numbers that are entered into the state system prior to the participant’s start date or reassessment date. The SAA conducts a monthly reconciliation based on the PACE organization’s enrollment/disenrollment list and the state’s Remittance Advice for the PACE capitation payment. This reconciliation process captures enrollments that may have been missed after the system compute deadline for enrollment, as well as capturing the date of death entered into the system...
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Medicare Part D. The Plan shall cooperate with Medicare Part D prescription drug plans (and Covered Individuals who are enrolled in such plans) with respect to coordination of benefits between the Plan and the Medicare Part D plan, including the provision of information to the Medicare Part D plan (or the Covered Individuals) regarding the benefits provided under the Plan for costs covered by the Medicare Part D plan. Covered Individuals enrolled in Medicare Part D plans shall cooperate with the Plan so that the Plan may perform its obligations under this subsection.
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Medicare Part D. Seller will continue to obtain Medicare Part D rebate information on a quarterly basis for rebates due for sales of Fareston under Seller’s label. Seller shall be responsible for all payments due through 12/31/12 pursuant to Section 9.8 of the Agreement. Subsequent to 12/31/12, Seller will pay these rebates and invoice Purchaser for reimbursement or forward this information to Purchaser for payment (as agreed upon by the parties). Purchaser should add Fareston to their own coverage gap agreement for Fareston sold under Purchaser’s label.
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Medicare Part D. The Plan Administrator is responsible for all aspects of ensuring that the Group Health Plan is in compliance with the requirements of the Medicare Modernization Act and the regulations implementing the new Medicare Part D drug benefit found at 42 C.F.R. Part 423, including but not limited to the requirement that group health plan sponsors (i) provide notices of creditable coverage to Medicare eligible Members informing them whether their prescription drug coverage under the Group Health Plan is actuarially equivalent to the Medicare Part D benefit and (ii) notify the Centers for Medicare & Medicaid Services of the creditable coverage status of the Group Health Plan’s prescription drug coverage.
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Medicare Part D. College acknowledges that Company provides pharmacy services to Medicare Part D plans (“Part D Plans”) and their members under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (“Medicare Part D”) and that Company must comply with the provisions set forth in Exhibit C attached to this Agreement, which is incorporated herein by this reference. As applicable to the functions performed by Students related to Part D Plans, College agrees, and will require Students to agree to the provisions set forth in Exhibit C.
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Medicare Part D. Resident authorizes Amsterdam or its agent (vendor pharmacy) to bill Medicare Part D, and retain any funds received from such billing, for all Medicare Part D eligible services that Resident receives. Resident, Resident Representative and/or Sponsor agree to pay (in accordance with the terms of this Agreement), or have Resident’s Medicaid, Medigap or other third party insurance carrier pay, all applicable Medicare Part D deductibles and co-insurancecharges.
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Medicare Part D. The Company does not sponsor a Medicare Part D Plan. The Company provides services as a subcontractor to a Medicare Part D Plan sponsored by a Person unaffiliated with the Company. The Company is in compliance with its subcontractor obligations in respect of such services and is in compliance with all Laws applicable to the services provided to such Medicare Part D Plan sponsor.
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Related to Medicare Part D

  • Medicare If the Resident meets the eligibility requirements for skilled nursing facility benefits under the Medicare Part A Hospital Insurance Program, the Facility will bill Medicare directly for Part A services provided to the Resident. Medicare will reimburse the Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG IV guidelines or successor guidelines thereto. If the Resident continues to be eligible, Medicare may provide coverage of up to 100 days of care. The first 20 days of covered services are fully paid by Medicare and the next 80 days (days 21 through 100) of the covered services are paid in part by Medicare and subject to a daily coinsurance amount for which the Resident is responsible. A Resident with Medicare Part B and/or Part D coverage, who subsequently exhausts his/her Part A coverage or no longer needs a skilled level of care under Part A, may still be eligible to receive coverage for certain Part B services (previously included in the Part A payment to the Facility) and/or Part D services when Part A coverage ends. Medicare will terminate coverage for Medicare beneficiaries receiving physical, occupational and/or speech therapy (“therapy services”) if the Resident does not receive therapy for three (3) consecutive days, whether planned or unplanned, for any reason, including illness or refusals, doctor appointments or religious holidays. If such therapy was the basis for Medicare Part A coverage, the Resident would be responsible for the cost of his/her stay, unless another payor source is available. If Medicare denies coverage and denies further payment and/or recoups any payment made to the Facility, the Resident, Resident Representative, and/or Sponsor hereby agree to pay to the Facility any outstanding amounts for unpaid services not covered by other third party payers, subject to applicable federal and state laws and regulations. Such amounts shall be calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and additional services provided to the Resident. Except for specifically excluded services, most nursing home services are covered under the consolidated billing requirements for Medicare Part A beneficiaries or under an all-inclusive rate for other third party insurers and managed care organizations (MCOs). Under these requirements, the Facility is responsible for furnishing directly, or arranging for, the services for its residents covered by Medicare Part A and MCOs. When not directly providing services, the Facility is required to enter into arrangements with outside providers and must exercise professional responsibility and control over the arranged-for services. All services that the Resident requires must be provided by the Facility or an outside provider approved by the Facility. Before obtaining any services outside of the Facility, the Resident must consult the Facility. While the Resident has the right to choose a health care provider, the Resident understands that by selecting the Facility, the Resident has effectively exercised his/her right of free choice with respect to the entire package of services for which the Facility is responsible under the consolidated billing and third party billing requirements. The Resident agrees that he/she will not arrange for the provision of ancillary services unless the Resident has obtained prior approval from the Facility. MEDICARE PART A, MANAGED CARE, AND THIRD-PARTY INSURANCE

  • HEALTH CARE PLANS ‌ Notwithstanding the references to the Pacific Blue Cross Plans in this article, the parties agree that Employers, who are not currently providing benefits under the Pacific Blue Cross Plans may continue to provide the benefits through another carrier providing that the overall level of benefits is comparable to the level of benefits under the Pacific Blue Cross Plans.

  • Medicaid If and when the Resident’s assets/funds have fallen below the Medicaid eligibility levels, and the Resident otherwise satisfies the Medicaid eligibility requirements and is not entitled to any other third party coverage, the Resident may be eligible for Medicaid (often referred to as the “payor of last resort”). THE RESIDENT, RESIDENT REPRESENTATIVE AND SPONSOR AGREE TO NOTIFY THE FACILITY AT LEAST THREE (3) MONTHS PRIOR TO THE EXHAUSTION OF THE RESIDENT’S FUNDS (APPROXIMATELY $50,000) AND/OR INSURANCE COVERAGE TO CONFIRM THAT A MEDICAID APPLICATION HAS OR WILL BE SUBMITTED TIMELY AND ENSURE THAT ALL ELIGIBILITY REQUIREMENTS HAVE BEEN MET. THE RESIDENT, RESIDENT REPRESENTATIVE AND/OR SPONSOR AGREE TO PREPARE AND FILE AN APPLICATION FOR MEDICAID BENEFITS PRIOR TO THE EXHAUSTION OF THE RESIDENT’S RESOURCES. Services reimbursed under Medicaid are outlined in Attachment “A” to this Agreement. Once a Medicaid application has been submitted on the Resident’s behalf, the Resident, Sponsor, and Resident Representative agree to pay, to the extent they have access to the Resident’s funds, to the Facility the Resident’s monthly income, which will be owed to the Facility under the Resident’s Medicaid budget. Medicaid recipients are required to pay their Net Available Monthly Income (“NAMI”) to the Facility on a monthly basis as a co-payment obligation as part of the Medicaid rate. A Resident’s NAMI equals his or her income (e.g., Social Security, pension, etc.), less allowed deductions. The Facility has no control over the determination of NAMI amounts, and it is the obligation of the Resident, Resident Representative and/or Sponsor to appeal any disputed NAMI calculation with the appropriate government agency. Once Medicaid eligibility is established, the Resident, Resident Representative and/or Sponsor agree to pay NAMI to the Facility or to arrange to have the income redirected by direct deposit to the Facility and to ensure timely Medicaid recertification. The Resident, Sponsor and Resident Representative agree to provide to the Facility copies of any notices (such as requests for information, budget letters, recertification, denials, etc.) they receive from the Department of Social Services related to the Resident’s Medicaid coverage. Until Medicaid is approved, the Facility may bill the Resident’s account as private pay and the Resident will be responsible for the Facility’s private pay rate. If Medicaid denies coverage, the Resident or the Resident’s authorized representative can appeal such denial; however, payment for any uncovered services will be owed to the Facility at the private pay rate pending the appeal determination. If Medicaid eligibility is established and retroactively covers any period for which private payment has been made, the Facility agrees to refund or credit any amount in excess of the NAMI owed during the covered period.

  • Health Care Insurance While a faculty member is on an approved leave of this type, the faculty member will be advised regarding the right to continue health care benefits in accordance with COBRA during the period of unpaid absence.

  • Medicaid Enrollment Treatment Grantees shall enroll as a provider with Texas Medicaid and Healthcare Partnership (TMHP) and all Medicaid Managed Care organizations in Grantee’s service region within the first quarter of this procurement term and maintain through the procurement term.

  • Health Care Operations Health Care Operations shall have the meaning set out in its definition at 45 C.F.R. § 164.501, as such provision is currently drafted and as it is subsequently updated, amended or revised.

  • Health Care Benefits (a) Each regular full-time employee may elect coverage for himself and his eligible dependents* under one of the following health insurance plans:

  • Dental Care Plan The Welfare Plan will include a Dental Care Plan which will reimburse members for expenses incurred in respect of the coverages summarized in Appendix "1". The Plan will not duplicate benefits provided now or which may be provided in the future by any government program.

  • Primary Care Clinic Employees and each of their covered dependents must individually elect a primary care clinic within the network of providers offered by the plan administrator chosen by the employee. Employees and their dependents may elect to change clinics within their clinic’s Benefit Level as often as the plan administrator permits and as outlined above.

  • Medical Care Leave An Employee who is unable to make the necessary arrangements for maintenance of personal health care outside of scheduled work time, shall be granted time off with pay. Such time off shall not exceed sixteen (16) working hours per calendar year. Hours in excess of sixteen (16) hours per calendar year shall be deducted from the Employee's sick leave accumulation.

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