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KEY POINTS

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  • Medicare enrollment qualifications include being at least 65 years of age; or, if under 65 years of age, having a disability, end-stage renal disease, or amyotrophic lateral sclerosis.

  • Medicare consists of Part A (hospital services), Part B (physician services), Part C (private insurance option to traditional Medicare) and Part D (prescription drug benefit).

  • Medicare services are not free and require monthly premium payments and various copayments.

  • Medicare does not cover numerous health-related services, such as hearing exams and hearing aids; eye care, routine eye exams, and corrective lenses; oral healthcare and dental appliances; cosmetic surgery; and long-term residential care.

  • Medications are covered through both Part B and Part D; Medicare Part D does not cover Part B medications.

  • Medicaid is a joint federal and state program for people with limited income and resources.

  • Each state has its own eligibility criteria and application procedures, and Medicaid services vary by state.

  • All Medicaid recipients who also qualify for Medicare receive some assistance in paying for coverage.

  • Compared to the average Medicare beneficiary, members eligible for both Medicaid and Medicare are younger and sicker, have less income and education, and have higher rates of mental illness and cognitive impairment.

  • Medicare is the primary source of prescription drug benefits for the dual-eligible population.

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INTRODUCTION TO MEDICARE AND MEDICAID

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Medicare, Medicaid, and other government programs often are the vehicles by which innovations in care are introduced to the United States health care system.1 Government officials are not always the originators of the innovations, but they can identify promising initiatives and take the lead to incorporate them; for example, prospective payment and managed care plans were implemented in Medicare and Medicaid before they were widely adopted by the private sector.

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Decades ago the Indian Health Service and the Veterans Health Administration introduced innovations in pharmacy services and advanced the role of clinical pharmacists. The Omnibus Budget Reconciliation Act of 1990 set the standard for counseling Medicaid patients and shaped legal requirements for pharmacist counseling in most states.2 The Medicare Modernization Act (MMA) of 2003 followed in this tradition by including medication therapy management (MTM) as a component of the prescription drug benefit under Part D. This law created MTM as a model service for patients who are at significant risk for drug-related morbidity—those whose age, disabilities, chronic illnesses, and low incomes make them especially vulnerable to the adverse effects of medicines.

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The Centers for Medicare & Medicaid Services (CMS) was not particularly prescriptive in 2006 when MTM was initiated under the Part D benefit. However, the requirements for MTM that followed are remarkably consistent with the essential elements of pharmaceutical care as defined by Hepler and Strand.3 That is, MTM is a mechanism for establishing accountability for drug therapy regimens in order to deliver definite outcomes that improve patients' quality of life. MTM within Medicare includes documentation, action plans, and follow-up ...

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