Health care can be challenging to navigate, and when you throw in a few complex terms, or acronyms, it’s easy to feel like you need to learn a new language just to understand how things work. But there’s help…

The Prime Therapeutics/Magellan Rx (Prime/MRx) Government Programs (GP) team is a trusted partner for government health plan clients/members on Medicare, managed Medicaid and employer retiree plans. After all, we believe that being informed on key health care terms and acronyms can demystify and possibly lead to better health outcomes.

Here are some key terms/acronyms you should know:

CMS, or Centers for Medicare & Medicaid Services
The Centers for Medicare & Medicaid Services (CMS) is the agency within the U.S. Department of Health and Human Services (HHS) that administers the nation’s major health care programs. CMS oversees programs including Medicare, Medicaid, the Children’s Health Insurance Program (CHIP) and state and federal health insurance marketplaces.

D-SNPs, or Dual Eligible Special Needs Plans
Often pronounced “D-snip,” Dual Eligible Special Needs Plans (D-SNPs) are a type of Medicare Advantage plan designed for people who are eligible for both Medicare and Medicaid. D-SNPs can help coordinate care from the two programs and make them more patient-focused and easier to navigate.

C-SNPs, or Chronic Condition Special Needs Plans
Often pronounced “C-snip,” these are Medicare Advantage Special Needs Plans (SNPs) designed for people who need extra support due to an eligible chronic or disabling condition. They include all the benefits of original Medicare Part A and Part B plans, but all C-SNPs are required to provide prescription drug coverage, and most include coverage for routine dental, vision and hearing care.

Some of the chronic conditions covered by C-SNPs include cancer, diabetes mellitus, dementia, HIV/AIDS, end-stage renal disease, chronic lung disorders, cardiovascular disorders, autoimmune disorders and chronic alcohol or drug dependence.

MAPD, or Medicare Advantage Prescription Drug Plan
Private health insurance companies administer Medicare Advantage Prescription Drug (MAPD) plans, which combine Medicare parts A, B and D under one policy. MAPD plans refer to Medicare Advantage plans that include prescription drug coverage.

EGWPs, or Employer Group Waiver Plans
Pronounced “eggwhip,” these plans are offered by employers for retirees and can be part of a Medicare Advantage or prescription drug plan. EGWPs must provide benefits that are identical or better than those offered by other Medicare plans. They also allow for customized coverage to support each employer’s retiree benefit commitments and may be fully, or partially, paid for by the employer, often providing drug benefits that are more comprehensive and cost-effective than what may be offered by other Part D plans.

IRA, or Inflation Reduction Act
The Inflation Reduction Act (IRA) provides meaningful financial relief for millions of people with Medicare by improving access to affordable treatments and strengthening the Medicare program both now and in the future.

This drug law makes improvements to Medicare that will expand benefits, lower drug costs and improve the strength of Medicare.

People with Medicare will benefit from lower prescription drug costs and a redesigned prescription drug program, which includes:

• Insulin available at $35/month per covered prescription
• Access to recommended adult vaccines without cost-sharing
• A yearly cap ($2,000 in 2025) on out-of-pocket prescription drug costs in Medicare
• The expansion of Medicare Part D’s low-income subsidy program (LIS or “Extra Help”) to 150% of the federal poverty level starting in 2024

The IRA makes Medicare stronger for current and future enrollees and makes health care more accessible, equitable and affordable by lowering what Medicare spends for prescription drugs and limiting increases in prices.

M3P, or Medicare Prescription Payment Plan
The Medicare Prescription Payment Plan (MPPP or M3P) was introduced under the IRA and allows beneficiaries to spread their cost sharing — also known as out-of-pocket costs (OOP) — over the course of the year. In the most extreme example, under the M3P, a beneficiary who reaches the $2,000 maximum out-of-pocket (MOOP) in January would pay 12 monthly payments of $166.67 rather than $2,000 in January and $0 the rest of the year. The program is effective Jan. 1, 2025.

As of the writing of this piece, CMS has not released all final guidance on the program and has stated its intention to release further guidance in the summer of 2024. Note that drugs not covered by Part D (e.g., weight loss medications) are not included in the M3P program.

As the health care industry continues to evolve, we’re here to support our clients and members with resources and tools to make better decisions.

Stay tuned for more from the Prime/MRx GP team on our blog. And for additional insights, requirements, and advice on the IRA, read my latest piece on page 44 of the summer edition of the Magellan Rx Report.