Medicare Improvement for Patients and Providers Act of 2008

1. Medicare Improvement for Patients and Providers Act of 2008 Preliminary Summary of Beneficiary and Plan Provisions July 14th, 2008

2. Beneficiary Improvements • Initial Preventive Exam • Eligibility extended from 6 months to one year after entry to Medicare • Not subject to the deductible • “End of Life” / Advance Directives planning added • Mental Health Co-Pays Equalized • Benzodiazepines and barbiturates covered by Part D

3. Medicare Low Income Programs • QI eligibility extended through 2009 • LIS/MSP assets equalized for January, 2010 • SSA funded to eliminate processing and application barriers; transmit data to states; states process as MSP application • No Part D late penalties for LIS eligibles • No estate recovery for Medicare Savings Program • In-kind income excluded • Life Insurance not considered an asset • State Health Insurance (SHIPs), AAAs and ADRC’s Programs funded for outreach

4. Special Needs Plans Provisions • SNP authority extended one more year • through plan year 2010; expires1/1/2011 • moratorium lifted; dual plans have new criteria • CMS prohibited from “designating” a plan as a SNP; all plans must apply. • 100% of new enrollees must be in the targeted enrollment category. • The plan may not impose higher cost sharing on the duals than permitted under Medicaid • Provisions effective in 2010

5. SNP Provisions: Quality • Care Management • Evidenced based model of care • Appropriate network of providers and specialists • Initial and annual assessment of physical, psychosocial and functional needs • Individual plan of care identifying goals, objectives, measureable outcomes and specific benefits • Care management included in CMS periodic audit • Quality Reporting • Plans must provide data to “measure health outcomes and other measures of quality“ • All data shall be at the plan level • May be based on claims data

6. SNP Provisions: Dual SNPs • Plan provides prospective enrollees a written statement describing • Benefits and cost sharing protections under Medicaid • Which Medicaid and cost sharing protections are covered by the plan • Plan has a contract with the state to provide benefits or arrange for Medicaid benefits to be provided. • Dual SNPs without a contract may operate, but cannot expand during 2010. • CMS must designate “staff and resources” to assist state coordination with SNPs • States are not required to contract with SNPs

7. SNP Provisions: Institutional SNPs • I-SNP members in the community must be assessed as needing an institutional level of care • Assessed by an entity other than the organization • Using the assessment tool of the state of residence

8. Chronic SNPs • “Chronic and disabling” definition amended • co-morbid and medically complex condition(s) • substantially disabling or life threatening • high risk of hospitalization or significant adverse outcome • require care across domains of care • HHS to convene a panel to determine which conditions meet this definition; AHRQ must serve on the panel.

9. Marketing Restrictions • Effective January,1 2009 • Contains all provisions of CMS’ proposed rules re: cold calling, cross selling, limitations on meals, gifts and incentives ( ACAP still reviewing ) • Strengthens State Oversight • Agents and brokers must be licensed • Plans must cooperate with state information requests.

10. MedPAC Studies • Chronic Care Demonstration • Feasibility of a standing Chronic Care Practice Network • Report due June 15, 2009 . • Quality Measurement • Recommend how comparable measures of performance and patient experience can be collected and reported by 2011 that compare quality across plans AND compare FFS to MA plans • Report Due March 31, 2010 on findings and recommended legislation and administrative actions • Medicare Advantage payments • Costs plans incur as reflected in their bids • Ways to improve the estimates of county level per capita spending including use of VA services by Medicare beneficiaries • Alternate payment approaches • Report Due March 31, 2010 on findings and recommended legislation and administrative actions

11. The “Pay-For” Provisions CBO Estimates Savings for All Provisions as $12.5b for 2009-2013; $47.5b for the 2009-2018; overall MA enrollment down 2.3 m from 2013 projections • Small changes in FFS; delay home oxygen volume purchase • Phase-out of indirect medical education (IME) • Plan year 2010 MA rates reduced by .06 • Reduced an additional .06 each subsequent year till phased out • PACE programs excluded • Adjustment to the Medicare Advantage stabilization fund. • Removes all but one dollar from the fund • PFFS Required to Have Networks • Areas with less than 2 network plans exempted • Network requirements assumed to reduce enrollment