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Overview of CMS

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  1. Overview of CMS

  2. CMS Headquarters

  3. DHHS Secretary Kathleen Sebelius

  4. CMS Administrator Dr. Donald Berwick

  5. Proposed Vision CMS is a major force and a trustworthy partner for the continual improvement of health and health care for all Americans.

  6. The “Three Part Aim” Better Health for the Population • Risk Factors • Vitality • Safe • Effective • Patient-Centered • Timely • Efficient • Equitable • Government • All Payers Better Care for Individuals Lower Cost through Improvement

  7. Medicare – The Beginning Medicare and Medicaid enacted in 1965 Implemented in 1966 Over 19 million enrolled on July 1, 1966

  8. What CMS Does • Administer the Medicare program • Work with the states to administer • Medicaid • Children's Health Insurance Program (CHIP) • Administer Health Insurance Portability and Accountability Act of 1996 (HIPAA) • Maintain quality standards • Long-term care facilities (nursing homes) • Clinical laboratories

  9. Medicare & Medicaid Statistics • Medicare enrollees • 19.1 million in 1966 • 45.9 million in 2009 • 50.1 million Medicaid enrollees in 2009 • Almost half, 24.9 million, are children 130% increase

  10. Drug Coverage Statistics • 90% (40 million) have drug coverage • Medicare • Another source • 26.6 million have Part D coverage • Growth of 1.5 million in one year • 9.6 million get extra help • 80% of those eligible

  11. U.S. Health Care Expenditures • National health expenditures in 2007 • $2.2 trillion • 16.2% of gross domestic product • Per person health care expenditures • $211 in 1965 • $7,421 in 2007 • $13,101 expected in 2017

  12. CMS’ 10 Regional Offices

  13. Four Consortia

  14. Atlanta Regional Office The Atlanta Regional Office serves eight states – Alabama Florida Georgia Kentucky Mississippi North Carolina South Carolina Tennessee

  15. The Atlanta Regional Office • Provides health care security for over 18 million people • 8.9 million Medicare beneficiaries • 9 million Medicaid recipients (including 1.6 million dual eligibles) • 725,000 CHIP kids

  16. Program Basics Medicare Medicaid Children’s Health Insurance Program

  17. Medicare • Medicare is the health insurance program for: • People age 65 and older • Certain people under age 65 with disabilities • People with all ages with End Stage Renal Disease (ESRD)

  18. Medicare Coverage Part A – Hospital Insurance Part B – Medical Insurance Part C – Medicare Advantage Plans Part D – Medicare Prescription Drug Coverage

  19. Medicare Part A • Inpatient Hospital Stays • Home Health Care • Skilled Nursing Care • Hospice • Blood

  20. Medicare Part B • Doctor’s services • Outpatient Hospital Services • Home Health Services • Preventive Services • Durable Medical Equipment

  21. Medicare Part C • Live in plan’s service area • Entitled to Medicare Part A • Enrolled in Medicare Part B • Continue to pay Part B premiums • May also pay monthly premium to plan • Don’t have ESRD at enrollment • Some exceptions

  22. Medicare Part C • Usually get all Part A and B services through plan • May have to use providers in plan’s network • Generally must still pay Part B premium • May get extra benefits • Vision, hearing, dental • Prescription drug coverage • Still in Medicare program • Get all Part A and Part B services • Have Medicare rights and protections

  23. Medicare Part D • Medicare Prescription Drug Coverage • Began January 1, 2006 • Provided through • Prescription drug plans • Medicare Advantage plans • Some employers and unions

  24. Medicaid

  25. Medicaid • Federal and State program • For some with limited income and resources • If eligible, most health care costs covered • Each state decides • Who is eligible • How people apply • Office names vary • Social services • Public Assistance

  26. Children’s Health Insurance Program

  27. Children’s Health Insurance Program Families who earn too much to qualify for Medicaid and who cannot afford private insurance may be able to qualify for CHIP For little or no cost, this insurance pays for: doctor’s visits; immunizations; hospitalizations, and emergency room visits Insure Kids Now (877-KIDS-NOW) or www.insurekidsnow.gov

  28. PATIENT PROTECTION AND AFFORDABLE CARE ACT

  29. Patient Protection & Affordable Care Act (ACA) Largenumber of changes Many changes effective this year and next year Only some of these are for CMS to implement

  30. Medicare changes from ACA Some provisions begin right away: Begins to close the Medicare Part D “donut hole”– $250 checks in 2010 Makes preventative care free under Medicare – effective 1/1/11 Moves open season out of the Christmas holiday period – effective 2011 (Oct 15 – Dec. 7) Reduction in number of MA plans for 2010 open season

  31. Medicare changes from ACA Other changes are more subtle, requiring further regulations and/or phased implementation – some you may have heard of: accountable care organizations discounts on brand name drugs in Part D beginning 2011 reports on health resource utilization to individual physicians incentives to reduce avoidable hospital re-admissions tying MA plan payments to clinical outcomes

  32. Other changes you may have read about HHS has created a new office to work with the insurance industry called the Office of Consumer Information & Insurance Oversight, or OCIIO You can see what they are working on at: www.hhs.gov/ociio public information at www.healthcare.gov

  33. OCIIO tasks Children with Pre-existing conditions- effective 6 months after enactment Interim High Risk Pools – effective in 2010 Preventing Rescissions if someone gets sick - effective 6 months after enactment Coverage for young people up to 26thbirthday - effective 6 months after enactment Early Retirees – effective 2010 Lifetime Limits - effective 6 months after enactment Restrictive annual limits on coverage - effective 6 months after enactment

  34. Pre-existing Condition Insurance Plan • Must be a US citizen or reside here legally; • Have been without health insurance for at least 6 months before applying • Have a pre-existing condition or denied coverage because of a health condition

  35. Pre-existing Condition Insurance Plan • For more information, please visit: • www.pcip.gov • 1-866-717-5826

  36. Helpful Resources 1-800 medicare /1-800-633-4227 Medicare.gov Cms.gov Medicare & You Handbook GeorgiaCares – the State Health Insurance Assistance Program 1-800-669-8387 Healthcare.gov Pcip.gov

  37. Contact Information Centers for Medicare and Medicaid Services Sam Nunn Federal Center 61 Forsyth Street, Suite 4-T-20 Atlanta, Georgia 30303 andriette.johnson@cms.hhs.gov 404-562-7410