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2004 REACH National Medicare Training Program

2004 REACH National Medicare Training Program. Speaker Name Group Name Date. Medicare Modernization Act of 2003. Module 9. Medicare Today. 41 million beneficiaries growing to over 62 million in 2020 $284 billion in expenditures growing to $898 billion in 2020

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2004 REACH National Medicare Training Program

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  1. 2004 REACH National Medicare Training Program Speaker Name Group Name Date

  2. Medicare Modernization Actof 2003 Module 9

  3. Medicare Today • 41 million beneficiaries growing to over 62 million in 2020 • $284 billion in expenditures growing to $898 billion in 2020 • Need to adapt to new health care delivery models • Need for supplemental coverage

  4. Current commercial market: 70% in PPOs or POS plans 25% in HMOs 5% in fee-for-service Medicare market: 90% in fee-for-service 10% in Medicare Advantage plans Medicare Today

  5. Clear Need For Reform • People with Medicare want: • More choices and better benefits • Health care delivery options • Improved access to care

  6. 2004 Drug discount card Medicare + Choice now Medicare Advantage Moratorium on therapy caps until 1/1/06 2006 Prescription drug plans Two new Medigap policies Part B deductible increases with premium Medicare Modernization Actof 2003 (MMA) • 2005 • Drug discount card • New preventive services • Part B deductible increases to $110

  7. Session Topics • Medicare-approved drug discount cards (2004-2005) • Medicare prescription drug plans (2006) • New preventive services (2005) • Medicare Advantage plans (2004) • Increased access to care in rural America (2004) • MMA demonstration projects (2004) • Other important provisions

  8. Session Topics • Medicare-approved drug discount cards • Medicare prescription drug plans • New preventive services • Medicare Advantage plans • Increased access to care in rural America • MMA demonstration projects • Other important provisions

  9. Drug Discount Cards Medicare-ApprovedDrug Discount Cards • Estimated savings of 15-30% on many drugs • Effective June 2004 • Temporary and voluntary • “Medicare-Approved” seal

  10. Drug Discount Cards Approved Drug Card Companies • Decide which drugs to discount • Decide pharmacy network • Charge up to a $30 annual enrollment fee • May offer mail order in addition to retail pharmacies • Must have a customer service system with a toll-free number

  11. Drug Discount Cards Enrolling In and Changing Cards • Apply directly to card company • Can enroll anytime • Can change during Coordinated Election Period • November 15 - December 31, 2004 • Effective January 1, 2005 • May change for special circumstances

  12. Drug Discount Cards $600 Credit • Provides immediate relief to certain people with lower incomes • No more than $12,569 for a single person • No more than $16,862 for a married couple • No asset limits • QMBs, SLMBs, and QIs deemed income-eligible • Coinsurance based on income (5% or 10%) • Cannot use for over-the-counter drugs

  13. Drug Discount Cards Applying for $600 Credit • Choose a discount card • Apply to the company offering your card • Can apply for credit at any time • Amount will be prorated in 2005 • Unused amounts carry over to next year • Need not reapply in 2005

  14. Drug Discount Cards Let’s meet Fred…. • Has card with $600 credit • Normally pays $100 retail • XYZ Pharmacy Card offers negotiated price of $75 • Fred pays coinsurance based on $75 • $75.00 x 5% = $3.75 • Remainder is deducted from the $600 credit • $75.00 - $3.75 = $71.25 • $600 - $71.25 = $528.75 credit remaining

  15. Drug Discount Cards State Pharmacy Assistance Programs • Can coordinate with the Medicare-approved drug discount card • Can educate members with lower incomes on $600 credit • Can pay coinsurance for lower-income members • Can pay enrollment fee for lower-income members

  16. Session Topics • Medicare-approved drug discount cards • Medicare prescription drug plans • New preventive services • Medicare Advantage plans • Increased access to care in rural America • MMA demonstration projects • Other important provisions

  17. Prescription Drug Plans Medicare Prescription Drug Plans • Available January 2006 • Offered through private prescription drug plans (PDPs) • Can be offered by Medicare Advantage plans

  18. Prescription Drug Plans Eligibility and Enrollment • Must be entitled to Part A and/or enrolled in Part B • Enrollment is voluntary • Enrollment penalties for persons who wait • Exception for those covered under other comparable insurance

  19. Prescription Drug Plans Eligibility and Enrollment • Initial enrollment • November 15, 2005 - May 15, 2006 • Subsequent years • Open enrollment November 15 - December 31 • Will not be enrolled automatically • Exception: Medicaid recipients with drug coverage

  20. Prescription Drug Plans Your Costs in 2006 • Generally about a $35 monthly premium • $250 deductible • 25% of drug costs from $250 to $2,250 • Medicare pays 75% • 100% of drug costs from $2,250 to $5,100 • After you spend $3,600, Medicare pays approximately 95%

  21. Prescription Drug Plans Let’s look at a case study • Aaron has a Medicare prescription drug plan and takes five prescription drugs. His Medicare prescription drug plan includes all of his drugs in its formulary. Aaron has paid his $35 premium from January through May and has met his $250 deductible. How much in drug costs does Aaron have to incur before he reaches the catastrophic limit?

  22. Prescription Drug Plans Lower-Income Assistance • Group 1 • Full benefit dual eligibles with incomes below 100% FPL • Group 2 • Full benefit dual eligibles and non-dual eligible beneficiaries with incomes of 100%-135% FPL and limited resources ($6,000 per individual and $9,000 married couple) • Group 3 • Beneficiaries with incomes of 135%-150% FPL and limited resources ($10,000 individual and $20,000 married couple)

  23. Prescription Drug Plans Lower-Income Assistance

  24. Prescription Drug Plans Electronic Prescribing • Medication errors reduced • Prescription automatically transmitted to pharmacy • Standard to be established and piloted in 2006 • Will alert to adverse drug interactions and less costly alternatives • Will be voluntary for doctors

  25. Session Topics • Medicare-approved drug discount cards • Medicare prescription drug plans • New preventive services • Medicare Advantage plans • Increased access to care in rural America • MMA demonstration projects • Other important provisions

  26. New Preventive Services New Preventive Services • “Welcome to Medicare” physical exam • Diabetes screening tests • Cardiovascular screening blood tests

  27. New Preventive Services “Welcome to Medicare” Physical Exam • Height and weight measurement • Blood pressure • Electrocardiogram (EKG) • Education and counseling • Referral for other preventive services • Coverage for a limited time

  28. New Preventive Services Diabetes Screening • Effective January 1, 2005 • For persons at risk—risk factors include • High blood pressure • High cholesterol • Overweight • Family history of diabetes • Over 65 years of age • Includes fasting plasma glucose test • Frequency limits apply • No deductible or coinsurance

  29. New Preventive Services Cardiovascular Screening • Effective January 1, 2005 • Blood tests for early detection of cardiovascular disease • Cholesterol levels • Frequency limits apply • No deductible or coinsurance

  30. Session Topics • Medicare-approved drug discount cards • Medicare prescription drug plans • New preventive services • Medicare Advantage plans • Increased access to care in rural America • MMA demonstration projects • Other important provisions

  31. Medicare Advantage Plans Medicare Advantage Plans • Better benefits and more choices • Improved access to doctors and care for people with Medicare • Reduced premiums and copays or improved benefits • PFFS enrollees will pay more for going to non-contract providers

  32. Medicare Advantage Plans Specialized Plans • Certain MA plans can limit enrollment to special needs population • Institutionalized beneficiaries • Dual eligibles • Possibly other “special needs” groups • Design options to best serve these populations

  33. Medicare Advantage Plans New Plan Options • New plan choices in 2006 • Most important new option—Regional Preferred Provider Organizations (PPO)

  34. Session Topics • Medicare-approved drug discount cards • Medicare prescription drug plans • New preventive services • Medicare Advantage plans • Increased access to care in rural America • MMA demonstration projects • Other important provisions

  35. Access to Care in Rural America Helping Rural America • Improve beneficiaries’ access to quality doctors, ambulance service, and home health care where they live • Nearly $25 billion in increased reimbursement

  36. Access to Care in Rural America Payment Increases to Hospitals • Standardizes reimbursement for hospitals • Modifies disproportionate share hospital payments • Increases payment to Critical Access Hospitals

  37. Session Topics • Medicare-approved drug discount cards • Medicare prescription drug plans • New preventive services • Medicare Advantage plans • Increased access to care in rural America • MMA demonstration projects • Other important provisions

  38. Demonstration Projects MMA Demonstration Projects • Competitive Acquisition Demonstration for Clinical Labs • Demonstration Project for Use of Recovery Audit Contractors • Rural Hospice Demonstration Project • Rural Community Hospital Demonstration • Frontier Extended Stay Clinic Demonstration

  39. Demonstration Projects MMA Demonstration Projects • Demonstration of Case-Mix Adjusted Payment for Renal Dialysis Services • Demonstration Project for Coverage of Certain Prescription Drugs and Biologicals • Medicare Health Care Quality Demonstration Project • Demonstration Project for Consumer-Directed Chronic Outpatient Services

  40. Demonstration Projects MMA Demonstration Projects • Medicare Care Management Performance Demonstration • Demonstration of Coverage of Chiropractic Services Under Medicare • Demonstration Project to Clarify the Definition of Homebound • Demonstration Project for Medical Adult Day- Care Services • Beneficiary Outreach Demonstration Program

  41. Session Topics • Medicare-approved drug discount cards • Medicare prescription drug plans • New preventive services • Medicare Advantage plans • Increased access to care in rural America • MMA demonstration projects • Other important provisions

  42. Other MMA Provisions Protections for Retirees • Retirees concerned about losing their EGHP • New law works to stabilize the erosion • Employer must qualify for subsidy • Subsidy will pay 28% of drug costs per beneficiary enrolled in EGHP • Of costs between $250 and $5,000

  43. Other MMA Provisions Appeals Process Reform • Transfer of hearing functions • Increase timeframes for decision-making

  44. Other MMA Provisions Changes to Part B Deductible • $100 since 1991 • Increases to $110 in 2005 • Updated based on Medicare expenditures, 2006 on

  45. Other MMA Provisions Changes to Part B Premium • Prior to MMA, standard Part B premium • Current premium is based on 25% of program spending in a year • Beginning 2007 through 2011, premium based on beneficiary income • No effect if income below $80,000

  46. Other MMA Provisions Therapy Limits • Limits created by the BBA 1997 • Moratorium effective until 2003 • Moratorium reinstated through 2005

  47. Other MMA Provisions Health Savings Accounts • Tax-advantaged savings accounts for medical expenses • Available to anyone under 65 • Must have a high deductible health plan • At least $1,000 deductible for individual • At least $2,000 deductible for family • Yearly contributions are limited • Distributions for medical expenses not taxed

  48. Other MMA Provisions Communicating with the Public • Medicare beneficiaries • Health care providers • Governors, state legislators, and local officials • Congress • Advocates • Other stakeholders

  49. For More Information • Visit www.medicare.gov • Call 1-800-MEDICARE (1-800-633-4227) • TTY 1-877-486-2048 • Call a SHIP counselor • See Medicare & You handbook for phone number • Visit www.cms.hhs.gov

  50. 2004 REACH National Medicare Training Program Thank you!

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