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Medicare Advanced. Barbara Childers, MSW Centers for Medicare & Medicaid Services. Session Topics Changes to Medicare as a result of healthcare reform Low Income Subsidy Program (Extra Help with Drug Plan Costs) Coordination of Benefits.

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Medicare Advanced

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    1. Medicare Advanced Barbara Childers, MSW Centers for Medicare & Medicaid Services

    2. Session Topics Changes to Medicare as a result of healthcare reform Low Income Subsidy Program (Extra Help with Drug Plan Costs) Coordination of Benefits

    3. Session A: Changes to Medicare as a result of healthcare reform Overview and Highlights Medicare Updates • Original Medicare • Medicare Advantage • Medicare Prescription Drug Coverage • DMEPOS

    4. Medicare Statistics • In 2009 • 46.3 million people were covered by Medicare • 38.7 million aged 65 and older • 7.6 million with a disability • About 24% in Part C (Medicare Advantage) • $502 billion - Total benefits paid

    5. New Legislation – Health Reform • Patient Protection and Affordable Care Act (PPACA) • Signed into law H.R. 3590 on March 23, 2010 • Makes numerous statutory changes to Medicare program • The Health Care and Education Reconciliation Act of 2010 (HCERA) • Signed into law H.R. 4872 on March 30, 2010 • Modifies PPACA and adds several new provisions • Together called the Affordable Care Act

    6. Highlights of Affordable Care Act • Closes prescription drug coverage “Donut Hole” • Strengthens the financial health of Medicare • Invests in fighting waste, fraud, and abuse • Will extend the financial health of Medicare by 12 years • Changes annual enrollment period for MA and PDP • Improves preventive services coverage • Promotes better care after a hospital discharge • Creates the Center for Medicare & Medicaid Innovation

    7. Highlights of Affordable Care Act (continued) • Help for early retirees (before age 65) • Temporary program to offset cost of expensive premiums • Extends dependent coverage to age 26 • Eliminates limits on benefits • Provides $11B for Federally Qualified Health Centers • Outpatient primary care and preventive services • “Safety net” providers • Community health centers • Public housing centers • Outpatient programs funded by the Indian Health Service • Programs serving migrants and the homeless ACA Section 1001

    8. Pre-Existing Condition Insurance Plan (PCIP) • A new health coverage option created by the Affordable Care Act (ACA) • Provides coverage for individuals with pre-existing conditions until the Health Insurance Exchanges are available in 2014 • A person applying for PCIP must: • Reside within the service area of the PCIP; • Be a U.S. citizen or reside in the U.S. legally; • Have been without health coverage for a minimum of 6 months before applying; and • Have a pre-existing condition, as defined by the PCIP and approved by HHS. • To learn more about this program, including how to apply in your state, go to “Find Your State” at or call 1-866-717-5826 (TTY 1-866-561-1604) which is open from 8 AM to 11 PM EST • To request more information, resources (drop-in articles, facts sheets, etc), presentation for your staff or for questions, please email

    9. Original Medicare Updates • Medicare Claims Limit • 2011 Amounts • Preventive Services • Face-to-Face Meeting Rules • Therapy Caps • Power-driven Wheelchairs • Medigap Policies

    10. Medicare Claims Limit • Maximum period for submission of Medicare claims • Reduced time period • Now not more than 12 months • Effective January 1, 2010 ACA Section 6404

    11. 2011 Part A Amounts • For inpatient hospital stays in 2011 • Each benefit period you pay • $1,132 total deductible for days 1 – 60 • $283 co-payment per day for days 61 – 90 • $566 co-payment per day for days 91 – 150 (60 lifetime reserve days) • All costs for each day beyond 150 days • For Skilled Nursing Facility Care • $141.50 per day for days 21 - 100

    12. 2011 Part B Amounts • Part B Annual Deductible - $162 • Part B Monthly Premium (hold harmless)

    13. Income-Related Part B Premium ACA Section 3402 • Effective January 1, 2011, Part B premium income thresholds frozen at 2010 levels through 2019 *Higher if you have a late enrollment penalty.

    14. Preventive Services • Medicare covers preventive services to help • Find health problems early, when treatment works best • Prevent certain diseases or illnesses/avoid complications • To encourage use and increase accessibility • Part B Deductible and Coinsurance eliminated • Services affected must have an “A” or “B” rating • By the United States Preventive Services Task Force • New Annual Wellness Visit ACA Section 4104 ACA Section 4103

    15. New Home Health Rules • Doctor must meet patient in person • 90 days before the start of care or 30 days after • May be conducted by hospitalist • Even if another doctor will continue the care/care plan ACA Section 6407

    16. New Hospice Rules • Doctor must meet patient in person • Within 30 days of recertification • Starting on the third benefit period • Doctor must be employed by or working under arrangement with hospice ACA Section 3132

    17. Extension of Therapy Cap Exceptions Process • Medicare limits coverage for outpatient therapy • Physical and speech-language pathology • Combined $1,860 per year • Occupational therapy $1,860 per year • Ability to request exception was to end 2009 • Process of therapy caps extension extended •  Therapy caps determined on calendar year basis • All patients began a new cap year on January 1, 2010 ACA Section 3103

    18. Power-Driven Wheelchairs • Medicare will no longer purchase power-driven wheelchairs with lump-sum payment • Medicare will pay over a 13-month period • Purchase option is maintained for complex rehabilitative power wheelchairs • Effective January 1, 2011 ACA Section 3136

    19. MIPPA Medigap Updates • Makes hospice coverage a basic benefit • Deletes preventive services coverage • Deletes at-home recovery coverage • Creates new Plans D & G, and M & N • Eliminates E, H, I, and J Plans

    20. 2010 Medigap Changes(* denotes new plans and benefits) MIPPA

    21. Medicare Advantage Updates Enrollment Period Disenrollment Period Cost limits/Plan Payments Complaint system Appeals

    22. Medicare Advantage Enrollment Periods • 2011 and beyond • New dates for AEP – October 15 – December 7 • Change plans or switch to Original Medicare • MA Open Enrollment Period eliminated ACA Section 3204

    23. New MA Annual Disenrollment Period • New in 2011 • January 1 – February 14 • Leave MA plan and switch to Original Medicare • Coverage begins first day of following month • May join Part D plan • Coverage begins first of month after plan gets form • To disenroll and switch to Original Medicare • Make a request directly to MA organization • Call 1-800-MEDICARE • Enroll in a standalone prescription drug plan ACA Section 3204

    24. MA – New for 2011 • MA Plans can’t charge more than Original Medicare • For certain services, e.g., chemotherapy, dialysis, and skilled nursing facility care • MA Plans must limit your out-of-pocket costs • For Part A and Part B covered services ACA Section 3202

    25. Payments to Medicare Advantage Plans • Frozen in 2011 • Benchmarks vary • Phased in over 3, 5, or 7 years depending on level of payment reductions • Medicare Advantage benchmarks reduced in 2012 • By 2014, 85% of funds plans receive must go to health care ACA Section 3203

    26. Improvement to PDP/MA-PD Complaint System • Secretary to develop easy-to use complaint system • Allows for collection and maintenance of complaints • Received through any source or by any mechanism • Against PDPs and MA-PD plans • Must report and initiate appropriate interventions • Must monitor and guide quality improvement • Model form on • Secretary to report to Congress annually ACA Section 3311

    27. Uniform Exceptions and Appeals for PDP/MA-PD Plans • Drug plan sponsors • Must use a single, uniform exceptions and appeals process • Must provide access to process • Toll-free telephone number • Internet website • Exceptions and appeals filed on/after January 1, 2012 ACA Section 3312

    28. Medicare Prescription Drug Coverage Updates • Income-related Premium • Low-Income Benchmark Premium • Coverage Gap

    29. Medicare Prescription Drug Coverage Premium • Higher income pay higher Part D premium • Uses same thresholds used to compute income-related adjustments to the Part B premium • As reported on your IRS tax return from 2 years ago • Must pay if you have Part D coverage • Effective January 2011

    30. Income-Related Adjustment to Part D Premium ACA Section 3308 • Base beneficiary Part D premium increases • People with incomes above the thresholds used to compute income-related adjustment to Part B premiums

    31. Part D Low Income Benchmark Premiums • Removes MA rebates/quality bonus payments from calculation of Low Income Subsidy benchmark • Effective January 1, 2011 • Provides for voluntary de minimis policy • Regional benchmark for WV is $34.07 (2011) • Allows Part D plans to absorb cost difference • Remain a $0 premium LIS plan • Effective January 1, 2011 ACA Section 3302 ACA Section 3303

    32. Part D Coverage Gap • If you reach the coverage gap in 2011 • You get a 50% discount on brand-name Rx drugs • You get a 7% discount for generic drugs • Entire price counts toward catastrophic coverage • Dispensing fees not discounted • Additional savings in coverage gap each year • Gap to be closed in 2020

    33. Medicare’s Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program

    34. DMEPOS—What You Need to Know • DMEPOS stands for • Durable Medical Equipment, Prosthetics, Orthotics and Supplies • Equipment /supplies covered under Medicare Part B • New competitive bidding program • Effective 1/1/11 • If you live in affected area and need certain products • You must use contract supplier, or • Medicare won’t cover

    35. DMEPOS—What You Need to Know • Expected to save Medicare and Beneficiaries • $28 billion over 10 years • $17 billion in Medicare expenditures • $11 billion in Beneficiary coinsurance and monthly premium payments

    36. Who will Competitive Bidding Affect? • Beneficiaries who have Original Medicare and • Permanently reside in a ZIP Code in a CBA • Obtain competitive bid items while visiting a CBA • To find out if a ZIP Code is in a Competitive Bidding Area • Call 1-800-MEDICARE • Visit • Medicare Advantage enrollees can use suppliers designated by their plan

    37. Round 1 Rebid CBAs • California – Riverside, San Bernardino, Ontario • Florida - Miami, Fort Lauderdale, Pompano Beach • Florida – Orlando, Kissimmee • Missouri and Kansas - Kansas City • North and South Carolina - Charlotte, Gastonia, Concord • Ohio - Cleveland, Elyria, Mentor • Ohio, Kentucky, and Indiana - Cincinnati, Middletown • Pennsylvania - Pittsburgh • Texas - Dallas-Fort Worth, Arlington

    38. Products Included in the Program • Oxygen, oxygen equipment, and supplies • Standard power wheelchairs, scooters • Complex rehabilitative power wheelchairs – Group 2 only • Mail-order diabetic supplies • Enteral nutrients, equipment, and supplies • Continuous Positive Airway Pressure (CPAP) devices and Respiratory Assist Devices (RADs) • Hospital beds and related accessories • Walkers and related accessories • Support surfaces (Group 2 mattresses/overlays) Miami only

    39. UsingContractSuppliers • Must use contract supplier • Item and services included in Competitive Bidding Program living in a CBA • Traveling to or visiting a CBA • Exceptions • Providers can supply certain items (ex: walkers) • Nursing facility can supply directly if a contract supplier

    40. Identifying Contract Suppliers • Call 1-800-MEDICARE (1-800-633-4227) • TTY users call 1-877-486-2048 • Visit • DMEPOS Supplier Locator Tool

    41. Points to Remember • The Competitive Bidding Program does NOT affect which physician or hospital you use • May need to change DMEPOS supplier to continue your Medicare coverage • May stay with current supplier if “grandfathered” • If in Medicare Advantage plan, check with your plan

    42. Round 2 • Expands program to 91 Metropolitan Statistical Areas • Request for bids begin in 2011 • Visit

    43. Session B: Extra Help with Drug Plan Costs What it is How to qualify Enrollment Continuing eligibility Your costs with Extra Help

    44. What is “Extra Help” • Sometimes called the Low-Income Subsidy (LIS) • For people with lowest income and resources • Pay no premiums or deductibles & small or no copayments • Those with slightly higher income and resources • Pay reduced deductible and a little more out of pocket • No coverage gap for people who qualify for LIS

    45. Qualifying for Extra Help • You automatically qualify for Extra Help if • You get full Medicaid benefits • You get Supplemental Security Income (SSI) • Medicaid helps pay your Medicare premiums • All others must apply with Social Security • Online at, or • Call 1-800-772-1213 (TTY 1-800-325-0778) • Ask for “Application for Help with Medicare Prescription Drug Plan Costs”(SSA-1020)

    46. Income and Resource Limits • Income • Below 150% Federal poverty level • $1,361.25 per month for an individual* or • $1,838.75 per month for a married couple* • Based on family size • Resources • Up to $12,640 (individual) • Up to $25,260 (married couple) • Resources include money in a checking or savings account, stocks, and bonds. • Resources don’t include your home, car, burial plot, burial expenses up to your state’s limit, furniture, or other household items, wedding rings or family heirlooms. 2011 amounts 2011 amounts *Higher amounts for Alaska and Hawaii

    47. Medicare and Full Medicaid • You are auto-enrolled in a plan unless • You are already in a Part D plan • You choose and join a plan on your own • You call the plan or 1-800-MEDICARE to opt out • You are covered 1st month you are covered by • Medicaid and are entitled to Medicare • Will get auto-enrollment letter on yellow paper • You have a continuous Special Enrollment Period

    48. Others Qualified for Extra Help • Facilitated into a plan unless • You already are in a Part D plan • You choose and join own plan • You’re enrolled in employer/union plan receiving subsidy • You call the plan or 1-800-MEDICARE to opt out • Coverage is effective 2 months after CMS notifies • Will get facilitated enrollment letter on green paper • Have continuous Special Enrollment Period

    49. People New to Extra Help • You can apply for Extra Help any time • If denied, can reapply if circumstances change • If in a Medicare drug plan and later qualify • Plan is notified you qualify for Extra Help • Plan refunds costs back to effective date of Extra Help • Deductibles/Premiums • Cost-sharing assistance

    50. LI-NET • Limited Income Newly Eligible Transition Program (LI-NET) • Combined auto-enrollment and Point-of-Sale Facilitated Enrollment • For full duals and SSI-only beneficiaries • Provides Part D coverage for all uncovered • Full duals and SSI-only beneficiaries retroactively • LIS eligible beneficiaries on a current basis