2011 Current Topics Module 4

2011 Current Topics Module 4

For state level data– http://www.cms.gov/

home/rsds.asp

08/08/2011 DRAFT Medicare Current Topics 2

2011 Enrollment

Medicare Medicaid Children’s Health Insurance Program

48.6M• 36.7M Original Medicare • 11.9M Medicare Advantage• 35.6M get Part D Rx benefitso 29.4M in Part Do 6.2M through Retiree Drug

Subsidyo 10.7M low-income have drug

coverage

67M5M+9.2M Medicare and Medicaid Eligible

I. Improving Care for IndividualsII. Better Coordination of CareIII. Fighting Fraud and Abuse

2. Agency Priorities


I. Improving Care for Individuals

Value-based Purchasing Focus on Hospital Acquired Conditions Reducing Unnecessary Hospital Readmissions Bonus Payments Preexisting Condition Insurance Plans

08/08/2011 4DRAFT Medicare Current Topics

Pre-Existing Condition Insurance Plans (PCIPs)

Covers people without insurance due to a pre-existing condition until 2014

Administered by state or Department of Health and Human Services

Premium not higher due to your condition– Standardized by age

Doesn’t base eligibility on income


ACA

PCIP Standard Covered Benefits

Primary and specialty care Hospital care Prescription drugs Home health care and hospice care Skilled nursing care Preventive health and maternity care


ACA

Who is eligible for PCIP coverage?

U.S. citizens or legal residents With a pre-existing medical condition Not have creditable health coverage

– For the previous 6 months before you apply Your state Consumer Assistance Program (CAP)

– Helps you enroll – File complaints and appeals

Information at https://www.pcip.gov/


ACA

Accountable Care Organizations (ACOs)

Providers organize ACOs– Facilitate provider coordination and cooperation

• Improve quality of care• Reduce unnecessary costs

– Voluntarily meet quality thresholds– Share in cost savings achieved for Medicare

Comment period closed– In listening mode


ACA

III. Fighting Fraud and Abuse

Save taxpayer dollars New steps


Fighting Fraud and Abuse

Tax dollars saved– Over $4 billion recovered and returned in 2010– Over $5 billion so far in 2011

Nine Anti-fraud Strike Force teams – In fraud hot spots around the country– Hundreds of convictions– Criminals had billed Medicare $100s of millions

Senior Medicare Patrol www.smpresource.org– Reached 1.5 million with critical information


Fraud and Abuse Prevention

New steps to keep criminals on the defensive– Tougher screenings for health care providers– Site visits– Keep fraudulent providers out of programs

• Medicare• Medicaid• CHIP

– Types identified as higher risk subject to more thorough screening


ACA

Fraud and Abuse Prevention

Identify trends that indicate fraud Increase penalties for fraud Authority to suspend payments – When credible allegation is being investigated $350 million for fraud fighting resources


ACA

Medicare– Original Medicare– Medicare Advantage (Part C)– Medicare Prescription Drug Coverage (Part D)

3. Medicare Updates


Part A Costs for Inpatient Hospital Stays


For each benefit period in 2011 You PayDays 1-60 $1,132 deductibleDays 61-90 $283 per dayDays 91-150 $566 per day (60 lifetime

reserve days)All days after 150 All Costs

Part A Costs for Skilled Nursing Facility Care


For each benefit period in 2011 You PayDays 1-20 $0Days 21-100 $141.50 per dayAll days after 100 All Costs

2011 Part B Amounts

Part B Annual Deductible - $162


Part B Monthly Premium (hold harmless since no Social Security COLA in 2011)

If your income is $85K or less and you paid this in 2010

You pay this in 2011

Notes

$96.40 $96.40$110.50 $110.50 If premium deducted from

Social Security$115.40 If premium not deducted

from Social SecurityNothing (not yet enrolled) $115.40 If new to Medicare in 2011

Income-Related Part B Premium

Part B premium income thresholds – Frozen at 2010 levels through 2019


If your Yearly Income in 2009 wasIn 2011

You Pay*File Individual Tax Return File Joint Tax Return$85,001–$107,000 $170,001–$214,000 $161.50$107,001–$160,000 $214,001–$320,000 $230.70$160,001–$214,000 $320,001–$428,000 $299.00above $214,000 above $428,000 $369.10

*Higher if you have a late enrollment penalty

Annual Wellness Visit

Once every 12 months covers– Comprehensive health risk assessment– Personalized prevention plan– Health advice– Referrals for education and counseling

No cost if doctor accepts assignment Can be performed by nurse practitioners and

physician’s assistants Effective January 1, 201108/08/2011 18DRAFT Medicare Current Topics

ACA

When to get Your Wellness Visit

Had Part B for at least 12 months– Welcome to Medicare physical not required

Had “Welcome to Medicare” exam– Must wait 12 months before annual Wellness visit

Effective January 1, 2011



Preventive campaign summer of 2011– Learn about covered preventive

services– PSA’s, online ads, community events– Access preventive publications

www.medicare.gov/share-the-health/

Medicare Advantage Enrollment Periods

MA Open Enrollment Period eliminated Annual Coordinated Election Period (AEP)– Now October 15 – December 7

• Enrollment effective January 1

– Known as Open Enrollment• Can change plan or switch to Original Medicare


ACA

New MA Annual Disenrollment Period

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

Between January 1-February 14– Effective first of the month after enrollment


ACA

New Special Enrollment Period

Can enroll in 5-Star MA, MAPD or PDP plan Enroll at any point during the year

– Once per year

New plan starts first of month after enrolled Star ratings on Planfinder October 1

– Updated yearly Effective December 8, 2011


Medicare Advantage Plans

Can’t charge more than Original Medicare– Chemotherapy– Dialysis– Skilled nursing facility care– Other certain services

Must limit your costs for Part A/B services Effective January 1, 2011


ACA

Payments to Medicare Advantage Plans

Frozen in 2011 Benchmarks vary

– % Original Medicare pays on average at county level

Phased in over 3, 5, or 7 years – Depending on level of payment reductions

MA benchmarks reduced in 2012 85% of funds must be spent on health care

– Effective 2014


ACA

Enrollment PeriodCoverage GapIncome-related PremiumIndian Health/AIDS Drug AssistanceLow-Income Benchmark Premium

Medicare Prescription Drug Coverage Updates


Open Enrollment Period

Formerly called the Annual Election Period Changes in 2011

– October 15 – December 7– Coverage begins January 1, 2011

• Joined/switched Medicare Advantage Plan• Joined/switched Medicare Prescription Drug Plan


ACA

New Special Enrollment Period

Can enroll in 5-Star MA, MAPD or PDP plan Enroll at any point during the year

– Once per year

New plan starts first of month after enrolled Star ratings on Planfinder October 1

– Updated yearly Effective December 8, 2011


Part D Coverage Gap

If you reach the coverage gap in 2011– You get a 50% discount on brand-name Rx drugs

• Counts toward TROOP

– 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


ACA

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• Beneficiary financial information not on Planfinder

Must pay if you have Part D coverage Social Security notifies beneficiary Effective January 1, 2011


ACA


Income-Related Adjustment to Part D PremiumFor IRS Reported Income 2 Years Prior You Pay

Individual Tax Return

File Joint Tax Return In 2011 In 2012

$85K or below $170K or below Base Premium (BP)

$85K – $107K $170,000.01 – $214,000 BP + $12.00 BP + $11.60

$107K – $160K $214,000.01 – $320,000 BP + $31.10 BP + $29.90

$160K – $214K $320,000.01 – $428,000 BP + $50.10 BP + $48.10

$214K and up $428,000.01 or higher BP + $69.10 BP + $66.40

ACA

Note: Can be appealed to SSA (not plan or CMS)

American Recovery and Reinvestment Act (ARRA) and the Health Information Technology for Economic and Clinical Health Act (HITECH)

Medicare’s “Blue Button”

5. Electronic Health Records Updates


EHR Incentive Program

Health Information Technology for Economic and Clinical Health Act (HITECH)

Provides incentive payments Use of electronic health records system Sometimes called “HITECH”


ARRA HITECH

Program Benefits

Increased data confidentiality Streamlined clinician workflow Improved quality of care For information and registration

– www.cms.gov/EHRIncentivePrograms/


ARRA HITECH

NEW: Medicare’s “Blue Button”

On www.MyMedicare.gov – Helps you manage your health information online– Download your Medicare claims – Download self-entered information

• Emergency contacts• Names of pharmacies and providers • Self-reported allergies • Medical conditions• Prescription drugs



Current Topics Resource Guide

Resources Medicare ProductsCenters for Medicare & Medicaid Services (CMS)1-800-MEDICARE(1-800-633-4227)(TTY 1-877-486-2048)www.medicare.govwww.cms.gov

Social Security1 800 772 1213 ‑ ‑ ‑TTY 1 800 325 0778 ‑ ‑ ‑www.socialsecurity.gov

Railroad Retirement Board1-877-772-5772www.rrb.gov

Pre-Existing Condition Insurance Planswww.pcip.gov

State Health Insurance Assistance Programs (SHIPs)*

*For telephone numbers call CMS1-800-MEDICARE (1-800-633-4227)1-877-486-2048 for TTY users

Medicare & You HandbookCMS Product No. 10050)

Your Medicare Benefits CMS Product No. 10116

Choosing a Medigap Policy: A Guide to Health Insurance for People with MedicareCMS Product No. 02110

Closing the Coverage Gap – More Prescription Drugs Are Becoming Affordable CMS Product No. 11493

To access these products:

View and order single copies at www.medicare.gov

Order multiple copies (partners only)at productordering.cms.hhs.gov. You must register your organization.

This training module is provided by the

For questions about training products, e-mail [email protected]

To view all available NMTP materials or to subscribe to our listserv, visit

cms.gov/NationalMedicareTrainingProgram

Documents

2011 Current Topics Module 4