Washington SHIBA Trainings CMS Region 10 Presenters Division of Financial Management & Fee for Service Operations: Lauri Tan Division of Medicare Health

Washington SHIBA Trainings

CMS Region 10 Presenters

Division of Financial Management & Fee for Service Operations: Lauri Tan

Division of Medicare Health Plan Operations: Steve Amaro Rod Haynes George Lombard

Regional External Affairs & SHIP Liaison: Julie Bannester

September 2015

2015 National Training Program

Module 4

Current Topics

July 2015

Current Topics

LessonsLessons

1. Legislative Updates2. CMS Goals and Initiatives3. Medicare Updates4. Medicaid/Children’s Health Insurance Program

Updates

3July 2015

Lesson 1—Legislative UpdatesLesson 1—Legislative Updates

Affordable Care Act (ACA) Medicare Access and CHIP Reauthorization Act of

2015 (MACRA) Strengthening Medicare and Repaying

Taxpayers Act of 2012 (SMART Act)

4Current TopicsJuly 2015

Lesson 2—CMS Goals and InitiativesLesson 2—CMS Goals and Initiatives

Paying Providers for Value, not Volume Medicare Shared Savings Program Open Payments Initiatives

• Oncology Care Model• Medicare Care Choices Model• Million Hearts• 5-Star Rating System for Additional CMS Compare

Websites


Lesson 3—Medicare UpdatesLesson 3—Medicare Updates

Program Enrollment Medicare Access and CHIP Reauthorization Act

Medicare Provisions Preventive services Medicare Secondary Payer Recovery Medicare Advantage (Part C) Medicare Prescription Drug Coverage (Part D)

July 2015 Current Topics 6

7July 2015 Current Topics

Medicare Program Enrollment

* May not add up due to rounding.

2015 Average Monthly Projected Enrollment in Millions

Medicare

Parts A and/or B 55.2

Aged 46.1

Disabled 9.1

Original Medicare Enrollment 39

Prepaid Enrollment 16.2

Medicare Advantage Enrollment 15.7

Part D (Medicare Advantage with Rx Coverage and Prescription Drug Plans) 39.6

Medicare Access and CHIP Reauthorization Act Medicare Provisions

Medicare Access and CHIP Reauthorization Act Medicare Provisions

Sustainable Growth Rate (SGR) Repeal and Medicare Provider Payment Empowering Beneficiary Choices through Continued Access to Information on

Physicians’ Services Medicare and Other Health Extenders Savings to Medicare and Medicaid programs Protecting the Integrity of Medicare Act of 2015 (PIMA) Prohibition of Inclusion of Social Security Numbers on Medicare Cards Continuing Automatic Extension Of Providers Opt Out Election Income-related Premium Adjustment for Parts B and D Extension of Probe and Educate Program of Two Midnight Rule Medigap (Medicare Supplement Insurance) Policy Changes


MACRA


Provisions to replace the Sustainable Growth Rate (SGR) formula to provide long-term stability to the Medicare physician fee schedule• Provides stable updates for 5 years and ensures no changes are made to

the current payment system for 4 years

• Establishes a streamlined and improved incentive payment program that will focus the fee-for-service system on providing value and quality

• Consolidates the 3 existing incentive programs, continuing the focus on quality, resource use, and meaningful electronic health records (EHRs)

• Provides financial incentive(s) for professionals to participate in tests of alternative payment models (APMs)

SGR Repeal and Medicare Provider Payment Modernization

MACRA


New publicly available information on doctors and other eligible providers on items and services furnished to Medicare beneficiaries• Number of services furnished • Submitted charges and payments for such services

The information would be searchable by the specialty or type of professional; characteristics of the services furnished; and location

Information on Physician Compare by 2016

Empowering Beneficiary Choices through Continued Access to Information on Physicians’ Services

MACRA


Extends increased payments for certain low-volume and small rural hospitals, doctors, therapy services, and ambulance providers

• Through either fiscal year 2017 or calendar year 2017 Depending on Medicare’s payment system to that type of provider

Extension of therapy cap exceptions process• Until January 1, 2018, and reforms the process of medical manual

review to help support the integrity of the Medicare program Extension for specialized Medicare Advantage (MA) Plans for special needs

individuals (Special Needs Plans)• This provision extends authority for SNPs through December 31, 2018

Permanent extension of the Qualifying Individual (QI) program Extends Transitional Medical Assistance under Medicaid

Medicare and Other Health Extenders

MACRA


Significant provisions include• Higher income thresholds starting in 2018 for determining Part B

and Part D premium subsidies Beginning in 2020, more people will pay higher Part B and Part

D premiums due to a change in the indexing of income thresholds

• Payment rate updates in 2018 for skilled nursing facilities, inpatient rehabilitation facilities, home health agencies, hospices and long-term care hospitals would be limited to 1%

• Planned 3.2% increase in inpatient hospital payment rate replaced by 0.5% increase each year from 2018-2023

Savings to Medicare and Medicaid programs

MACRA


Strengthening Medicare’s ability to fight fraud and build on existing program integrity policies• Prohibiting Social Security numbers on Medicare cards (no later than 4

years after enactment)

• Preventing payments for items and services furnished to incarcerated individuals, individuals not lawfully present, and deceased individuals

• Modifying Medicare Durable Medical Equipment Face-to-Face Encounter Documentation Requirement

• Requiring Valid Prescriber National Provider Identifiers on Pharmacy Claims (starting plan year 2016)

• Option to Receive Medicare Summary Notice Electronically (starting in Fall of 2015)

Protecting the Integrity of Medicare

MACRA


Prohibits Social Security account numbers on Medicare cards starting in 2019

The new Medicare Beneficiary Identifier (MBI) will be• Recognizably different than the Medicare Health Insurance

Claim Number (HICN)

• The same length as the HICN

• Displayed on the Medicare cards

• Will be used by external partners (Beneficiary, Provider, Plans, etc.) participating in claims processing and other related activities when interacting with CMS

Prohibition of Inclusion of Social Security Numbers on Medicare Cards

MACRA


Extend Opt Out election beginning on the date the affidavit is signed to include each subsequent 2-year period • Unless the physician or practitioner provides notice not later

than 30 days before the end of the previous 2-year period

Beginning not later than February 1, 2016, make the list publicly available through website • Number and characteristics of opt-out physicians and

practitioners

Continuing Automatic Extension Of Providers Opt Out Election

MACRA


Income-related Premium Adjustment for Parts B and D

Beginning in 2020, the income thresholds would be adjusted each year by increasing the previous year’s income threshold amounts by the consumer price index for urban consumers.

Modified Adjusted Gross Income Threshold for Years Prior to 2018

Modified Adjusted Gross Income Threshold for Years Beginning in 2018

Applicable Percentage

More than $85,000 but not more than $107,000


35%



50%



65%

More than $214,000 More than $160,000 80%

MACRA


Allows CMS to continue use of the Medicare Administrative Contractor (MAC) “probe and educate” program to assess provider understanding and compliance with the “2-Midnight Rule” • On a pre-payment basis• Through September 30, 2015

Allows CMS to identify providers that have properly understood and implemented the 2-midnight benchmark, and those providers who might benefit from additional education, as evidenced by high claim error rates

Extension of Probe and Educate Program of 2-Midnight Rule

MACRA


Limitation on certain Medigap policies for people newly eligible for Medicare • On or after January 1, 2020

• Medigap policies sold to newly eligible Medicare beneficiaries Will no longer provide coverage for the Part B deductible

Newly eligible means an individual who, before January 1, 2020, is neither 65, nor has Part A

Plans C and F will become Plans D and G respectively for policies sold to those newly eligible • Policies bought before January 1, 2020, won’t be affected

Medigap (Medicare Supplement Insurance) Policy Changes

Section 1882 SS Act


Multi-target stool DNA test (Cologuard™)• Covered for certain people with Medicare every 3 years if they

Are between 50–85 Show no signs or symptoms of colorectal disease Are at average risk for developing colorectal cancer

Hepatitis C Screening • Single once-in-a-lifetime screening test

• Covered for adults who don't meet the high-risk determination

• Born from 1945 through 1965

New Medicare Preventive Services

ACA


Lung cancer screening• Low Dose Computed Tomography once per year for certain people with

Medicare

Pneumococcal vaccine update• An initial pneumococcal vaccine for all Medicare beneficiaries who’ve never

received the vaccine under Medicare Part B

• A different second pneumococcal vaccine 1 year after the first vaccine was administered (11 full months have passed following the month in which the last pneumococcal vaccine was administered)

• All people with Medicare are eligible

• No copayment or deductible for the vaccines with Original Medicare if the provider accepts assignment

Medicare Preventive Services Continued

ACA


SMART Act final rule effective April 28, 2015• Established a formal appeals process for applicable plans

where the Secretary seeks Medicare Secondary Payer (MSP) recovery directly from an applicable plan

Liability insurance– Self Insurance– No-fault insurance– Workers’ compensation laws or plans

• Applicable plan may appeal the amount of the debt and/or the existence of the debt

Medicare is required to send a notice to people with Medicare who received the items or services at issue

Strengthening Medicare and Repaying Taxpayers Act of 2012

SMART

Medicare Advantage Plans (Part C)Medicare Advantage Plans (Part C)

Expanded rewards and incentive programs Low-performing plans



Focus on encouraging participation in activities that promote• Improved health• Prevention of injuries and illness• Efficient use of health care resources

Can’t discriminate based on race, gender, chronic disease, institutionalization, frailty, health status, or other impairments

Must be designed so all enrollees are able to earn rewards Can’t be offered in the form of cash or other monetary

rebates or be used to target potential enrollees

Medicare Advantage OrganizationsExpanded Rewards and Incentives

Reg 4159-F

Low-Performing Health Plan (LPP) Termination

Termination of consistently low-performing plans (LPPs) on December 31, 2016• If plan receives Part C or Part D summary score of

less than 3 stars for 3 consecutive years Plans will be identified when plan ratings data

is released in early October 2015• LPPs currently have icon on Medicare Plan Finder• Affected beneficiaries will have an opportunity to

join a new plan


Medicare Prescription Drug Coverage (Part D)Medicare Prescription Drug Coverage (Part D)

Requirements for Prescribers Low Performing Plan Terminations Improved Coverage in the Coverage Gap Access to Preferred Cost-Sharing Pharmacies



CY 2015 final rule issued May 23, 2014 requires prescribers of Part D drugs • Be enrolled in an approved status, or

• Have a valid opt-out affidavit on file for their prescriptions to be covered under Part D

Requirement for Prescribers

CMS-4159-F


The June 1, 2015, interim final rule changed enforcement date to June 1, 2016• Requires pharmacy claims and beneficiary requests for reimbursement

for Part D prescriptions Written by prescribers other than physicians and eligible professionals

permitted by state or other applicable law to prescribe medications Not be rejected at point of sale by the plan if all other requirements

are met

• Requires plans to allow a provisional 3-month supply When prescription is written by a prescriber eligible to enroll but who

isn’t enrolled in or opted out of Medicare

Requirement for Prescribers Continued

CMS-4159-F


Plans will be required to make disclosures of their outlier status in 2016 plan marketing materials if their network analysis finds that their plans offer access to a PCSP within• 2 miles of fewer than 40% of urban beneficiaries’ residences; • 5 miles of fewer than 87% of suburban beneficiaries’

residences; or • 15 miles of fewer than 70% of rural beneficiaries’ residences.

CMS will take compliance actions if plan doesn’t provide the required disclosures

Preferred Cost Sharing Pharmacies (PCSPs)—Outliers


Some plans offer very low access to PCSPs in certain geographic area types compared to other plans• Urban, suburban, and rural

CMS will publish information on PCSP access for each plan offering preferred cost-sharing by geographic area type

CMS will identify “outliers” and work with plans that are extreme outliers to address access and marketing representation

Access to Preferred Cost-Sharing Pharmacies (PCSPs)

Final CY 2016 Call Letter


Termination of consistently low-performing plans (LPPs) on December 31, 2016• If plan receives a summary score of less than 3

stars for 3 consecutive years Plans will be identified when plan ratings data

is released in early October 2015• LPPs currently have icon on Medicare Plan Finder• Affected beneficiaries will have an opportunity to

join a new plan

Low-Performing Prescription Drug Plan (LPP) Termination

Improved Coverage In The Coverage Gap

Year What You Pay for Covered Brand-Name Drugs in the

Coverage Gap

What You Pay for Covered Generic Drugs in the Coverage Gap

2015 45% 65%2016 45% 58%2017 40% 51%2018 35% 44%2019 30% 37%2020 25% 25%

06/01/2015 Understanding Medicare 31

Lesson 4—Medicaid/Children’s Health Insurance Program (CHIP) Updates

Lesson 4—Medicaid/Children’s Health Insurance Program (CHIP) Updates

Medicaid and Children’s Health Insurance Program (CHIP) Enrollment

Medicare Access and CHIP Reauthorization Act CHIP provisions



Medicaid and Children’s Health Insurance Program (CHIP) Enrollment

*Doesn’t add up due to rounding

2015 Average Monthly Projected Population in Millions*

Medicaid Total 66.7

Aged 5.5

Blind/Disabled 9.8

Children 29.3

Adults 15.1

Expansion Children .7

Expansion Adult 6.4

Children’s Health Insurance Program 6.2


Medicaid agencies are required to screen all provider applications, including initial applications, applications for a new practice location, and applications for re-enrollment or revalidation, based on a categorical risk level of “limited,” “moderate,” or “high” • Starting July 31, 2015

State Medicaid agencies must establish categorical risk levels for providers and provider categories who pose an increased financial risk of fraud, waste or abuse to the Medicaid program• When the agency determines that a provider’s categorical risk level is

“high,” or when the agency is otherwise required to do so under state law, the agency must require providers to consent to criminal background checks, including fingerprinting

Implementation of Fingerprint-Based Criminal Background Checks

42 CFR 455.414-416


Preserves and extends CHIP funding through fiscal year 2017• Would likely provide enough funds to cover some amount of

projected 2018 expenditures• CHIP program is authorized through 2019

Extension of Express Lane Eligibility (ELE) • Permits states to rely on findings, for things like income, household

size, or other factors of eligibility, from another program designated as an Express Lane agency to facilitate enrollment in health coverage. Express Lane agencies may include

SNAP, School Lunch, TANF, Head Start, and WIC Extension of Outreach and Enrollment Program

Medicare Access and CHIP Reauthorization Act CHIP provisions

MACRA

Navigating the Medicare Plan FinderNavigating the Medicare Plan Finder

April 2015

What is the Medicare Plan Finder?What is the Medicare Plan Finder?

Internet tool on Medicare.gov that let’s you • View and compare your health and drug coverage

options in your area• Identify which plans cover your prescriptions at most

affordable cost where you shop• Enroll in a Part D or Medicare Advantage Plan

April 2015 Navigating the Medicare Plan Finder 37

http://www.medicare.gov/

Getting Started: What You Will NeedGetting Started: What You Will Need

Your Zip Code Medicare card List of prescriptions

• Strength and quantity• Use of generics

Pharmacy you use Other helpful information Other health insurance cards Subsidy eligibility Medicaid, Low Income Subsidy April 2015 Navigating the Medicare Plan Finder 38

Medicare.gov HomepageMedicare.gov Homepage


Plan Finder HomepagePlan Finder Homepage


Plan Finder Search OptionsPlan Finder Search Options


Step 1 of 4: General Search OnlyStep 1 of 4: General Search Only

LIS Notice states what percentage the beneficiary is

expected to pay for their premium.


General Search Only-Select Your Current Plan

General Search Only-Select Your Current Plan

Select Your current plan from a list of plans in your

area.


Step 2: Enter Your DrugsStep 2: Enter Your Drugs


Entering DrugsEntering Drugs


Pop-up box to indicate dosage, quantity, frequency and where you buy

Pop-up box to indicate dosage, quantity, frequency and where you buy

IMPORTANT TO ENTER AS PRESCRIBED


Lower Cost Generic optionLower Cost Generic option


My Drug ListMy Drug List


Print Drug ListPrint Drug List

click when ready for next STEP


Step 3: Select a PharmacyStep 3: Select a Pharmacy


Select Up to Two Pharmacies and View on MapSelect Up to Two Pharmacies and View on Map


Step 4: Refine Your Plan ResultsStep 4: Refine Your Plan Results


Plan Results PagePlan Results Page


Star Ratings(Look at Customer Satisfaction, Complaints, Experiences, Pricing)

Star Ratings(Look at Customer Satisfaction, Complaints, Experiences, Pricing)


Plan Results Page – Key InformationPlan Results Page – Key Information


Default Sort for Medicare Advantage Plans with Drug Coverage

Default Sort for Medicare Advantage Plans with Drug Coverage


Compare up to 3 PlansCompare up to 3 Plans


Prescription Drug Plan Details PagePrescription Drug Plan Details Page

Prescription Drug Plan

Details Page defaults to the Drug

Cost & Coverage Tab


Bar Chart to Show When Changes in Coverage Levels Occur

Bar Chart to Show When Changes in Coverage Levels Occur


View Details of CostsView Details of Costs


Plan Details – Drug CoveragePlan Details – Drug Coverage

NEW to Drug Costs

Coverage TAB


Drug Coverage InformationDrug Coverage Information


View Drug Benefit SummaryView Drug Benefit Summary


“View Drug Benefit Summary” button to see if plan has Preferred Pharmacy prices

“View Drug Benefit Summary” button to see if plan has Preferred Pharmacy prices


View Pharmacy NetworkView Pharmacy Network

NEW


Medicare Health Plan with Drug Coverage View

Medicare Health Plan with Drug Coverage View

Links to–Plan website–Important Notes–Provider & physician network


Health Plan Benefits Tab- Costs and Other Important Information

Health Plan Benefits Tab- Costs and Other Important Information


Health Plan BenefitsHealth Plan Benefits


Customizable Print ReportCustomizable Print Report


Compare Side-by-SideCompare Side-by-Side


Comparing Fixed CostsComparing Fixed Costs


Comparing Your Out-of-Pocket CostsComparing Your Out-of-Pocket Costs


Compare and Print View Drug Cost Summary

Compare and Print View Drug Cost Summary

April 2015 73

Print Comparison ReportPrint Comparison Report


Compare Plans Drug UpdatesCompare Plans Drug Updates


Online Enrollment CenterOnline Enrollment Center


April 2015 77Navigating the Medicare Plan Finder

Click here on watermark

Enter your SHIP office phone number below



CMS National Training ProgramCMS National Training Program

To view all available NTP training materials, or to subscribe to our email list, visit

CMS.gov/Outreach-and-Education/Training/ CMSNationalTrainingProgram/index.html

For questions about training products email [email protected]

http://www.cms.gov/Outreach-and-Education/Training/CMSNationalTrainingProgram/index.html

http://www.cms.gov/Outreach-and-Education/Training/CMSNationalTrainingProgram/index.html

mailto:[email protected]

Exercise 1: Medicare Enrollment Periods

Exercise 2: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Competitive Bidding Program

Exercise 3: The Health Insurance Marketplace and Medicare

Casework Exercises

Exercise 1Mr. Santos’ birthday is February 15, 1947. Mr. Santos has 40 quarters, but he continues to work and is covered by his employer group health plan. Mr. Santos decided to retire on June 30, 2015.• What is the appropriate enrollment period to use?• How long does Mr. Santos have to enroll in Medicare?• When should Mr. Santos apply for Medicare?• What if Mr. Santos takes COBRA? When should he

apply for Medicare? Why?

82

Exercise 1 (cont’d)

83

Mar Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar

E E E E CE C

E CE C

E CE C

E CE C

E C

Exercise 1 (cont’d)

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar

COBRA

G E P

E

C

84

Under this scenario, if the beneficiary takes COBRA and did not enroll until March (end of the GEP) will the beneficiary have a Part B late enrollment penalty (LEP) ?

Exercise 2

A dialog on

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies

Competitive Bidding Program

85

Exercise 3

Mr. Gonzalez is 64 years old. He is enrolled in the WA State Health Benefit Exchange. In 4 months Mr. Gonzalez will turn 65. Mr. Gonzalez came to see you today for advice.

What are the questions that you need to ask Mr. Gonzalez?

86

87

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Documents

Washington SHIBA Trainings CMS Region 10 Presenters Division of Financial Management & Fee for Service Operations: Lauri Tan Division of Medicare Health