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2011 Current Topics Module 4. For state level data http://www.cms.gov/home/rsds.asp. 9.2M Medicare and Medicaid Eligible. 2. Agency Priorities. Improving Care for Individuals Better Coordination of Care Fighting Fraud and Abuse. I. Improving Care for Individuals. Value-based Purchasing - PowerPoint PPT Presentation
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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
08/08/2011 DRAFT Medicare Current Topics 3
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
08/08/2011 5DRAFT Medicare Current Topics
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
08/08/2011 6DRAFT Medicare Current Topics
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/
08/08/2011 7DRAFT Medicare Current Topics
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
08/08/2011 8DRAFT Medicare Current Topics
ACA
III. Fighting Fraud and Abuse
Save taxpayer dollars New steps
08/08/2011 9DRAFT Medicare Current Topics
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
08/08/2011 10DRAFT Medicare Current Topics
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
08/08/2011 11DRAFT Medicare Current Topics
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
08/08/2011 12DRAFT Medicare Current Topics
ACA
Medicare– Original Medicare– Medicare Advantage (Part C)– Medicare Prescription Drug Coverage (Part D)
3. Medicare Updates
08/08/2011 DRAFT Medicare Current Topics 13
Part A Costs for Inpatient Hospital Stays
08/08/2011 14DRAFT Medicare Current Topics
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
08/08/2011 15DRAFT Medicare Current Topics
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
08/08/2011 16DRAFT Medicare Current Topics
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
08/08/2011 17DRAFT Medicare Current Topics
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
08/08/2011 19DRAFT Medicare Current Topics
08/08/2011 20DRAFT Medicare Current Topics
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
08/08/2011 21DRAFT Medicare Current Topics
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
08/08/2011 22DRAFT Medicare Current Topics
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
08/08/2011 23DRAFT Medicare Current Topics
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
08/08/2011 24DRAFT Medicare Current Topics
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
08/08/2011 25DRAFT Medicare Current Topics
ACA
Enrollment PeriodCoverage GapIncome-related PremiumIndian Health/AIDS Drug AssistanceLow-Income Benchmark Premium
Medicare Prescription Drug Coverage Updates
08/08/2011 DRAFT Medicare Current Topics 26
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
08/08/2011 27DRAFT Medicare Current Topics
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
08/08/2011 28DRAFT Medicare Current Topics
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
08/08/2011 29DRAFT Medicare Current Topics
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
08/08/2011 30DRAFT Medicare Current Topics
ACA
08/08/2011 31DRAFT Medicare Current Topics
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
08/08/2011 DRAFT Medicare Current Topics 32
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”
08/08/2011 33DRAFT Medicare Current Topics
ARRA HITECH
Program Benefits
Increased data confidentiality Streamlined clinician workflow Improved quality of care For information and registration
– www.cms.gov/EHRIncentivePrograms/
08/08/2011 34DRAFT Medicare Current Topics
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
08/08/2011 35DRAFT Medicare Current Topics
08/08/2011 36DRAFT Medicare Current Topics
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