Download - 2004 REACH National Medicare Training Program

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2004 REACH National Medicare Training Program

Speaker NameGroup Name

Date

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Medicare Modernization Actof 2003

Module 9

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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

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Medicare Today

Current commercialmarket:• 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

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Clear Need For Reform

• People with Medicare want:– More choices and better benefits– Health care delivery options – Improved access to care

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Medicare Modernization Act of 2003 (MMA)

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

2005• Drug discount

card• New preventive

services• Part B deductible

increases to $110

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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

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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

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Medicare-ApprovedDrug Discount Cards

• Estimated savings of 15-30% on many drugs

• Effective June 2004

• Temporary and voluntary

• “Medicare-Approved” seal

Drug Discount Cards

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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

Drug Discount Cards

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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

Drug Discount Cards

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$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

Drug Discount Cards

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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

Drug Discount Cards

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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

Drug Discount Cards

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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

Drug Discount Cards

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Session TopicsMedicare-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

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Medicare Prescription Drug Plans

• Available January 2006

• Offered through private prescription drug plans (PDPs)

• Can be offered by Medicare Advantage plans

Prescription Drug Plans

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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


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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


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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%


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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?


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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)


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Lower-Income Assistance


Group 1(below 100%

FPL)

Group 2(100-135% FPL)

Group 3(135-150% FPL)

Premium $35/month

$0 $0 Sliding scale based on income

Deductible $250/year

$1/$3 co-pay $0 $50

Coinsurance up to $3,600 out of pocket

$1/$3 co-pay $2/$5 co-pay 15% coinsurance

Catastrophic 5% or $2/$5 co-pays

$0 $0 $2/$5 co-pay

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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


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Session Topics

Medicare-approved drug discount cardsMedicare prescription drug plans

• New preventive services• Medicare Advantage plans• Increased access to care in rural America• MMA demonstration projects• Other important provisions

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New Preventive Services

• “Welcome to Medicare” physical exam

• Diabetes screening tests

• Cardiovascular screening blood tests


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“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


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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


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Cardiovascular Screening

• Effective January 1, 2005

• Blood tests for early detection of cardiovascular disease

• Cholesterol levels

• Frequency limits apply

• No deductible or coinsurance


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Session TopicsMedicare-approved drug discount cardsMedicare prescription drug plansNew preventive services

• Medicare Advantage plans• Increased access to care in rural America• MMA demonstration projects• Other important provisions

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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


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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


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New Plan Options

• New plan choices in 2006

• Most important new option—Regional Preferred Provider Organizations (PPO)


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Session TopicsMedicare-approved drug discount cardsMedicare prescription drug plansNew preventive servicesMedicare Advantage plans

• Increased access to care in rural America• MMA demonstration projects• Other important provisions

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Helping Rural America

• Improve beneficiaries’ access to quality doctors, ambulance service, and home health care where they live

• Nearly $25 billion in increased reimbursement

Access to Care in Rural America

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Payment Increases to Hospitals

• Standardizes reimbursement for hospitals

• Modifies disproportionate share hospital payments

• Increases payment to Critical Access Hospitals

Access to Care in Rural America

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Session TopicsMedicare-approved drug discount cardsMedicare prescription drug plansNew preventive servicesMedicare Advantage plans Increased access to care in rural America

• MMA demonstration projects• Other important provisions

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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

Demonstration Projects

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• 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


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• 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


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Session TopicsMedicare-approved drug discount cardsMedicare prescription drug plansNew preventive servicesMedicare Advantage plans Increased access to care in rural AmericaMMA demonstration projects

• Other important provisions

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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

Other MMA Provisions

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Appeals Process Reform

• Transfer of hearing functions

• Increase timeframes for decision-making


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Changes to Part B Deductible

• $100 since 1991

• Increases to $110 in 2005

• Updated based on Medicare expenditures, 2006 on


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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


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Therapy Limits

• Limits created by the BBA 1997

• Moratorium effective until 2003

• Moratorium reinstated through 2005


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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


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Communicating with the Public

• Medicare beneficiaries

• Health care providers

• Governors, state legislators, and local officials

• Congress

• Advocates

• Other stakeholders


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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

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2004 REACH National Medicare Training Program

Thank you!