medicare and the affordable care act: what you need to know for 2011 and beyond age & disability...
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Medicare and the Affordable Care Act:What you need to know for 2011 and beyond
Age & Disability OdysseyJune 21, 2011
Stephanie MinorSenior LinkAge Line® Program Consultant, Minnesota Board on Aging
Michaela Monoghan
Centers for Medicare & Medicaid Services
Ashley Setala
Centers for Medicare & Medicaid Services
Deb SiebenalerAdult Protection, Minnesota Department of Human Services
Overview• In 2011
– Medicare Part A– Medicare Part B– Medicare Part C– Medicare Part D– Affordable Care Act Medicare changes
The Important DISCLAIMER
• Information contained within this Power Point about the Affordable Care Act is subject to change at any time– Federal regulations must still be issued
and could result in changes to the information contained within this presentation
The Medicare Facts• Medicare covers 47 million Medicare beneficiaries
– 39 million seniors; 8 million under-65 disabled– 47 percent live on an income below 200% poverty– 29 percent in fair/poor health
• Medicare is a critical part of policy discussions related to the federal budget– 12 percent of federal spending
• Medicare is a major player in the US health care system– 23 percent of national personal health care spending
Medicare Part A
• Most people receive Part A premium free– Bene and/or spouse paid Federal Insurance Contributions
Act (FICA) taxes while working
• People with less than 10 years of Medicare- covered employment– Can still get Part A, but will pay a monthly premium
• 2011 Part A Premium if worked 30-39 quarters = $248• 2011 Part A Premium if worked less than 30 quarters = $450
Medicare Part A Coverage
• Hospital inpatient care• Skilled nursing facility (SNF) care• Home health care• Hospice care• Blood
Medicare Part A Hospital Inpatient Coverage• Up to 90 days of inpatient hospital services in each benefit period
– A benefit period begins when bene admitted to hospital and ends when bene has been out of the hospital for 60 days OR
– Have not received Medicare-covered care in a SNF or hospital for 60 consecutive days from day of discharge
• Lifetime Reserve Days– 60 days of inpatient hospital coverage (not SNF) following a 90 day
hospital stay
– Can use only once in lifetime
• Medicare-certified specialty psychiatric hospital: 190 Lifetime Days
Medicare Part A Hospital Inpatient Coverage
• 2011 Part A Deductible – $1,132 for days 1-60
• 2011 Copayment– $283 per day for days 61-90 (same benefit period)
– $566 per day for days 91-150 (60 lifetime reserve days)
• Deductible is a fixed dollar amount paid for benefits before Medicare pays
• Copayment is a fixed dollar amount paid when a Medicare covered service is received
• Coinsurance is the amount required to be paid after Medicare deductibles; a percentage that can vary
HOT TOPIC: Observation Status• Days spent in the hospital under Observation Status do not satisfy the 3 day
prior hospital stay requirement to qualify for Medicare SNF coverage
• Hospital services provided under Observation status require the bene to pay a copayment for each individual outpatient hospital service
– The copayment for a single outpatient hospital service cannot be more than the Part A Hospital inpatient deductible BUT
– The total copayment for all services provided may be more than the Part A Hospital inpatient deductible
• New notice for hospitals to provide to beneficiaries alerting them to difference between observation status and inpatient status
– Note: Notice is not mandatory at this time.
• Please contact the Senior LinkAge Line® about Observation cases where a bene wants to pursue an appeal (1-800-333-2433)
Medicare Part A Skilled Nursing Facility Coverage
• Covers up to 100 days of care in a SNF for each benefit period if – Daily skilled nursing and/or rehab services are needed– Prior to SNF admission, the bene must have a 3 day hospital stay
• Hospital stays that are Observation Status do not satisfy this requirement
– Must be admitted to a SNF within 30 days of the qualifying hospital stay
– If Medicare qualified, Medicare pays for day 1-20 at 100%. Days 21-100 have a $141.50 copayment per day (2011 amount)
Medicare Part A Home Health Care Coverage
• Care provided must meet Medicare criteria– Plan of care approved by physician requires skilled nursing and skilled
home health care services; AND
– Bene must be homebound AND
– Skilled nursing care is needed on a part-time or intermittent basis AND• Less than 8 hours per day• No more than 28 hours per week
– Medicare can cover up to 35 hours in unusual cases
– Care is provided by a Medicare-certified home health agency
– There is no limit to the number of visits that can be covered
Medicare Part A Home Health Care Coverage
• Medicare will not pay for – 24 hour care
– Home delivered meals
– Homemaker or custodial care services
– Prescription drugs are NOT covered under the Part A Home health care benefit
Medicare Part A Hospice Coverage
• For a bene to qualify for Medicare Hospice coverage– Must have Part A
– Physician and the hospice medical director certify that bene has a terminal illness and life expectancy is 6 months or less
– Bene signs a statement electing to have Medicare pay for palliative care, such as pain management, rather than trying to cure the bene condition.
– Bene terminal condition is documented in medical record
– Receive care from a Medicare-certified hospice agency
– Bene does not need to be homebound to qualify for benefit
Medicare Part A Hospice Coverage
• Certification for Hospice Care– At the beginning of each Certification period, the physician must
certify that bene is terminally ill • First Certification – 90 days• Second Certification – 90 days• Third Certification and beyond– unlimited number of 60 day periods
• Ending Hospice Care– Bene always has the right to stop Medicare hospice care at any
time and get Medicare-covered curative care for the terminal illness
– Bene can return to hospice again later if qualifies
Medicare Part A Blood Coverage
• Covers blood transfusions for hospital or skilled nursing facility bene
• There is no limit on the amount of blood or the number of transfusions Medicare will cover
• Pay for the first 3 pints of blood unless bene or other donates 3 pints of blood
Medicare Part B
• 2011 Monthly Premium for most– $96.40-$110.50 - $115.40
• 2011 Annual Deductible – $162
• 2011 Coinsurance– 20% of Medicare approved amount for all Part B services
except mental health outpatient treatment and home health care
– 45% of Medicare approved amount for Part B mental health outpatient treatment
Affordable Care Act and Medicare Part B Premium• Freezes income threshold for Part B premiums paid by
higher income beneficiaries from 2011-2019– $85,000 individuals– $170,000 couples– No longer indexed for inflation– More beneficiaries will pay increased Part B premium– Begins January 1, 2011
Medicare Part B• Physician Services• Durable Medical Equipment, Prosthetics, Orthotics, Supplies• Ambulance Services• Preventive Care Services• Outpatient Physical, Speech and Occupational Therapy• Blood• Chiropractic Care• Outpatient Mental Health Services (55%/45%)• Home Health Care• X-rays and Lab Tests• Limited Prescription Drugs
Medicare Part B Outpatient Mental Health Coverage
• Medicare covers mental health services on an outpatient basis provided by either a doctor, clinical psychologist, clinical social worker, clinical nurse specialist, or physician assistant in an office setting, clinic, treatment center or hospital outpatient department.
• Bene is responsible for 45% of the Medicare-approved amount.– Bene amount will reduce to 40% effective January 1, 2012– Bene may also have to pay a separate copayment for the facility
service
Medicare Part B Prescription Drug Coverage
• Part B covers a limited number of outpatient prescription drugs.
• Participating pharmacy or doctor must accept assignment on prescription drugs covered under Part B.
• Part B covers drugs that aren’t usually self-administered when given in a hospital outpatient department or doctor’s office. – Self-administered drugs provided in an outpatient setting like an
emergency room or observation unit may be covered under Medicare Part D, but not Medicare Part B
Medicare Part B Prescription Drug Coverage
• Some Antigens: Prepared by doctor and administered by trained person• Osteoporosis Drugs: Injectable drugs for osteoporosis for certain
women • Erythropoisis–stimulating Agents (such as Epogen®, Procrit®,
Epoetin alfa, or Aranesp®, Darbepoetin alfa): By injection if bene has end-stage renal disease or to treat anemia related to certain conditions
• Blood Clotting Factors: Has hemophilia and given to self by injection. • Injectable Drugs: Covers most injectable drugs administered by a
licensed medical practitioner, if the drug is considered reasonable and necessary for treatment.
Medicare Part B Prescription Drug Coverage
• Immunosuppressive Drugs: For transplant patients if the transplant was paid for by Medicare (or paid by private insurance that paid as a primary payer to bene Medicare Part A coverage) in a Medicare-certified facility.
– Note: Medicare Part D plans may cover immunosuppressive drugs, even if Medicare or an employer or union group health plan didn’t pay for the transplant.
• Oral Cancer Drugs: Some cancer drugs bene takes by mouth if the same drug is available in injectable form.
• Oral Anti-Nausea Drugs: When used as part of an anti-cancer chemotherapeutic regimen and administered within 48 hours to be used as a full therapeutic replacement for intravenous anti-nausea drugs.
• Medicare also covers some drugs used in infusion pumps and nebulizers if considered reasonable and necessary. (including insulin)
Medicare Advance Beneficiary Notice• Notice that physician, supplier and provider must give before
furnishing an item or service if they believe that Medicare may deny payment.
• Providers are not required to give an ABN for services or items explicitly excluded from Medicare coverage– Example: Hearing aids
• Advise to always select the option on the ABN that they want a claim submitted to Medicare or the provider is not required to submit the claim
• ABNs only apply to bene in Original Medicare, not Medicare Advantage
Minnesota Medicare Supplements
• Works with Original Medicare
• Basic and Extended Basic benefits are available when a bene enrolls in Medicare, regardless of age or health problems
• Effective June 1, 2010, a new hospice benefit was added as a core benefit available with every Medicare supplement purchased– Will cover all cost-sharing for Part B hospice care and respite care
expenses
• Medicare SELECT
Minnesota Medicare Population
• 775,930 Medicare beneficiaries – 15% of total Minnesota population– 321,109 enrolled in a Medicare Advantage Plan (Part C)
• 2008-2010 enrollment increased by 27%
– 88% of MN Medicare beneficiaries have prescription drug coverage (68% through Part D)
Overall changes with Medicare Advantage (Part C)
• Beginning January 2012, payments to the Medicare Advantage plans will be reduced
• Effective January 1, 2014, all Medicare Advantage plans will be required to pay at least 85% of the premium dollars toward payment of the beneficiary’s medical claims
• 5 Star-rating system: – Beginning January 2012, plans will be able to receive higher payments if
they can demonstrate they are providing high-quality care to enrollees (must receive 4 or 5 stars)
– Beginning 2012, plans receiving a 5-star rating may enroll beneficiaries year-round.
New Medicare Advantage Disenrollment Period• January 1, 2011 – February 14, 2011• During this new Medicare Advantage Disenrollment period,
– Beneficiaries can disenroll from a Medicare Advantage plan and switch to Original Medicare
– Beneficiaries can enroll in a Stand Alone PDP plan for Part D coverage even if they did not have Medicare Part D coverage with their Medicare Advantage plan
– Beneficiaries enrolled in a Medicare Advantage plan cannot switch to another Medicare Advantage plan
– Beneficiaries in Original Medicare cannot enroll in a Medicare Advantage plan
Affordable Health Care Act and Medicare Part D: Minnesota Medicare Beneficiaries in 2010
• 775,930 Medicare beneficiaries in Minnesota– 88% of the Minnesota Medicare population has prescription drug
coverage (68% have it through Medicare Part D)
– In 2009• 63,700 Minnesota Medicare beneficiaries hit the Part D donut hole
Medicare Part D Info
• Medicare Part D Benefit for 2011– Same deductible as 2010 ($310)
– Increase in Initial Coverage Limit by $10• $2840 in 2011
– Out of pocket threshold is same as 2010 ($4,550)
– Donut Hole $2840.01-$4,550 in 2011• Reduced brand name and generic prices
2011 Part D Plan Changes
• 73% of the Stand Alone PDP are not offering any significant gap coverage in 2011– 67% will have no gap coverage
– 6% will cover fewer than 10% of generic drugs on their formulary
Medicare Part D
• Higher Part D premium for higher-income beneficiaries– Income related monthly adjustment amount – The additional amount is a percentage based on the national base
premium ($32.34)• The percentage increases as income increases, and ranges from 35% to
80%
– The additional amount will be deducted from a beneficiary’s monthly SSA/RRB benefit
• Beneficiaries will receive a notice from SSA
• It does not go to the Part D plans
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Affordable Health Care Act and Medicare Part D: Medicare Prescription Drug Benefit Changes
• 2010– $250 Rebate Check for beneficiaries who reach the donut hole anytime in 2010– Beneficiaries with Medical Assistance and Medicare (dual eligible) and people
receiving the Medicare Part D Extra Help (Low Income Subsidy) are not eligible for the $250 rebate
• 2011– 50% discount on brand name drugs purchased while the beneficiary is in the
donut hole– 7% discount on co-insurance for generic drugs purchased while the beneficiary
is in the donut hole. Beneficiary pays 93%
Medicare Part D• Closes the coverage gap over time
– Medicare Coverage Gap Discount Program• Begins on January 1, 2011
– Receive up to a 50% discount on Part D covered brand-name drugs and a 7% discount on generic drugs (2011)
• Gradually reduces the out-of-pocket costs for brand-name and generic drugs
• Gap will be “closed” by 2020– Beneficiaries still liable for 25% co-insurance between the initial
coverage limit (ICL) and the catastrophic coverage level– Reduces the catastrophic coverage level; it currently stands at
$6,440 in total annual Part D drug costs.
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5%95% Catastrophic Benefit
100%
75%25%
$310 Deductible
Monthly Premium
$2,840.01 - $6,447.50
$310.01 - $2,840
$.01 - $310
Over $6,447.50 (copays of $2.50/$6.30 or 5%)
Drug Costs
Beneficiary CostsPart D Plan
2011Part D Standard Benefit
No Extra Help (LIS)
Donut Hole50% discount on Brand Name drugs
7% discount on co-insurance for generic drugs
5%95% Catastrophic Benefit
25% of Drug cost
75%25%
$ Deductible
Monthly Premium
Unknown
Unknown
Unknown
Unknown
Drug Costs
Beneficiary CostsPart D Plan
Fully Phased in 2020Part D Standard Benefit
Beneficiary donut hole cost sharing reduced to 25% for drug costs
Donut Hole 75%
2011 Benchmark Plans for Minnesota
• A prescription drug plan with a monthly premium at or below the low income premium subsidy amount
• MN Benchmark Amount in 2011: $37.47• 9 Options for 2011
– Ensure plan is still a benchmark in in 2012
• Dual eligible premiums for these plans are completely covered by LIS– Duals can enroll in non-benchmark plans, but
will have out of pockets costs for the premium
2011 Minnesota Part D Benchmark Plans• BCBS MedicareBlue Rx Standard• First Health Part D Premier• HealthSpring Prescription Drug Plan• Humana Walmart – Preferred Rx Plan• Universal American Community CCRx Basic• Silverscript CVS Caremark Value• Sterling Rx• United Healthcare AARP Medicare Rx Preferred• WellCare Classic
Low-Income Subsidy• Redetermination Process
– Allows widows and widowers to delay redetermination for the LIS for 1-year after the death of a spouse (effective January 1, 2011)
– Requires CMS to transmit, within 30 days of a beneficiary being automatically reassigned to a new Part D plan, information on the differences between the former plan’s and new plan’s formularies and information on the coverage determination, exception, appeal and grievance processes (begins in 2011)
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2011 Medicare Part D for Dual Eligibles
• All dual eligibles including: – Waivers
– MA-EPD
• All Medicare Savings Program enrollees– QMB
– SLMB
– QI
• On SSI and no Medicaid
Catastrophic Benefit100% PlanNo co-pays
Co-Pays
Co-Pays
$1.10/$3.30 <100% FPL
$2.50/$6.30 >100% FPL
No premiumsNo deductibles
$.01 - $6,447.50
Over $6,447.50
Beneficiary Costs
Part D Plan
2011 Part D Full Extra Help (LIS)No Premiums if in Benchmark PlanNo DeductibleNo CoinsuranceNo Doughnut HoleNo monthly cap on co-pays
Drug Costs
Full Dual Eligible Co-pays
2007 2008 2009 2010 2011
Copays SNF and ICF/MR does not apply to assisted living
$0 $0 $0 $0 $0
Income < 100% FPG
$1/generic$3.10/brand
name
$1.05/generic$3.10/brand
name
$1.10/generic$3.20/brand
name
$1.10/generic$3.30/brand
name
$1.10/generic$3.30/brand
name
Income > 100% FPG
$2.15/generic$5.35/brand
name
$2.25/generic$5.60/brand
name
$2.40/generic$6.00/brand
name
$2.50/generic$6.30/brand
name
$2.50/generic$6.30/brand
name
Catastrophic BenefitCo-Pays $2.50/$6.30
15% 85%
$63 Deductible
Sliding Scale Premiums
$63.01- $6,447.50
$.01 -$63
Over $6,447.50
Drug Costs
Beneficiary Costs
Part D Plan
2011Part D Partial Extra Help (LIS)
•Lower Premiums•Lower Deductible
•Lower Coinsurance•No Doughnut Hole
will vary
Medicare Part D Info
• Beginning January 1, 2013– Medicare Part D coverage for benzodiazepines and
barbiturates will begin
• Cost-sharing– Eliminates cost-sharing for dual-eligible beneficiaries
receiving services under a Medicaid home and community-based services (HCBS) waiver program
– Effective no earlier than January 1, 2012
Annual Election Period Change
• Beginning Fall 2011, the Annual Election Period will change to
• October 15, 2011- December 7, 2011 (54 days)
• Will need to make plan changes during this time period– No changes from December 8 – December 31, 2011
• Plan enrollment effective date will be January 1, 2012
• Can change Medicare Advantage Plans or Stand Alone PDP Plans
• PLEASE HELP spread the word to your Medicare beneficiaries!
Preventive Services• New Annual Wellness visit
– Beneficiaries receive personalized prevention plan services (PPPS)
• Establish or update the individual’s medical and family history
• List individual’s current medical providers and suppliers and all prescribed medications
• Record measurements of height, weight, body mass index, blood pressure and other routine measurements
• Detect any cognitive impairment
• Establish a screening schedule for the next 5 to 10 years
• Provide personal health advice and coordinate appropriate referrals and health education
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Preventive Services• Eliminates cost-sharing for most Medicare-covered
preventive services– Annual Part B deductible and 20% coinsurance– Effective January 1, 2011
• Eliminates the Part B deductible for tests that begin as colorectal cancer screening tests, but based on findings from the test, become diagnostic or therapeutic services
19
Web Tools for Beneficiaries and Caregivers• Nursing Home Compare Website: Requires CMS to add
certain information to its Nursing Home Compare Medicare website that includes:
• Staffing data• Links to state websites regarding state nursing home survey
and certification programs• Model complaint form• Summary of substantiated complaints• Information on criminal violations by a facility or its employees
23
Web Tools for Beneficiaries And Caregivers• Physician Compare Website
– Requires the Secretary of HHS to develop by January 1, 2011 a “Physician Compare” website with information on physicians enrolled in the Medicare program and other eligible professionals who participate in the Physician Quality Reporting Initiative
– Adding to the new Physician Compare website (available no later than January 1, 2011), requires the Secretary of HHS to implement, by January 1, 2013, a plan for making available comparable information on physician performance including quality and patient experience measures, patient outcomes, coordination of care, safety, effectiveness and timeliness of care, and other information
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Your Link to An Expert: Senior LinkAge Line®• Senior LinkAge Line® 1-800-333-2433
– Statewide– Objective– Comprehensive– Individualized assistance by phone, in your community and in your
home– Federally designated State Health Insurance Assistance Program
(SHIP) for Minnesota– There is no fee or charge for assistance provided– Does not sell, endorse or promote any insurance, long-term care or
health care product• Senior LinkAge Line® is your Long-term Care Options and Medicare
Expert in Minnesota
MinnesotaHelp Network™ is here to help you
• Senior LinkAge Line® 1-800-333-2433• Disability Linkage Line® 1-866-333-2466• Veterans Linkage Line™ 1-888-LinkVet• www.MinnesotaHelp.info® (including Live Chat)• http://longtermcarechoices.minnesotahelp.info/• Local community based sites throughout Minnesota
Questions?
• Contact Information– Stephanie Minor
– 651-431-2602
Elder Justice Act/ MN Adult Elder Justice Act/ MN Adult ProtectionProtectionoverviewoverview
Age and Disability Odyssey
June 21, 2011Deb Siebenaler
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Age of Adult Protection Report Vulnerable Adults CY 2009
Age Group Total Percent
Under 30 1,912 11.0%
30 to 49 3,050 17.6%
50 to 64 3,239 18.7%
65 to 74 1,951 11.2%
75 to 84 3,163 18.2%
85+ 4,032 23.2%
Grand Total 17,347 100.0%
Number of Reports: 23,148
Number of Vulnerable Adults: 17,369
missing age data: 22
DHS Data Warehouse April, 2010
Elder Justice Act Elder Justice Act Title XX of the Social Security Act
is amended to include Elder Justice. Elder Justice Coordinating Council
Authorization – such sums Advisory Board on Elder Abuse,
Neglect, and Exploitation Authorization such sums
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Elder Justice Act Elder Justice Act Forensic Centers
Authorization – 4M FY 2011 (to 8M FY 2013, 2014)
Enhancement of long-term care -Grants to enhance training and recruitment and retention of staff, coordination with secretary of labor to recruit and train long term care staff Authorization: 20M FY 2011, 17M FY
2012, 15M FY 2013 and 2014
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Elder Justice ActElder Justice Act Adult Protective Services Functions and
Grants Grants to States: appropriated by the
percentage of total number of elders who reside in the United States who resides in that State - MN 2007 Census 60 and Older Population = 878,200 (1.68% of total population) Estimated EJA funds for MN = 1,566,435
continued
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continuedcontinued Adult Protective Services (Only for Adult
Protective Services – may not be used for any other purpose)
Funds provided to unit of government responsible for providing adult protective services within the State.
Funds will supplement not supplant current expenditures for Adult Protective services in the State.
Authorization: 100M FY 2011-2014
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Elder Justice ActElder Justice Act Adult Protection - State
Demonstration Programs – Grants Training modules for purpose of detecting
or preventing elder abuse Prevention financial exploitation of elders Methods to detect elder abuse Evaluation on forensic training Other matters relating to elder abuse
Authorization: 25M each FY 2011 - 2014
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Elder Justice ActElder Justice Act Long-Term Care Ombudsman
Program Grants and Training Improve capacity for Long-Term Care
Ombudsman Program to respond to and resolve complaints about abuse and neglect Authorization: 5M 2011l 7.5M 2012; 10M 2013
and 2014
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Elder Justice ActElder Justice Act Protecting Residents of Long-Term
Care Facilities National Training Institute for
Surveyors National Back up system (24/7) to
State complaint intake systems. Authorization: 12M for each FY 2011 – 2014
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Elder Justice ActElder Justice Act Reporting to law enforcement of crimes
occurring in federally funded long-term care facilities. Individual shall report to the Secretary
and 1 or more law enforcement entities any reasonable suspicion of a crime against any individual who is a resident of or is receiving care from the facility.
No authorization
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Elder Justice ActElder Justice Act National Nurse Aide Registry
Authorization – Such sums
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