2004 REACH National Medicare Training Program
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Transcript of 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
Prescription Drug Plans
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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
Prescription Drug Plans
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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%
Prescription Drug Plans
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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?
Prescription Drug Plans
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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)
Prescription Drug Plans
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Lower-Income Assistance
Prescription Drug Plans
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
Prescription Drug Plans
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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
New Preventive Services
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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
New Preventive Services
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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
New Preventive Services
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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
New Preventive Services
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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
Medicare Advantage Plans
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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
Medicare Advantage Plans
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New Plan Options
• New plan choices in 2006
• Most important new option—Regional Preferred Provider Organizations (PPO)
Medicare Advantage Plans
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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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MMA Demonstration Projects
• 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
Demonstration Projects
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MMA Demonstration Projects
• 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
Demonstration Projects
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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
Other MMA Provisions
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Changes to Part B Deductible
• $100 since 1991
• Increases to $110 in 2005
• Updated based on Medicare expenditures, 2006 on
Other MMA Provisions
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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
Other MMA Provisions
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Therapy Limits
• Limits created by the BBA 1997
• Moratorium effective until 2003
• Moratorium reinstated through 2005
Other MMA Provisions
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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
Other MMA Provisions
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Communicating with the Public
• Medicare beneficiaries
• Health care providers
• Governors, state legislators, and local officials
• Congress
• Advocates
• Other stakeholders
Other MMA Provisions
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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!