Medicare Benefits and Updates SENIOR HEALTH INSURANCE PROGRAM

Transcription

1 Medicare Benefits and Updates SENIOR HEALTH INSURANCE PROGRAM Governor s Conference on Aging 2013

2 Welcome 2 JOSHUA B. FRYE, M.S. Staff Development Specialist IL Senior Health Insurance Program- SHIP 320 W. Washington Springfield, IL Phone Fax

3 What is SHIP? Senior Health Insurance Program Established in 1988 Free Medicare counseling program, sponsored by the State of Illinois, Department of Insurance SHIP does not sell or solicit insurance Dedicated to educating people with Medicare SHIP trains volunteer counselors throughout Illinois 3 Provides one-on-one counseling through community based sites for Medicare Beneficiaries, family members and caregivers

4 Medicare has four parts Medicare 4 Part A Hospital Insurance Part B Medical Insurance Original Medicare Part C Medicare Advantage HMO, PPO, PFFS, SNP, and MSA Also know as Managed care Part D Prescription Drug Coverage Medicare Supplement Insurance Not to be confused with secondary insurance

5 Piecing together Medicare Original Medicare 5 Medicare Advantage Part A Part B Part A & B MedSup or Secondary Part D or Secondary Some will include Part D

6 Part A Covered Services 6 Inpatient Hospital Care Skilled Nursing Facility Care Home Health Care Hospice Care

7 Part A Costs for Inpatient Hospital Stays For each benefit period in 2013 Days 1-60 Days Days All days after You Pay (2013) $1,184 deductible $296 per day $592 per day (60 lifetime reserve days) All Costs

8 Part A Costs for Skilled Nursing Facility Care 8 For each benefit period in 2013 You Pay (2013) Days 1-20 $0 Days $148 per day All days after 100 All Costs

9 Part B Covered Services Medical Expenses Home Health Care Outpatient Hospital Services Durable Medical Equipment (DME) 9

10 2012 Part B Amounts 10 Part B Annual Deductible - $147 Part B Monthly Premium If your income is $85K or less and you paid this in 2012 You pay this in 2013 $99.90 $104.90

11 Income-Related Part B Premium Part B premium income thresholds 11 Frozen at 2010 levels through 2019 If your Yearly Income in 2011 was In 2013 You Pay* File Individual Tax File Joint Tax Return Return $85,001 $107,000 $170,001 $214,000 $ $107,001 $160,000 $214,001 $320,000 $ $160,001 $214,000 $320,001 $428,000 $ above $214,000 above $428,000 $ *Higher if you have a late enrollment penalty

12 Medicare Preventive Services Implemented January 1, 2011 Elimination of Part B Deductible and Coinsurance You pay nothing for most preventive services When a doctor or health care provider accepts assignment The amount you pay varies and depends on whether you get your Medicare benefits through 12 Original Medicare (fee-for-service); or Medicare Advantage Plan (HMO, PPO, etc) Some services are completely free!

13 Preventive Services New in 2012 Alcohol Misuse Counseling Behavioral Therapy for Cardiovascular Disease 13 Depression Screening Sexually Transmitted Infections Screening and Counseling

14 New Fraud Partnership 14 GOAL: Reveal and halt scams that cut across a number of public and private payers. Shares information and best practices in order to improve detection and prevent payment of fraudulent health care billings. The partnership will enable those on the front lines of industry anti-fraud efforts to share their insights more easily with investigators, prosecutors, policymakers and other stakeholders.

15 New Fraud Prevention Efforts Tougher sentences for people convicted of health care fraud. Criminals will receive 20 to 50 percent longer sentences for crimes that involve more than $1 million in losses; Enhanced screenings of Medicare and Medicaid providers and suppliers to keep fraudsters out of the program. Suspended payments to providers and suppliers engaged in suspected fraudulent activity. 15

16 Health Care Fraud The administration s efforts to date have already resulted in over $10.7 billion in recoveries of health care fraud over the last three years. d a.html 16

17 DMEPOS Competitive Bidding Program: 17 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program

18 DMEPOS Competitive Bidding Part B covered equipment and supplies New Competitive Bidding Program Round 1 began January 1, 2011 in 9 areas Parts of CA, FL, IN, KS, KY, MO, NC, OH, PA, SC, TX Beneficiaries must use contract suppliers In certain areas For certain products Competitive Bidding Program will expand Round 2 - Effective July 1, 2013 Chicago-Joliet-Naperville, IL-IN-WI St. Louis, MO-IL Visit 18 MMA MIPPA ACA

19 Who is Affected by Competitive Bidding? Beneficiaries who have Original Medicare and Live in a Competitive Bidding Area (CBA), or Obtain competitive bid items while visiting a CBA To see if ZIP code is in a CBA Call MEDICARE ( ) TTY users should call Visit Medicare Advantage enrollees use plan suppliers 19

20 Products Included in Competitive Bidding Program Round 1 Rebid Round 2* Oxygen, oxygen equipment, and supplies Enteral nutrients, equipment, and supplies Continuous Positive Airway Pressure (CPAP) devices and Respiratory Assist Devices (RADs), and related supplies and accessories Hospital beds and related accessories Walkers and related accessories Support surfaces (Group 2 mattresses and overlays) (in Miami area only) Standard power wheelchairs, scooters, and related accessories Complex rehabilitative power wheelchairs and related accessories (Group 2) Mail-order diabetic supplies Not included 20 Oxygen, oxygen equipment, and supplies Enteral nutrients, equipment, and supplies Continuous Positive Airway Pressure (CPAP) devices and Respiratory Assist Devices (RADs), and related supplies and accessories Hospital beds and related accessories Walkers and related accessories Support surfaces (Group 2 mattresses and overlays) Standard (power and manual) wheelchairs, scooters, and related accessories Not included (CMS evaluating suitability of this product category under the program) National mail-order competition for diabetic supplies will occur at same time as Round 2 competition Negative pressure wound therapy pumps and related supplies and accessories

21 Using Contract Suppliers Must use contract supplier for products included in the Competitive Bidding Program if Living in a Competitive Bidding Area (CBA), or Traveling to, or visiting, a CBA Exceptions 21 Doctors and hospitals can supply certain items (e.g., walkers) Nursing facility can supply items directly if it is a contract supplier

22 Identifying Contract Suppliers Call MEDICARE ( ) TTY users call Visit the Medicare Supplier Directory 22 Look for star icon Identifies Competitive Bidding Program suppliers and products

23 Timeline for Round 2 23 Fall 2012* CMS announces single payment amounts, begins contracting process Spring 2013* CMS announces contract suppliers, begins contract supplier education campaign Spring 2013* CMS begins supplier, referral agent, and beneficiary education campaign July 1, 2013* Implementation of DMEPOS Competitive Bidding Program Round 2 and National Mail-order Competition contracts and prices *Target date

24 Medicare Part C Medicare Advantage (MA) Provided through private insurance companies Offered through HMO, PPO, PFFS, MSA an SNP Must offer all services covered under Medicare Part A and Part B May be able to offer extra services May include Drug Coverage Cannot have a Medicare Supplement plan while in Part C 24 Must live in plans service area Must follow plans guidelines for coverage

25 Medicare Part D 25 Began in 2006 Offered by private companies contracted with Medicare to provide prescription drug coverage Available to anyone enrolled in Medicare Part A and/or Part B Coverage offered: Stand-alone Prescription Drug Plan (PDP), or As part of a Medicare Advantage Plan (MA-PD)

26 Medicare Prescription Drug Coverage Premium 26 Individuals with higher incomes pay a higher Part D premium Same income thresholds are used to compute income-related adjustments to the Part B premium As reported on your IRS tax return 2 years prior ACA Must pay additional Part D amount to SSA.

27 Income-Related Adjustment to Part D Premium 27 ACA If your Yearly Income in 2011 was File Individual Tax Return File Joint Tax Return In 2013 You Pay $85,000 or below $170,000 or below Plan Premium (PP) $85, $107,000 $170, $214,000 PP + $11.60 $107, $160,000 $214, $320,000 PP + $29.90 $160, $214,000 $320, $428,000 PP + $48.30 $214, or higher $428, or higher PP + $66.60

28 2013 Part D Benefit Limits Annual Deductible Up to $320 Up to $325 Initial Coverage Limit $2,930 $2, True-Out-of-Pocket Limit (TrOOP) Catastrophic Coverage Limit Copayment for a generic or preferred drug that is a multisource drug after catastrophic coverage limit All other drugs after catastrophic coverage limit $4,700 $4,750 $6, $6, $2.60 $2.65 $6.50 $6.60

29 Benefit Stage 2013 Part D Cost Sharing Coverage Range = Total Rx Cost Medicare and/or Drug Plan Pays Beneficiary Pays Stage I Annual Deductible $0-$325 0% or $0 100% Stage II Initial Coverage $325-$ % 25% Stage III Coverage Gap/ Donut Hole $ % -Brand Name 21% - Generic 47.5% -Brand Name 79% - Generic Stage IV Catastrophic Coverage $ & Up 95% 5%

30 Deductible and Initial Coverage Deductible Up to $ Annual, amount of money paid by the beneficiary or on behalf of the beneficiary prior to drug coverage beginning. Initial Coverage to $2970 of total, retail Rx costs At this point, beneficiary pays 25% of Rx costs

31 Donut Hole or Coverage Gap Between $2,970 and $6, in full drug costs 31 The beneficiary s cost-sharing for drugs increases once a beneficiary uses $2,970 in drug costs. This is called the donut hole. Note: the full cost of the drug (not just the co-pay the beneficiary was paying during the initial coverage limit) is used to reach the donut hole.

32 More Affordable Prescription Drugs Discounts for % discount on brand-name drugs and 21% subsidy on generic-drugs during the donut hole. 32 Elimination of the Donut Hole by 2020 Your cost-share should be approximately 25% during the plan year.

33 Part D Coverage Gap 5.2 million beneficiaries have saved over $3.9 billion on Rx drugs 33 In the first half of 2012, over 1 million people with Medicare saved a total of $687 million on prescription drugs in donut hole coverage gap for an average of $629 in savings this year. In Illinois: 144,226 beneficiaries reached the coverage gap $96 Million in total gap discounts $667 average gap discount per beneficiary

34 Cost Sharing for Brand-name Drugs in the Medicare Part D Coverage Gap,

35 Cost Sharing for Generic Drugs in the Medicare Part D Coverage Gap,

36 Catastrophic Coverage 36 After $6, in full drug costs are accumulated At this point, the plan pays 95%, and the beneficiary pays 5% or $2.65/$6.60 (whichever is greater for the remainder of the calendar year).

37 Formulary Changes for 2013 Plans are not allowed to make any changes to their formularies during the AOEP and within the first 60 days of the contract year. Typically, Medicare drug plans will not remove a drug from its formulary unless the drug is withdrawn from the market by the FDA. Maintenance Changes are allowed. Step therapy, tier changes, prior approval Benzodiazepines and Barbiturates will appear. 37

38 Home and Community Based Waiver Services (HCBS) 38 There are 9 HCBS programs in Illinois: S/Pages/default.aspx Children & Young Adults with Dev Disabilities Support Waiver Children & Young Adults with Dev Disabilities Residential Waiver Children that are Technologically Dependent/Medically Fragile Persons with Disabilities Persons with Brain Injuries Adults with Dev Disabilities Persons who are Elderly Persons with HIV or Aids Supportive Living Facilities Administered through: Illinois Department on Aging DHS Division of Rehabilitative Services DHS Division of Development Disability Services Includes DRS Home Services Program Includes Department on Aging Community Care Program

39 Special Part D Co-Pay Structure 39 NEW in 2012 For dual eligibles (full Medicaid and Medicare benefits) receiving Home and Community Based Waiver Services (HCBS) $0 co-pay for prescriptions Similar to co-pay structure for duals in a nursing home Must keep dual eligible status Contact your DHS case worker with any questions regarding this program.

40 Use Medicare.gov for resources Top 7 Services on Medicare.gov Find out what Medicare costs in 2013 Find health and drug plans, compare and enroll Apply on-line for Medicare Find out if Medicare covers your tests, items, services Get Extra Help with prescription drug costs Find out how Medicare works with your other insurance Get a new Medicare card Link to MyMedicare.gov 40

41 SHIP Resources and Publications Medicare Supplement Premium Comparison Guide Medicare Medicare & You 2012 handbook TTY Social Security Administration Extra Help application Dept on Aging

42 42 Thank you