Health Pricing Boot Camp August 10-11, 2009 Session 1b: Medicare Coverage for the Aged and Disabled
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1 Health Pricing Boot Camp August 10-11, 2009 Session 1b: Medicare Coverage for the Aged and Disabled Charles P. Miller, FSA, MAAA
2 Introductions Daniel W. Bailey, FSA, MAAA Ingenix Consulting Russell D. Willard, ASA, MAAA Actuarial Director Humana, Inc. Chuck Miller, FSA, MAAA Principal and Consulting Actuary Milliman, Inc. 1 August 5, 2009 SOCIETY OF ACTUARIES Antitrust Notice for Meetings Active participation in the Society of Actuaries is an important aspect of membership. However, any Society activity that arguably could be perceived as a restraint of trade exposes the SOA and its members to antitrust risk. Accordingly, meeting participants should refrain from any discussion which may provide the basis for an inference that they agreed to take any action relating to prices, services, production, allocation of markets or any other matter having a market effect. These discussions should be avoided both at official SOA meetings and informal gatherings and activities. In addition, meeting participants should be sensitive to other matters that may raise particular antitrust concern: membership restrictions, codes of ethics or other forms of self-regulation, product standardization or certification. The following are guidelines that should be followed at all SOA meetings, informal gatherings and activities: DON T discuss your own, your firm s, or others prices or fees for service, or anything that might affect prices or fees, such as costs, discounts, terms of sale, or profit margins. DON T stay at a meeting where any such price talk occurs. DON T make public announcements or statements about your own or your firm s prices or fees, or those of competitors, at any SOA meeting or activity. DON T talk about what other entities or their members or employees plan to do in particular geographic or product markets or with particular customers. DON T speak or act on behalf of the SOA or any of its committees unless specifically authorized to do so. DO alert SOA staff or legal counsel about any concerns regarding proposed statements to be made by the association on behalf of a committee or section. DO consult with your own legal counsel or the SOA before raising any matter or making any statement that you think may involve competitively sensitive information. DO be alert to improper activities, and don t participate if you think something is improper. If you have specific questions, seek guidance from your own legal counsel or from the SOA s Executive Director or legal counsel. 2 August 5, 2009
3 Welcome to Seattle! Things to do places to see: Pike Place Market Space Needle/EMP Waterfront Safeco Field (Seattle Mariners) Pioneer Square Duck Tours Street Car to Lake Union Monorail to Seattle Center 3 August 5, 2009 Medicare Coverage for the Aged and Disabled Presented by Chuck Miller Milliman, Inc. Principal & Consulting Actuary August 10, 2009
4 Agenda Medicare Timeline Eligibility/Covered Population The ABCD s of Medicare Benefits Provider Reimbursement Funding Supplemental Coverage Medicare Advantage (Part C) Part D 5 August 5, 2009 Medicare: A Timeline of Key Developments 1965: President Johnson signed into law Medicare and Medicaid Programs Former President Truman is the first to enroll Part A Deductible: $40 Part B Premium: $3 July 1, 1966: Coverage begins All persons aged 65 and over automatically covered for Part A 19 million beneficiaries enrolled 1972: Nixon signed the Social Security Amendments of 1972 Eligibility extended to the disabled and ESRD populations 6 August 5, 2009
5 Medicare: A Timeline of Key Developments (cont.) 1982: TEFRA Increased Part B deductible to cover 25% of program costs TEFRA authorized Medicare HMOs Set payments to cover 95% of FFS costs Goals: create incentives to manage care more efficiently and save Medicare money 1997: BBA created the Medicare+Choice program Goals: reduce spending, minimize variation in payments by county, give seniors more choice Created new plans: local PPOs and PFFS 7 August 5, 2009 Medicare: A Timeline of Key Developments (cont.) 2003: Medicare Moderization Act (MMA) Renamed the program Medicare Advantage Authorized regional PPOs and SNPs Modified and increased payments to plans 2006: Part D program implemented 2008: Part A Deductible: $1,024 Part B Premium: $96.40 (higher if income exceeds $85,000) Total Medicare Beneficiaries: 44.8 million Medicare Advantage Enrollment: 9.4 million Total Medicare Spending: $444 billion 8 August 5, 2009
6 people age 65 or older, people under age 65 with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant). 9 August 5, 2009 The Medicare Population Currently, 44 million beneficiaries some 15 percent of the U.S. population are enrolled in the Medicare program. Enrollment is expected to rise to 79 million by Only one in 10 beneficiaries relies solely on the Medicare program for health care coverage. The rest have some form of supplemental coverage to help with medical expenses. Approximately 7.3 million are eligible due to disability and 205,000 are eligible as a result of End-Stage Renal Disease (ESRD) 10 August 5, 2009
7 Characteristics of the Medicare Population, 2007 Percent of total Medicare population: Income less than 200% FPL 3+ chronic conditions 46% 44% Cognitive/mental impairment Fair/poor health Less than high school education 26% 29% 29% Under-65 disabled 2+ ADL limitations Age % 17% 15% Long-term care facility resident 4% NOTES: ADL is activity of daily living. The federal poverty (FPL) threshold for people age 65 and over was $10,210/individual l and $13,690/couple in SOURCE: Income data from US Census Bureau, Current Population Survey published on statehealthfacts.org; ; all other data from Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey 2007 Access to Care file. 11 August 5, 2009 Small Percentage of Beneficiaries Account for a Large Portion of the Total Cost 12 August 5, 2009
8 The ABC s of Medicare Part A: Hospital Insurance Inpatient hospital Skilled nursing facility Home health Hospice Part B: Supplementary Medical Insurance Outpatient hospital Physician drugs and biologicals that cannot be self-administered PT/OT/ST Durable medical equipment (DME) Ambulance service 13 August 5, 2009 Medicare Benefits Part A (2009) 14 August 5, 2009
9 Part A Basics Eligibility Entitlement begins automatically at age 65 if also eligible for Social Security benefit Also eligible if entitled to Social Security disability If age 65+ and not eligible for Part A, can voluntarily enroll Funding Payroll tax Federal Hospital Insurance (HI) Trust 2.9% total, split evenly between employer and employee Federal Hospital Insurance (HI) Trust running out of $$ Member premiums (very few members pay a premium) Taxes on Social Security Benefits Interest Income Trust funded projected to be insufficient in August 5, August 5, 2009
10 17 August 5, 2009 The ABC s of Medicare Part A: Hospital Insurance Inpatient hospital Skilled nursing facility Home health Hospice Part B: Supplementary Medical Insurance Outpatient hospital Physician Drugs and biologicals that cannot be self-administered PT/OT/ST Durable medical equipment (DME) Ambulance service 18 August 5, 2009
11 Medicare Benefits Part B (2009) 19 August 5, 2009 Part B Basics Eligibility Voluntary Program Pay monthly premium ($ $308.30, depending on income) Individual is eligible for enrollment in Part B program if the individual is entitled to Part A benefits or has attained the age of 65 and is (a) a resident of the United States and is (b) either a citizen of the United States or permanent resident Funding Supplementary Medical Insurance (SMI) Trust Pay monthly premium ($ $308.30, depending on income) Covers 25% of expenses General Revenues and Interest Income Covers 75% of expenses SMI Trust rebalanced each year so won t run out of $$ 20 August 5, 2009
12 21 August 5, 2009 How Are Providers Reimbursed? Provider Reimbursement = Prospective Payment System Inpatient Diagnostic Related Groups (DRG) Case Rates Outpatient Ambulatory Payment Classification (APCs) Physician Resource Based Relative Value Scale (RBRVS) Units x Conversion Factor = Payment Rate Other Fee Schedules Lab, DME, etc. 22 August 5, 2009
13 Supplemental Coverage Medicare Supplement / MediGap Standardized packages (A-L, 12 options) that fill in the gaps and provide additional benefits, administered by private companies All Medigap plans must cover certain basic benefits (Plan A) Medicare Part A Coverage: Coinsurance for hospital days ($267 in 2009) and Coinsurance for each day ($534 in 2009) (up to 60 days in your lifetime) Cost of 365 extra hospital days in your lifetime, once you've used all Medicare hospital benefits Medicare Part B coverage: Generally, all coinsurance and copayment amounts after you meet the $135 (in 2009) yearly deductible for Medicare Part B The first three pints of blood Plans B-L offer additional coverage Part A deductible, Part B deductible, SNF, preventive care, etc. 23 August 5, August 5, 2009
14 The ABC s of Medicare Part A: Hospital Insurance Part B: Supplementary Medical Insurance Part C: Medicare Advantage (MA) Program Direct contracts with health plans to provide coverage Part D: Prescription Drug Program Prescription Drug Plans (PDPs) Competitive bids to provide prescritpion drug only coverage MA-PD Plans (Medicare Advantage + Prescription Drugs) Each contracted organization must provide drug coverage 25 August 5, 2009 Part C Plan Types Coordinated Care Plans HMO with or without point of service (POS) Provider Sponsored Organization (PSO) PPO (local or regional) Special Needs Plan Private Fee-for-Service Plan MSA high deductible plan and contribution to Medical Savings Account Religious Fraternal Benefit Plan 26 August 5, 2009
15 Part C Basics Benefits MA organization must provide members with all original Medicarecovered services (Parts A and B), except hospice. All benefits must be health-related offered uniformly to all members priced in the bid filed with CMS mentioned in marketing vehicles MA plans typically offer benefits much richer than FFS Medicare Funding Health Plans contract directly with CMS (Centers for Mediare and Medicaid Services) to take full Part A and B risk Benchmark payment rates published by county Payment rates are risk adjusted Annual bids due the 1 st Monday of June 27 August 5, 2009 Medicare Advantage Enrollment 28 August 5, 2009
16 Medicare Advantage Marketplace Over 11 Million Covered by MA-PD Plan in % of total beneficiaries in MA Plans Nine states with 30+% enrollment Eleven states with <10% enrollment Half of all MA enrollees live in six states CA, FL, NY, OH, PA, and TX Enrollment rates are substantially higher in urban than in rural counties 2009 Plan Type Enrollment (Millions) Local HMO 6.9 Local PPO 0.9 Regional PPO 0.4 PFFS 2.4 MSA/Cost/Other 0.5 Total August 5, 2009 Part D Basics Eligibility Entitled to benefits under Part A and enrolled in Part B Lives in a Part D plan service area Voluntary Enrollment Plan Types Standalone PDPs MA-PDs (e.g., HMOs, PPOs) Funding Medicare Prescription Drug Account Member premium (2009 National Average approx. $30/month) General Revenues and Interest Income Payments from states for their dual eligibles Additional cost of enhanced benefits responsibility of the member 30 August 5, 2009
17 If YOU think Part D is confusing 31 August 5, Defined Standard Part D Benefit 32 August 5, 2009
18 Part D Coverage Sources 33 August 5, 2009 Thank You! Chuck Miller Milliman (Seattle) (206) chuck.miller@milliman.com 34
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