Health Care Reform, Medicare, and You. How the Affordable Care Act affects people with Medicare. Be Happy. Live Healthy.
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1 Health Care Reform, Medicare, and You How the Affordable Care Act affects people with Medicare Be Happy. Live Healthy.
2 Health care reform impacts Medicare The Affordable Care Act (ACA) isn t just for the younger generations. If you re on Medicare right now or are approaching age 65, it may affect you. This sweeping health care reform legislation has changed much about health insurance since it was passed in Some changes are already in place and more are still to come during the next few years. Read through this brochure to find out some of the ways the ACA impacts Medicare coverage. This brochure contains information that may help you understand some of the new rules. It is intended for informational purposes only and should not be considered legal advice. The information is not specific to WPS policies, but rather intended as general educational material; actual plan details may vary. For detailed information and guidance related to the Affordable Care Act, please talk to your health insurance agent/broker or your WPS representative. In the emerging health care reform era, your agent is likely to become an even more important resource. You can also refer to (the official website for health care reform set up by the U.S. Department of Health and Human Services), your attorney, or your accountant. Seniors get extra benefits from the ACA The Affordable Care Act (ACA) gives Medicare-age people a little extra help. It protects basic Medicare benefits and improves other benefits. Under the health care reform law, no guaranteed Medicare benefits are cut or eliminated. 1 Donut hole You ve probably heard about the coverage gap, or donut hole, in Medicare prescription drug coverage. The ACA helps you pay for your drugs when you reach this gap. In 2013, people in the donut hole pay 47.5% of what the plan charges for brand-name drugs, which is a 52.5% discount. 2 There is also a 21% discount on generic drugs. By 2020, the amount people pay will shrink to 25% until they reach the catastrophic coverage level. One important note here is that although you will pay only a percentage of the price for the brand-name drug, the entire drug cost will count toward the amount you need to qualify for catastrophic coverage. Schedule for Drug Discounts in the Coverage Gap 3 Year Brand-name drug discount Generic drug discount % 21% % 28% % 35% % 42% % 49% % 56% % 63% % 75%
3 Preventive services One of the aspects of ACA that many people like is that preventive services 4 are 100% covered. There s no copay and you don t have to meet your deductible first. Your annual wellness visit and your necessary screenings are all covered. Benefits include: Abdominal aortic aneurysm screening Alcohol misuse screening and counseling Bone mass measurements (bone density) Cardiovascular disease screening Cardiovascular disease (behavioral therapy) Cervical and vaginal cancer screening Colorectal cancer screening Depression screening Diabetes screening Diabetes self-management training Glaucoma tests HIV screening Mammograms (screening) Nutrition therapy services Obesity screening and counseling One-time Welcome to Medicare preventive visit Prostate cancer screening Sexually transmitted infection screening and counseling Shots: flu, hepatitis B, pneumococcal Tobacco use cessation counseling Yearly Wellness visit You can read more about the expanded preventive and screening services put in place by the ACA online at www. medicare.gov/coverage/preventive-and-screening-services. html.
4 Help for long-term care In the United States, there are currently millions of older adults who need help at home and are often forced to spend their life savings to get the care they need. Medicare does not cover long-term care at home and many people do not purchase private long-term care insurance. Medicare pays only for time-limited, medically necessary skilled nursing facility care or home health care if you meet certain conditions. 5 Through ACA, federal funds will be given to states that provide in-home services through Medicaid. PACE The Program of All-Inclusive Care for the Elderly 6 (PACE) is a Medicare and Medicaid program that allows people who otherwise need nursing home-level care to remain at home. PACE provides coverage for prescription drugs, doctor visits, transportation, home care, check-ups, hospital visits, and even nursing home stays when necessary. To qualify for PACE, you must meet the following conditions: You are age 55 or older. You live in the service area of a PACE organization. You are certified by your state as needing a nursing home level of care. At the time you join, you are able to live safely in the community with the help of PACE services. In Wisconsin, as of June 2013, PACE programs are available in Waukesha and Milwaukee. You can check for the availability of a PACE organization in your area online at Elder abuse ACA also requires enhanced training for workers who care for seniors. It adds protections against elder abuse, neglect, and financial exploitation. In 2012, the U.S. Department of Health and Human Services made $5.5 million 7 in Prevention and Public Health Fund resources available to test interventions for elder abuse prevention in States and tribal communities. These funds will support strategies to effectively prevent and detect instances of elder abuse, neglect and exploitation so individuals are better supported and able to safely remain and thrive in their own homes. A new agency, the Administration for Community Living, was created in April Its website, gov/, is full of resources, including longtermcare.gov/, which can help with planning for long-term care.
5 Higher premiums for higher-income earners Beginning in 2007, Medicare Part B beneficiaries whose income was greater than $85,000 for an individual or $170,000 for a couple were required to pay a higher Part B premium. 8 The amount of the increase ranges from 35 to 80% of Part B program costs, depending on the income level. The premium changes were originally indexed to rise with inflation, but were frozen by the Affordable Care Act (ACA) from 2011 through This freeze will increase the number of beneficiaries who will pay the higher premium during these years. In 2020 and thereafter, the income thresholds will once again be indexed to inflation. Higher-income Medicare beneficiaries who are enrolled in Part D prescription drug plans will also pay higher premiums for those plans as a result of the ACA. 8 The Part D change follows the same income levels as the Part B change: individuals making $85,000 or more or a couple making $170,000 or more will pay between 35 and 80% more for their Part D plans. As with Part B, the income thresholds are frozen until Percentage of Part B and Part D Program Costs Covered by Premium 8 Standard Income-Based Percentage 25% 35% 50% 65% 80% Income Level for Individuals Income Level for Couples $85,000 or less $85, ,000 $170,000 or less $170, ,000 $107, ,000 $214, ,000 $160, ,000 $320, ,000 $214,001 or more $428,001 or more
6 Stretching the Medicare Trust Fund The Affordable Care Act (ACA) reduces Medicare spending growth, which extends the solvency of the Medicare Part A Trust Fund for nine more years. This extension means the fund is expected to have insufficient funds to pay all hospital bills beginning in 2024 rather than To extend the fund s life, ACA will reduce overpayments 1 to Medicare Advantage (MA) plans, which are used by about 25% of seniors. MA plans cost Medicare about 13% more than original Medicare. About half of the savings will come from slowing down payment increases to providers, such as hospitals, nursing homes, and home health agencies. About 10% of the savings will come from reducing fraud and waste, along with eliminating program inefficiencies. Some savings will also come from higher-income beneficiaries paying higher Medicare premiums. The slowdown in payment increases will save money for the Medicare program. The independent, non-partisan Congressional Budget Office (CBO), which is in charge of the Medicare budget, estimates that the law will save Medicare about $400 billion over the next 10 years. If you re concerned that Medicare benefits will be reduced, don t worry. Payments to doctors are not reduced and this slowdown does not affect Medicare benefits in any way.
7 Sources 1 National Council on Aging. Straight Talk for Seniors : How does the health reform law affect you? (2010). Retrieved from straight-talk-for-seniors-on.html 2 Medicare.gov. Costs in the Coverage Gap (June 2013). Retrieved from gov/part-d/costs/coverage-gap/part-d-coverage-gap.html 3 Medicare.gov. More savings in the drug coverage gap coming through 2020 (June 2013). Retrived from 4 Medicare.gov. Preventive and Screening Services (June 2013). Retrieved from medicare.gov/coverage/preventive-and-screening-services.html 5 LongTermCare.gov. Who Pays for Long-Term Care? (2013). Retrieved from 6 Medicaid.gov. Program of All-Inclusive Aid for the Elderly (PACE) (). Retrived from Support/Integrating-Care/Program-of-All-Inclusive-Care-for-the-Elderly-PACE/Program-of- All-Inclusive-Care-for-the-Elderly-PACE.html 7 U.S. Department of Health & Human Services. HHS grants to help protect seniors, test elder abuse prevention strategies (June 14, 2012). press/2012pres/06/ a.html 8 Kaiser Family Foundation. Medicare Policy Issue Brief: Income-Relating Medicare Part B and Part D Premiums Under Current Law and Recent Proposals: What Are the Implications for Beneficiaries? (February 2012). Retrieved from com/2013/01/8276.pdf 9 The Journal of the American Medical Association. Medicare s Role and Future Challenges (Nov. 28, 2012). Retrieved from
8 WPS Health Insurance can help you understand Medicare better! Visit for instant access to simple online tools that help you manage your health and health care: Member Area If you have a WPS policy, then you can manage your account online. Find a doctor, view your claims and benefits, request a new ID card, update your address, or check eligibility coverage. Health Center Consult an array of powerful online resources to make better health decisions. You can use action-oriented tools and information to help manage chronic conditions such as asthma and diabetes. Learning Center Access information and interactive tools, from articles and checklists to glossaries and guides, to better understand health insurance and more effectively manage your family s health and wellness. We re here for you! If you have questions about your health plan or about health insurance in general, contact your local agent, call us at or us at WPSIndividualSales@wpsic.com Wisconsin Physicians Service Insurance Corporation. All rights reserved
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