Medicare Advanced Barbara Childers, MSW Centers for Medicare & Medicaid Services.
Post on 01-Apr-2015
217 Views
Preview:
Transcript
Medicare AdvancedBarbara Childers, MSW
Centers for Medicare & Medicaid Services
Session TopicsA.Changes to Medicare as a
result of healthcare reformB.Low Income Subsidy Program
(Extra Help with Drug Plan Costs)
C.Coordination of Benefits
2
Session A: Changes to Medicare as a result of healthcare reform
1.Overview and Highlights2.Medicare Updates
Original Medicare Medicare Advantage Medicare Prescription Drug
Coverage DMEPOS
3
In 2009 – 46.3 million people were covered by Medicare
• 38.7 million aged 65 and older• 7.6 million with a disability
– About 24% in Part C (Medicare Advantage)– $502 billion - Total benefits paid
4
Medicare Statistics
Patient Protection and Affordable Care Act (PPACA)–Signed into law H.R. 3590 on March 23, 2010–Makes numerous statutory changes to Medicare program
The Health Care and Education Reconciliation Act of 2010 (HCERA)
–Signed into law H.R. 4872 on March 30, 2010–Modifies PPACA and adds several new provisions
Together called the Affordable Care Act
5
New Legislation – Health Reform
Highlights of Affordable Care Act
Closes prescription drug coverage “Donut Hole” Strengthens the financial health of Medicare
– Invests in fighting waste, fraud, and abuse– Will extend the financial health of Medicare by 12 years
Changes annual enrollment period for MA and PDP Improves preventive services coverage Promotes better care after a hospital discharge Creates the Center for Medicare & Medicaid
Innovation
6
Highlights of Affordable Care Act (continued)
Help for early retirees (before age 65)– Temporary program to offset cost of expensive premiums
Extends dependent coverage to age 26 Eliminates limits on benefits Provides $11B for Federally Qualified Health Centers
– Outpatient primary care and preventive services– “Safety net” providers
• Community health centers• Public housing centers• Outpatient programs funded by the Indian Health Service• Programs serving migrants and the homeless
7
ACA Section
1001
Pre-Existing Condition Insurance Plan (PCIP) A new health coverage option created by the Affordable Care Act (ACA) Provides coverage for individuals with pre-existing conditions until the
Health Insurance Exchanges are available in 2014 A person applying for PCIP must:
– Reside within the service area of the PCIP;– Be a U.S. citizen or reside in the U.S. legally;– Have been without health coverage for a minimum of 6 months
before applying; and – Have a pre-existing condition, as defined by the PCIP and approved
by HHS. To learn more about this program, including how to apply in your state,
go to “Find Your State” at www.pcip.gov or call 1-866-717-5826 (TTY 1-866-561-1604) which is open from 8 AM to 11 PM EST
To request more information, resources (drop-in articles, facts sheets, etc), presentation for your staff or for questions, please email PCIPro3@cms.hhs.gov
9
Original Medicare Updates Medicare Claims Limit 2011 Amounts Preventive Services Face-to-Face Meeting Rules Therapy Caps Power-driven Wheelchairs Medigap Policies
Medicare Claims Limit
Maximum period for submission of Medicare claims – Reduced time period– Now not more than 12 months
Effective January 1, 2010
10
ACASection
6404
11
2011 Part A Amounts
For inpatient hospital stays in 2011– Each benefit period you pay
• $1,132 total deductible for days 1 – 60 • $283 co-payment per day for days 61 – 90• $566 co-payment per day for days 91 – 150
(60 lifetime reserve days)• All costs for each day beyond 150 days
For Skilled Nursing Facility Care – $141.50 per day for days 21 - 100
2011 Part B Amounts
Part B Annual Deductible - $162 Part B Monthly Premium (hold harmless)
12
If your income is $85K or less and you paid this in 2010
You pay this in 2011
Notes
$96.40 $96.40$110.50 $110.50 If premium deducted from
Social Security$110.50 $115.40 If premium not deducted
from Social Security$0 $115.40 If new to Medicare in 2011
Income-Related Part B Premium
Effective January 1, 2011, Part B premium income thresholds frozen at 2010 levels through 2019
ACASection
3402
13
If your Yearly Income in 2009 was In 2011 You Pay*
File Individual Tax Return File Joint Tax Return$85,001–$107,000 $170,001–$214,000 $161.50$107,001–$160,000 $214,001–$320,000 $230.70$160,001–$214,000 $320,001–$428,000 $299.00above $214,000 above $428,000 $369.10*Higher if you have a late enrollment penalty.
14
Preventive Services
Medicare covers preventive services to help– Find health problems early, when treatment works best– Prevent certain diseases or illnesses/avoid complications
To encourage use and increase accessibility– Part B Deductible and Coinsurance eliminated
• Services affected must have an “A” or “B” rating • By the United States Preventive Services Task Force
New Annual Wellness Visit
ACASection
4104
ACASection
4103
New Home Health Rules
Doctor must meet patient in person– 90 days before the start of care or 30 days after– May be conducted by hospitalist
• Even if another doctor will continue the care/care plan
15
ACASection
6407
New Hospice Rules
Doctor must meet patient in person– Within 30 days of recertification– Starting on the third benefit period– Doctor must be employed by or working under
arrangement with hospice
16
ACASection
3132
Extension of Therapy Cap Exceptions Process
Medicare limits coverage for outpatient therapy– Physical and speech-language pathology
• Combined $1,860 per year
– Occupational therapy $1,860 per year Ability to request exception was to end 2009 Process of therapy caps extension extended
– Therapy caps determined on calendar year basis– All patients began a new cap year on January 1, 2010
17
ACASection
3103
Power-Driven Wheelchairs
Medicare will no longer purchase power-driven wheelchairs with lump-sum payment
Medicare will pay over a 13-month period Purchase option is maintained for complex
rehabilitative power wheelchairs Effective January 1, 2011
18
ACASection
3136
19
Medigap Updates
Makes hospice coverage a basic benefit Deletes preventive services coverage Deletes at-home recovery coverage Creates new Plans D & G, and M & N Eliminates E, H, I, and J Plans
MIPPA
20
2010 Medigap Changes(* denotes new plans and benefits)
Basic Benefits
Deleted Coverage
Deleted Plans
Plan D Plan G Plan M * Plan N *
Add Hospice Coverage- Part A coinsurance*
(Part A coinsurance + 365 days; Part B coinsurance or copayments for outpatient; blood, first 3 pints per year)
Preventive Services; No In-Home Recovery
E, H, I, J Basic, including 100% Part B Coinsurance
Skilled Nursing Facility coinsurance
Part A Deductible
Foreign Travel Emergency
(In-Home recovery deleted)
Basic, including 100% Part B Coinsurance
Skilled Nursing Facility Coinsurance
Part A Deductible
100% Part B Excess *
Foreign Travel Emergency
(In-Home Recovery deleted)
Basic, including 100% Part B Coinsurance
Skilled Nursing Facility Coinsurance
50% Part A Deductible
Foreign Travel Emergency
Basic, including 100% Part B Coinsurance (except up to $20 office visit copayment; up to $50/ER)
Skilled Nursing Facility coinsurance
Part A Deductible
Foreign Travel Emergency
MIPPA
21
Medicare Advantage Updates
Enrollment Period Disenrollment Period Cost limits/Plan Payments Complaint system Appeals
Medicare Advantage Enrollment Periods
2011 and beyond– New dates for AEP – October 15 – December 7
• Change plans or switch to Original Medicare
– MA Open Enrollment Period eliminated
ACASection
3204
22
New MA Annual Disenrollment Period
New in 2011 January 1 – February 14
– Leave MA plan and switch to Original Medicare• Coverage begins first day of following month
– May join Part D plan• Coverage begins first of month after plan gets form
To disenroll and switch to Original Medicare– Make a request directly to MA organization– Call 1-800-MEDICARE– Enroll in a standalone prescription drug plan
ACASection
3204
23
MA – New for 2011
MA Plans can’t charge more than Original Medicare– For certain services, e.g., chemotherapy, dialysis,
and skilled nursing facility care MA Plans must limit your out-of-pocket costs
– For Part A and Part B covered services
24
ACASection
3202
Payments to Medicare Advantage Plans
Frozen in 2011 Benchmarks vary Phased in over 3, 5, or 7 years depending on level of
payment reductions Medicare Advantage benchmarks reduced in 2012 By 2014, 85% of funds plans receive must go to
health care
25
ACASection
3203
Improvement to PDP/MA-PD Complaint System
Secretary to develop easy-to use complaint system – Allows for collection and maintenance of complaints
• Received through any source or by any mechanism • Against PDPs and MA-PD plans
– Must report and initiate appropriate interventions– Must monitor and guide quality improvement
Model form on medicare.gov Secretary to report to Congress annually
ACASection
3311
Uniform Exceptions and Appeals for PDP/MA-PD Plans
Drug plan sponsors– Must use a single, uniform exceptions and appeals process – Must provide access to process
• Toll-free telephone number• Internet website
Exceptions and appeals filed on/after January 1, 2012
ACASection
3312
28
Medicare Prescription Drug Coverage UpdatesIncome-related PremiumLow-Income Benchmark PremiumCoverage Gap
Medicare Prescription Drug Coverage Premium
Higher income pay higher Part D premium– Uses same thresholds used to compute income-related
adjustments to the Part B premium• As reported on your IRS tax return from 2 years ago
Must pay if you have Part D coverage Effective January 2011
29
Income-Related Adjustment to Part D Premium Base beneficiary Part D premium increases
– People with incomes above the thresholds used to compute income-related adjustment to Part B premiums
30
If your Yearly Income in 2009 was In 2011 You Pay File Individual Tax Return File Joint Tax Return
$85,000 or below $170,000 or below Base Premium (BP)
$85,000.01 – $107,000 $170,000.01 – $214,000 BP + $12.00
$107,000.01 – $160,000 $214,000.01 – $320,000 BP + $31.10
$160,000.01 – $214,000 $320,000.01 – $428,000 BP + $50.10
$214,000.01 or higher $428,000.01 or higher BP + $69.10
ACASection
3308
Part D Low Income Benchmark Premiums
Removes MA rebates/quality bonus payments from calculation of Low Income Subsidy benchmark
– Effective January 1, 2011 Provides for voluntary de minimis policy
– Regional benchmark for WV is $34.07 (2011)– Allows Part D plans to absorb cost difference– Remain a $0 premium LIS plan– Effective January 1, 2011
31
ACASection
3302
ACASection
3303
Part D Coverage Gap
If you reach the coverage gap in 2011– You get a 50% discount on brand-name Rx drugs– You get a 7% discount for generic drugs– Entire price counts toward catastrophic coverage– Dispensing fees not discounted
Additional savings in coverage gap each year Gap to be closed in 2020
32
33
Medicare’s Durable Medical Equipment, Prosthetics, Orthotics and Supplies(DMEPOS) Competitive Bidding Program
34
DMEPOS—What You Need to Know
DMEPOS stands for– Durable Medical Equipment, Prosthetics, Orthotics and
Supplies Equipment /supplies covered under Medicare Part B New competitive bidding program
– Effective 1/1/11 If you live in affected area and need certain products
– You must use contract supplier, or – Medicare won’t cover
35
DMEPOS—What You Need to Know
Expected to save Medicare and Beneficiaries – $28 billion over 10 years
• $17 billion in Medicare expenditures• $11 billion in Beneficiary coinsurance and monthly
premium payments
36
Who will Competitive Bidding Affect?
Beneficiaries who have Original Medicare and– Permanently reside in a ZIP Code in a CBA– Obtain competitive bid items while visiting a CBA
To find out if a ZIP Code is in a Competitive Bidding Area– Call 1-800-MEDICARE– Visit medicare.gov
Medicare Advantage enrollees can use suppliers designated by their plan
37
Round 1 Rebid CBAs California – Riverside, San Bernardino, Ontario Florida - Miami, Fort Lauderdale, Pompano Beach Florida – Orlando, Kissimmee Missouri and Kansas - Kansas City North and South Carolina - Charlotte, Gastonia,
Concord Ohio - Cleveland, Elyria, Mentor Ohio, Kentucky, and Indiana - Cincinnati, Middletown Pennsylvania - Pittsburgh Texas - Dallas-Fort Worth, Arlington
38
Products Included in the Program
1. Oxygen, oxygen equipment, and supplies2. Standard power wheelchairs, scooters 3. Complex rehabilitative power wheelchairs – Group 2 only4. Mail-order diabetic supplies 5. Enteral nutrients, equipment, and supplies 6. Continuous Positive Airway Pressure (CPAP) devices and
Respiratory Assist Devices (RADs)7. Hospital beds and related accessories8. Walkers and related accessories9. Support surfaces (Group 2 mattresses/overlays) Miami only
39
Using Contract Suppliers
Must use contract supplier– Item and services included in Competitive Bidding Program
living in a CBA– Traveling to or visiting a CBA
Exceptions– Providers can supply certain items (ex: walkers)– Nursing facility can supply directly if a contract supplier
40
Identifying Contract Suppliers
Call 1-800-MEDICARE (1-800-633-4227) TTY users call 1-877-486-2048 Visit medicare.gov/supplier
– DMEPOS Supplier Locator Tool
41
Points to Remember
The Competitive Bidding Program does NOT affect which physician or hospital you use
May need to change DMEPOS supplier to continue your Medicare coverage
May stay with current supplier if “grandfathered” If in Medicare Advantage plan, check with your plan
42
Round 2
Expands program to 91 Metropolitan Statistical Areas Request for bids begin in 2011 Visit cms.gov/DMEPOSCompetitiveBid/
Session B: Extra Help with Drug Plan CostsWhat it isHow to qualifyEnrollmentContinuing eligibilityYour costs with Extra Help
43
44
What is “Extra Help”
Sometimes called the Low-Income Subsidy (LIS) For people with lowest income and resources
– Pay no premiums or deductibles & small or no copayments Those with slightly higher income and resources
– Pay reduced deductible and a little more out of pocket No coverage gap for people who qualify for LIS
45
Qualifying for Extra Help
You automatically qualify for Extra Help if– You get full Medicaid benefits– You get Supplemental Security Income (SSI) – Medicaid helps pay your Medicare premiums
All others must apply with Social Security– Online at www.socialsecurity.gov, or – Call 1-800-772-1213 (TTY 1-800-325-0778)
• Ask for “Application for Help with Medicare Prescription Drug Plan Costs” (SSA-1020)
Income and Resource Limits
46
Income– Below 150% Federal poverty level
• $1,361.25 per month for an individual* or• $1,838.75 per month for a married couple*• Based on family size
Resources– Up to $12,640 (individual)– Up to $25,260 (married couple)
• Resources include money in a checking or savings account, stocks, and bonds.
• Resources don’t include your home, car, burial plot, burial expenses up to your state’s limit, furniture, or other household items, wedding rings or family heirlooms.
2011 amounts
2011 amounts
*Higher amounts for Alaska and Hawaii
47
Medicare and Full Medicaid
You are auto-enrolled in a plan unless– You are already in a Part D plan– You choose and join a plan on your own– You call the plan or 1-800-MEDICARE to opt out
You are covered 1st month you are covered by– Medicaid and are entitled to Medicare
Will get auto-enrollment letter on yellow paper You have a continuous Special Enrollment Period
48
Others Qualified for Extra Help
Facilitated into a plan unless– You already are in a Part D plan– You choose and join own plan – You’re enrolled in employer/union plan receiving subsidy– You call the plan or 1-800-MEDICARE to opt out
Coverage is effective 2 months after CMS notifies Will get facilitated enrollment letter on green paper Have continuous Special Enrollment Period
49
People New to Extra Help
You can apply for Extra Help any time– If denied, can reapply if circumstances change
If in a Medicare drug plan and later qualify– Plan is notified you qualify for Extra Help– Plan refunds costs back to effective date of Extra Help
• Deductibles/Premiums• Cost-sharing assistance
LI-NET
Limited Income Newly Eligible Transition Program (LI-NET)
– Combined auto-enrollment and Point-of-Sale Facilitated Enrollment
• For full duals and SSI-only beneficiaries
Provides Part D coverage for all uncovered– Full duals and SSI-only beneficiaries retroactively– LIS eligible beneficiaries on a current basis
50
Access to LI-NET
Three ways to access the LI-NET program1. Auto Enrollment by CMS‐2. Point of Service (POS) Use3. Submitting a receipt (Rx already paid out-of-pocket)
– During eligible periods
51
LI-NET Coverage and Enrollment
Coverage– Full Dual/SSI-only up to 36 months– Partial Dual/LIS Applicants up to 30 days– Unconfirmed up to 7 days
Enrolled in LI NET for temporary coverage – In Standard PDP for future coverage
Open Formulary, No Prior Authorization, No Pharmacy Restrictions
Standard PDP Rights for Enrollees, Eligibility Reviews for Non-Enrollees
52
53
Auto- and Facilitated Enrollment
CMS identifies and enrolls people each month– Randomly assigned to plans
• Premiums at or below regional low-income premium subsidy amount
• May join MA plan meeting special needs
If you are already enrolled in an MA plan– You’ll be enrolled in the same plan with Rx coverage (MA-
PD)– If offered by your current plan
54
Enrollment Notices
CMS notifies people of enrollment in a PDP – Auto-enrollment letter on yellow paper– Facilitated enrollment letter on green paper
• Denotes either full or partial subsidy• Includes list of area plans at/below regional low-
income premium subsidy amount
MA plan sends notice if enrollment in MA-PD See Guide to Consumer Mailings handout
55
Re-establishing Eligibility for People Who Automatically Qualify
CMS re-establishes eligibility in the Fall – For next calendar year– If you no longer automatically qualify
• CMS sends letter in September on gray paper– Includes SSA application
– If you automatically qualify & your copayment changed• CMS sends letter In early October on orange paper
56
Continuing Eligibility
People who are already qualified – Four types of redetermination processes
• Initial• Cyclical or recurring• Subsidy-changing event (SCE)• Other event (change other than SCE)
57
Extra Help in 2011 – What You Pay
Group 1 Group 2 Group 3
Premium $0* $0 Sliding scale based on income
Yearly deductible $310/year
$0* $0 $60
Coinsurance up to $4,550 out of
$1.10/$3.20 copay
$2.40/$6.00 copay
Up to 15% coinsurance
Catastrophic coverage
$0 $0 $2.40/$6.00 copay
*If you join a basic plan with a premium at or below the regional low-income premium subsidy amount.
Session C: Coordination of Benefits
1.Overview2.Health Coverage Coordination3.Prescription Drug Coverage
Coordination4.Information Sources
58
59
Coordination of Benefits (COB)
The goal of COB is to ensure proper payment– Identify the available health benefits– Coordinate the payment process– Prevent mistaken payment of Medicare benefits
60
COB Benefits Everyone
Individuals and their caregivers– Less stress
Healthcare providers– Identifies all available health and drug benefits– Streamlines the payment process – Supports Part D plans in tracking true out-of-pocket costs – Provides quality customer service
Healthcare system– Protects the Medicare trust fund
61
What Is MSP?
Medicare Secondary Payer mandates– Certain insurance pays health care bills first– Medicare pays second– Identify other insurance that may pay first
Medicare is primary– In the absence of other insurance
States play a crucial role in MSP in some issues– Workers’ Compensation– Liability insurance
62
Identifying the Appropriate Payer
Possible coverage combinations– Medicare may be primary payer– Medicare may be secondary payer– Medicare may not make payment
Data sources include– Initial Enrollment Questionnaire (IEQ)– Doctors and other providers– Group health plans– Employers
63
COB Systems
IRS/SSA/CMS Data Match Databases maintained by multiple stakeholders
– Federal agencies– States– Plans– Pharmacies– Assistance programs
64
COB Contractors
Group Health Incorporated (GHI)– Consolidates activities to support
• Collection, management and reporting of other coverage• Coordinates the payment process to prevent mistaken
payment of Medicare benefits• Doesn’t process claims, recovery, or claim specific
inquiries– Centralizes COB for Medicare Secondary Payer
RelayHealth– Centralizes COB for Medicare Part D– Acts as TrOOP facilitator
2. Health Coverage Coordination
Other Health Care Payers Determining Who Pays First
65
Other Possible Health Care Payers
66
67
Other Possible Health Care Payers
No-fault or liability insurance Workers’ compensation Federal Black Lung Program COBRA continuation coverage Employer/retiree group health plans
– Federal Employee Health Benefits Program– Military coverage through veterans’ benefits
• VA• TRICARE For Life
– Others
68
No-Fault Insurance
Pays regardless of who is at fault Medicare is secondary payer Medicare may make conditional primary payment
– If claim not paid promptly• Usually within 120 days
– Person won’t have to use own money to pay bill– Must be repaid when claim is resolved
69
Liability Insurance
Protects against certain claims– Negligence, inappropriate action, or inaction
Medicare is secondary payer – Health care professionals must attempt to collect before
billing Medicare Medicare may make conditional payment
– If the liability insurer will not pay promptly• Usually within 120 days
– Medicare recovers conditional payment
70
Workers’ Compensation
Medicare will not pay for health care related to workers’ compensation claims
If workers’ compensation claim denied– Claim may be filed for Medicare payment
Medicare may make conditional payment
71
Federal Black Lung Program
Lung disease caused by coal mining Services under this program
– Considered workers’ compensation claims– Not covered by Medicare
Information– Federal Black Lung Program– 1-800-638-7072
72
COBRA Employees and dependents can keep health
coverage after leaving their EGHP– If private or state/local government employer
with 20 or more employees– Called “continuation coverage”– Continues for 18, 29, or 36 months
• Depending on the qualifying event
Person must pay entire premium
73
COBRA and Medicare
Medicare is usually primary – Medicare is secondary during 30-month coordination
period for End-Stage Renal Disease (ESRD) State Health Insurance Assistance Program (SHIP)
counselors can help– West Virginia SHIP: 877-987-4463
74
Bankruptcy of Former Employer
COBRA rules may offer protection – May require continued coverage by another company
under same corporate structure
May be able to get “COBRA-for-life”– Benefits can change– Cost of coverage can go up
75
Federal Employee Health Benefits Program (FEHBP)
An Employer Group Health Plan (EGHP) Pays secondary when person retires Pays first
– If person with Medicare or covered spouse still working
– For person or spouse during first 30 months of eligibility due to ESRD
76
VA Benefits
People with Medicare and VA benefits – Can obtain treatment under either program– Must choose which benefit to use each time
Generally– Medicare cannot pay for service authorized by VA– VA cannot pay for service covered by Medicare
VA member could be subject to a penalty – For enrolling "late" for Medicare Part B
TRICARE For Life (TFL)
TRICARE's Medicare-wraparound coverage– Available to all Medicare-eligible TRICARE beneficiaries
Medicare is primary TRICARE acts as secondary payer
– Minimizes out-of-pocket expenses– Benefits cover Medicare's coinsurance and deductible
MUST have Medicare Parts A and B
77
How TRICARE For Life Works with Medicare
Use Medicare provider– Medicare provider will file claims with Medicare– Medicare pays its portion and forwards claim to TFL– TFL pays provider directly for TRICARE-covered services
Services covered by both Medicare and TRICARE– Medicare pays first– TFL pays remaining
Services covered by TRICARE but not by Medicare– TFL pays first– Medicare pays nothing
78
Determining Who Pays First – Health Coverage
79
80
When Medicare is Primary
Medicare is the only insurance Other source of coverage is
– Medigap policy– Medicaid– Retiree benefits– Indian Health Service– Veterans benefits and TRICARE for Life – COBRA continuation coverage
• Except 30-month coordination period for people with End-Stage Renal Disease (ESRD)
81
Medicare is Secondary
To employer group health plans (EGHP)*– 65+ and still working: EGHP 20 or more employees– Disability: EGHP 100 or more employees– ESRD: Any size EGHP after initial 30-months
To non-EGHP involving– Workers’ Compensation (WC) – Black Lung Program– No-fault/liability insurance
Page 6 - Medicare and Other Health Benefits: Your Guide to who Pays First, CMS Pub. #02179
82
83
Page 7 - Medicare and Other Health Benefits: Your Guide to who Pays First, CMS Pub. #02179
84
Employer Group Health Plans
Offered by many employers and unions– Current employees– Retirees– Spouse or family members
May be fee-for-service plan May be managed care plan Can choose to keep or reject
85
EGHP and Working Aged
Age 65 or older and – Working and covered by EGHP or– Covered by working spouse’s EGHP
Medicare is generally secondary payer– If employer has 20 or more employees– For self-employed, if covered by EGHP of employer with
20 or more employees
86
LGHP and Medicare Due to Disability
Medicare based on disability and – Working and covered by large EGHP (LGHP) or– Covered by LGHP of working spouse
• Or other family member
Medicare is secondary payer– If employer has 100 or more employees or– Self-employed, if covered by LGHP of employer with 100 or
more employees
87
EGHP and End-Stage Renal Disease
Medicare and ESRD and covered by EGHP of any size– Coverage through self or family member– Need not be based on current employment
Medicare is secondary payer– During 30-month coordination period– Unless Medicare already primary to retiree plan
88
EGHP and ESRD
EGHP primary payer for first 30 months Medicare becomes primary after 30 months Separate 30-month coordination periods
– Each time eligible for Medicare based on ESRD Applies only to people with ESRD For details
– www.cms.gov/ESRDGeneralInformation
89
Retiree Health Plans
Medicare pays first Retiree coverage pays second
– Might offer additional benefits• Prescription drug coverage• Routine dental care
– Refer to plan’s benefits booklet• Coverage for spouse• Employer/union may change benefits, change premiums,
or cancel coverage
3. Coordination of Prescription Drug Benefits
Other Possible Drug Coverage Identifying the Appropriate
Payer
90
Other Possible Drug Coverage
91
92
Other Possible Drug Coverage
• Medicaid programs• State Pharmacy
Assistance Programs (SPAPs)
• Patient Assistance Programs (PAPs) and charities
• AIDS Drug Assistance Programs (ADAPs)
• Safety-net providers • Indian Health Service
coverage• Personal health
savings accounts• Part B drug coverage• FEHBP• VA• TRICARE
Identifying the Appropriate Prescription Drug Coverage Payer
93
94
Part D COB Contractors
Group Health Inc. (GHI) and Relay Health– GHI - Centralizes COB for Medicare– Relay Health is the TrOOP Facilitator (True Out-of-
Pocket costs)
95
Medicare Part D
Medicare usually primary – Part D plan pays first
Situations involving Employer Group Health Plans– Part D plan denies primary claims
Non-group health plan situations– Part D plan makes conditional primary payment
• To ease burden on enrollee• Medicare is reimbursed
96
Other Drug Coverage and Part D Enrollment Considerations
Current coverage is creditable– Coverage as good as Medicare drug coverage– Can keep it as long as still offered– Won’t pay penalty if enroll in Part D later
Current coverage NOT creditable– Coverage not as good as Medicare drug coverage– Can enroll in Part D 10/15 - 12/7 in 2011– Late enrollment may result in penalty
97
Part D and Medicaid People with both Medicare and Medicaid
– Get drug coverage from Medicare– Get low-income assistance (“Extra Help”)
States may opt to cover non-Part D drugs– Does not count toward TrOOP
COB between plans, states, and pharmacies– Not required– Part D plans may choose to share data– Some Special Needs Plans coordinate services
for Medicaid recipients
98
Qualified SPAP
Coverage secondary to Part D– Contributions count toward TrOOP
May opt to participate in COB and TrOOP facilitation, to help
– Effectively wrap around Part D– Speed up reimbursement of erroneous payments– Facilitate timely access to prescriptions
Some may enroll members in Part D Must be non-discriminatory
99
Patient Assistance Programs and Charities
Sponsored by– Pharmaceutical manufacturers– Other entities
Provide for low-income patients – Financial assistance
• Cost-sharing or premiums– Free products– Incomes below 200% Federal poverty level– No prescription drug coverage– Insufficient prescription drug coverage
100
AIDS Drug Assistance Programs
Help pay for HIV/AIDS drug treatments Contributions do count toward TrOOP
– Effective January 1, 2011 Can choose to participate in COB either
– Electronically at point-of-sale or– By submitting paper claims to TrOOP contractor
Health ReformSection
3314
101
Safety-Net Providers Serve low-income communities Examples include
– Federally Qualified Health Centers– Rural Health Clinics– Critical Access Hospitals
Offer services through a “closed pharmacy” Many in 340B Drug Pricing Program
– Allows them to buy prescription drugs at lower prices
102
Employer/Union Drug Plan Options
EGHP options– Take Retiree Drug Subsidy– Become a Medicare drug plan– Wrap around Medicare drug coverage– Pay enrollees’ Medicare drug plan premium
May change at any time during year– Not required to make changes during specific enrollment
period
103
Important Considerations for People with Retiree Coverage
Most retiree plans offer generous coverage for entire family
– Employer/union must disclose how its plan works with Medicare drug coverage
– Talk to benefits administrator for more information People who drop retiree drug coverage
– May lose other health coverage– May not be able to get it back– Family members may lose coverage
104
People With Retiree Coverage Who Qualify for Extra Help
Those with limited income and resources– Income at or below 150% of Federal poverty level
Pay very little for prescriptions in a Part D Plan CMS automatically enrolls people with Medicare and
full Medicaid benefits– Including those with retiree drug coverage– May have to choose between Medicare drug coverage
and retiree coverage
105
Retiree Coverage and Extra Help
CMS encourages employers/unions to– Allow those disenrolling by mistake to re-enroll– Allow separate package for family members– Add supplemental coverage option– Help retirees who choose to opt out of Medicare drug
coverage– Coordinate with state Medicaid or other
assistance programs
106
How Prescription Assistance Programs and Charities Work with Part D
Charities can wrap around the Part D benefit Charities can participate in COB either
– Electronically at point-of-sale or– Submitting paper claims to TrOOP contractor
Manufacturer-sponsored PAPs can choose to operate outside the Part D benefit
– No interaction with TrOOP– PAPs should still coordinate with Part D plans
107
How Safety-Net Providers Work with Part D
Part D plans encouraged to contract with safety-net providers
Contributions by safety-net providers– Generally do not count toward TrOOP– Count toward TrOOP if unadvertised AND either
• Offered in non-routine manner• Offered to Extra Help recipients
108
Personal Health Savings Accounts Contributions count toward TrOOP when not
structured as group health plan– Health Savings Accounts– Flexible Spending Accounts– Medicare Medical Savings Accounts
Contributions do not count toward TrOOP– When structured as group health plan
• Health Reimbursement Arrangements– Must participate in COB
109
Medicare Part B and Part D
Systems do not automatically coordinate Guidelines help differentiate
– Part B-covered drugs– Part D-covered drugs
Details available on CMS website
110
How FEHB Works with Part D
FEHB considered creditable drug coverage– As good as Medicare drug coverage
People can have both FEHB and Part D– Adding Part D provides little, if any, savings
• Unless qualify for Extra Help
COB contractor captures/maintains enrollment data
111
How VA Works with Part D
VA offers creditable drug coverage– As good as Medicare drug coverage
People can choose which benefit to use– VA– Medicare– Single prescription cannot be covered by both
COB contractor captures/maintains enrollment data
112
How TRICARE for Life Works with Part D
TFL considered creditable drug coverage– As good as Medicare drug coverage
People can have both TFL and Part D– Adding Part D may benefit people who qualify
for Extra Help COB contractor captures/maintains enrollment data
4. Information Sources
113
114
Information Sources
COBRA Contacts– EGHP benefits administrator– Department of Labor
• 1-866-4-USA-DOL (1-866-487-2365)• www.dol.gov/dol/topic/health-plans/cobra.htm• State department of insurance
– Medicare Coordination of Benefits Contractor• 1-800-999-1118
– CMS Health Insurance Hotline• 410-786-1565• 1-877-267-2323, extension 6-1565• www.cms.gov/COBRAContinuationofCov
115
Information Sources
Coordination of Benefits Contractor – 1-800-999-1118 (TTY 1-800-318-8782 )– To get information on who pays first – To report changes in your insurance information
Medicare Coordination of Benefits– www.cms.gov/COBGeneralInformation/– www.cms.gov/COBAgreement/
116
Information Sources
Medicare and Other Health Benefits: Your Guide to Who Pays First
– www.medicare.gov/Publications/Pubs/pdf/02179.pdf
117
Information Sources
Medicare/TRICARE Benefit Overview– www.tricare.mil/mybenefit/home/overview/Plans
Department of Defense (To get information about the TRICARE Pharmacy Program
– 1-877-363-1303 (TTY 1-877-540-6261) Department of Veterans Affairs
– 1-800-827-1000 (TTY 1-800-829-4833 ) Medicare Secondary Payer Recovery Contractor
– 1-866-677-7220 (TTY 1-866-677-7294)
118
Information Sources
Office of Personnel Management (for FEHBP)– 1-888-767-6738 (TTY 1-800-878-5707)
U. S. Department of Labor – Federal Black Lung Program
• http://www.dol.gov/compliance/laws/comp-blba.htm
– COBRA• www.dol.gov/dol/topic/health-plans/cobra.htm
119
Introduction to Medicare Resource GuideResources Medicare Products
Centers for Medicare & Medicaid Services (CMS)1-800-MEDICARE(1-800-633-4227)(TTY 1-877-486-2048)www.medicare.gov
www.CMS.gov
Social Security1 800 772 1213 ‑ ‑ ‑TTY 1 800 325 0778 ‑ ‑ ‑http://www.socialsecurity.gov/
Railroad Retirement Board1-877-772-5772http://www.rrb.gov/
State Health Insurance Assistance Programs (SHIPs)*
*For telephone numbers call CMS1-800-MEDICARE (1-800-633-4227)1-877-486-2048 for TTY users
http://www.medicare.gov/caregivers/
http://www.HealthCare.gov
http://www.pcip.gov
http://www.Benefits.gov
http://www.Insurekidsnow.gov
Affordable Care Act www.healthcare.gov/center/authorities/patient_protection_affordable_care_act_as_passed.pdf
Medicare & You HandbookCMS Product No. 10050)
Your Medicare Benefits CMS Product No. 10116
Choosing a Medigap Policy: A Guide to Health Insurance for People with MedicareCMS Product No. 02110
To access these products
View and order single copies at www.medicare.gov
Order multiple copies (partners only)at productordering.cms.hhs.gov. You must register your organization.
This training module provided by the
For questions about training products, e-mail NMTP@cms.hhs.gov
To view all available NMTP materials or to subscribe to our listserv, visit
cms.gov/NationalMedicareTrainingProgram
top related