1 Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging February 2015 Helping Medicare Beneficiaries Stay Healthy Audio Portion: 1-866-740-1260 Web Portion: www.ReadyTalk.com Code: 4796976
1Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
February 2015
Helping Medicare Beneficiaries Stay
Healthy
Audio Portion: 1-866-740-1260
Web Portion: www.ReadyTalk.com
Code: 4796976
6Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
What we’ll cover
Medicare Preventive Services
• What’s covered
• Who’s eligible
• Costs
NCOA’s Healthy Aging National Chronic Disease Self-
Management Education (CDSME) Resource Center
State CDSME collaborative efforts
Nevada – Ken Napier
Maryland – Sarah Bush
Washington – Melody Coleman
7Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Paying for Preventive Services in 2015
In Original Medicare pay nothing for preventive
services if provider accepts assignment
ACA waived coinsurance and deductible for A and B rated
services for the US Preventive Services Task Force (USPSTF)
May pay more if provider doesn’t accept assignment
May have copayment
If doctor performs other services not part of covered preventive
benefits, or
For certain preventive services rated less than A or B by USPSTF,
or
If you are in a Medicare Advantage or other Medicare health plan
Source: MLN Matters News Flash updated 12/5/14
8Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
What is Covered?
Welcome To Medicare Preventive visit
Yearly “Wellness” visit
Abdominal aortic aneurysm screening
Alcohol misuse screening and counseling
Bone mass measurement
Breast cancer screening (mammogram)
Cardiovascular disease (CVD) Risk
Reduction Visit
Cardiovascular disease screenings
Cervical and vaginal cancer screening
Colorectal cancer screenings
• Screening fecal occult blood test
• Screening flexible sigmoidoscopy
• Screening colonoscopy
• Screening barium enema
Depression screening
Diabetes screenings
Diabetes self-management training
Flu shots (Vaccine)
Glaucoma tests
Hepatitis B shots (Vaccine)
HIV screening
New 2/6/15 Lung Cancer Screening
Medical nutrition therapy services
Obesity screening and counseling
Pneumococcal shot (Vaccine)
Prostate cancer screening
Sexually transmitted infections screening
and counseling
Tobacco use cessation counseling
More information: Full CMS Preventive Services PPT
9Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
“Welcome to Medicare” Preventive Visit
Once within first 12 months of getting Part B
Provider will
• Review medical and social history
• Measure height, weight and body mass index
• Perform a simple vision test
• Review risk factors for depression and level of safety
• Educate and counsel you to help you stay well
• Refer you for additional screenings if needed
Pay nothing if doctor accepts assignment
• Clinical lab tests are not included
Covered by Part B with coinsurance and deductible for labs
10Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Annual (Yearly) Wellness Visit (AWV)
Can’t be within 12 months of your Welcome to
Medicare Preventive Visit
Available once every 12 months
Focus is on “wellness”
• not a routine physical check up
• MLN article
Pay nothing if doctor accepts assignment
11Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
AWV Includes
Review of medical and family history
Update medical providers, suppliers, and medications lists
Measure height, weight, body mass index, blood pressure, pulse, and
temperature
Detection of cognitive impairments
Depression screening
Assess functional capacity and level of safety at home
Referrals for health education and preventive counseling
Health risk assessment (in-person or may complete prior to visit) asks
about
Personalized Prevention Plan Services (PPPS) a screening schedule
for 5 to 10 years
12Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Why are there charges for the AWV?
Call the provider to verify the charges
Most likely received services outside the scope of
the AWV
• Provider identifies an acute condition that requires
investigation, diagnosis or treatment
• Services are separate and distinct from the AWV even
though they occur during the same visit and require 20%
coinsurance and deductible
13Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
VaccinesVaccine Type Medicare
Coverage
Coverage Rules & Frequency Cost in Original
Medicare
Influenza Part B Medicare pays for (and recommends) one shot
every flu season. Additional flu vaccines may be
covered if considered medically necessary
$0
Shingles All Part D
plans must
cover
One shot paid for (and recommended) after age
60. Patient must check with plan to find out
specific rules for administration and payment
Vary by plan
Pneumococcal
(pneumonia)
Part B Medicare pays for one shot, recommended for all
adults aged 65+ and younger adults with chronic
health conditions
$0
Hepatitis B Part B Series of three shots, paid for by Medicare for
high- or medium-risk individuals, including those
with hemophilia, end stage renal disease,
diabetes, and other chronic conditions that lower
resistance to infection
$0
Source: NCOA Tip Sheet Vaccines: What Medicare Pays For
14Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Cancer Screenings
Type of cancer
screened
Medicare
Coverage
Coverage Rules & Frequency Cost in Original
Medicare
Breast Part B Screening mammograms every 12 months
for women age 40 and over. Medicare
covers one baseline mammogram for
women between ages 35 and 39.
$0
Cervical and
Vaginal
Part B Pelvic and pap tests every 2 years or every
12 months for women at high risk (including
child-bearing age, and cancer or abnormal
tests in last 3 years)
$0 but may be
charges for other
care delivered during
the visit
Prostate Part B PSA blood test and digital rectal exam are
covered every 12 months for men age 50
and over.
PSA test = $0
Rectal exam =
coinsurance and
deductible apply (not
A or B rated by
USPSTF)
NEW Lung Part B Annual low-dose computed tomography (CT)
scan for those at high risk (see next slide for
high-risk definition)
$0
15Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
NEW Lung Cancer Screening
CMS Decision Memo effective 2/5/15
Dec. 2013 USPSTF awarded a “B” grade to the CT screening
Coverage for individuals• Age 55 to 77,
• Smoked the equivalent of one pack of cigarettes per day for 30 years,
• Current smoker or quit within last 15 years, and
• Asymptomatic (no signs or symptoms of lung cancer)
American Lung Association Fact Sheet
16Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Cancer Screenings - Colorectal
Screening Test If Normal Risk Covered
Once Every
If High Risk Covered
Once Every
You Pay
Screening Fecal
Occult Blood Test
Age 50 or older
12 months 12 months No deductible or
copayment
for this test.
Screening Flexible
Sigmoidoscopy
Age 50 or older
4 years or 10 years after
a previous screening
colonoscopy
Every 4 years No deductible or
copayment
for this test.
Screening
Colonoscopy
No minimum age
10 years (generally) or 4
years after a previous
flexible sigmoidoscopy
Every 24 months
(unless a screening flexible
sigmoidoscopy is
performed, then only every
4 years)
No deductible or
copayment
for this test.
Screening Barium
Enema
Age 50 or older
4 years when used
instead of a
sigmoidoscopy or
colonoscopy
Every 24 months (as an
alternative to a covered
screening colonoscopy).
There is no deductible for
this test. You pay 20% of
the Medicare-approved
amount for the doctor’s
services. In a hospital
outpatient setting, you pay
a copayment.
17Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Screening vs. Diagnostic Services
Screening Diagnostic
Costs $0 20% coinsurance and
deductible apply
Purpose Helps prevent or find disease early Diagnosis disease when
exhibiting symptoms or
manage chronic conditions
Example:
Mammogram
Beneficiary has no symptoms or prior
history of breast cancer and goes for
annual check up
Test ordered based on pain
or an identified lump, as
medically necessary
Example:
Colonoscopy
Test ordered based on age, if a polyp is
removed the removal is preventive.
However, the lab testing of the polyp is
diagnostic and requires coinsurance
(deductible waived).
Test ordered based on
symptoms like irregularity or
bleeding, as medically
necessary
18Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Preventive Services Usage – 2013 State data
Source: CMS Beneficiaries Using Free Preventive Services 2013
19Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Medicare-Medicaid State Profiles
Source: MMCO State Data Center Medicare-Medicaid State Profiles
20Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Resources
NCOA Fact Sheets
• Original Medicare: Preventive Benefits Overview
• Quick-Reference Chart: Medicare’s Preventive Benefits
• A Closer Look: Medicare’s Annual Wellness Visit (AWV)
• Medicare Health Risk Assessment and AWV
• Vaccines: What Medicare Pays For
• Welcome to Medicare Exam
Personalized help
• Area Agency on Aging or Aging Disability Resource Centers
o Eldercare.gov
• Senior Health Insurance and Assistance Programs (SHIP)
o http://www.shiptacenter.org/
21Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Resources
CMS
• Your Guide to Preventive Services Booklet
• Preventive Services Checklist
• Medicare.gov Preventive & Screening Services
• NTP Medicare Preventive Services PowerPoint and workbook
• Staying Healthy: Medicare’s Preventive Services
• Hospital Discharge Checklist
• Welcome to Medicare Preventive Visit Q & A
• Questions to Ask about Medicare Preventive Services
• MyMedicare.gov Card
• Medicare helps cover Diabetes supplies and services (2 pg)
• Medicare & You Handbook (pgs 41-61 apple next to Prev. Svcs)
22Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Resources
CMS Product Ordering website (partners only) Order multiple copies at http://productordering.cms.hhs.govYou must register your organization.
CMS Medicare Learning Network
The Medicare Learning Network® (MLN) Preventive Services page provides
educational products for health care professionals. These products contain
coverage, coding, billing, reimbursement, and claim filing information.
• ABCs of Providing the Welcome to Medicare Preventive Visit/
Initial Preventive Physical Examination (IPPE)
• ABCs of Providing the Annual Wellness Visit (AWV)
• Preventive Services
23Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Chronic Disease Self-Management Education
Can Increase the Quality and Years of Life
Cora Plass, MSW
Senior Director, National CDSME Resource Center
February 26, 2015
Helping Medicare Beneficiaries Stay Healthy
24Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
NCOA Social Impact Goal: Older Adults
Older adults will have:
Greater economic security through increased
access to benefits, financial resources, and job
opportunities
Improved health and reduced disability through
greater access to proven programs
Enhanced capacity to live independently in
communities
25Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
NCOA Social Impact Goal: Organizations & Programs
Community organizations serving older adults will
achieve:
Greater social impact, capacity, and sustainability
Public programs will:
More effectively meet the needs of older adults,
especially those who are struggling
26Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Overarching goal: To help older adults live longer and
healthier lives
Supports expansion and sustainability of evidence-based
health promotion and disease prevention programs
Collaborates with federal, state, and community partners to
achieve its goals
2 National Resource Centers funded by ACL/AoA:
Chronic Disease Self-Management Education (CDSME)
Falls Prevention
Other topics include physical activity, behavioral health, and
oral health
Center for Healthy Aging
27Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Funded by ACL, AoA for more than a decade
Develops and disseminates information and resources to
support expansion and sustainability of CDSME programs
Provides communication channels for networking and
sharing best practices
Manages and maintains national database for CDSME:
16,000 workshops offered in 46 states, DC, and Puerto Rico
Offered in 52% of counties in the US
Nearly 180,000 participants served
Average age 66, mostly female
More than half have MCC
Who We Are – National CDSME Resource Center
28Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
80% of older adults have at least one chronic disease
Nearly 2 of every 3 have multiple chronic conditions
U.S. health care is most costly in the world
95% of health care costs for older Americans are for
chronic diseases
Spending escalating with the increase in chronic
diseases and the aging population
Fragmented care; patient lost in health care maze
Primary focus has been on “sick care” rather than
prevention
Health Care Challenges: Why Our Work Is Important
29Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Goals for Transforming Health Care
30Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Self-management helps participants take control of their
health and make lifestyle changes that lead to better health
outcomes and a better quality of life
An array of programs developed by Dr. Kate Lorig at
Stanford, including:
Chronic Disease Self-Management (CDSMP)
In English and Spanish
Diabetes Self-Management (DSMP)
In English and Spanish
Chronic Pain Self-Management (CPSMP)
Cancer Thriving and Surviving
CDSME Programs
31Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
6 workshop sessions held once a week
Each session 2 ½ hours, highly interactive
Co-facilitated by 2 trained leaders, one of
whom has an ongoing health condition
Detailed script provided for leaders
Core content similar across programs:
Symptom management/social role function
Builds self-efficacy
Participants set personal goals and action
plans
Problem solving to overcome challenges
Program Overview
32Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Action
Planning
Managing
Pain and
Fatigue
Fitness/
Exercise
Getting a Good
Night’s Sleep
Problem-
solving
Dealing with
Difficult
Emotions
Healthy
Eating/Weight
Management
Working with
Health
Professionals
Decision
Making
Better
Breathing
Communication Medication
Usage
CDSMP Program Overview
33Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Self-Efficacy or ConfidencePeople who believed there was nothing they could
do to help themselves didn’t improve.
BUT those with confidence in their ability to make changes improved.
Participants are taught to set goals and action plans and to use problem solving to
overcome barriers to making lifestyle changes.
Why It Works
34Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Improved self-rated health
Increased self-efficacy
Less reported disability
Increased energy/less fatigue
Increased healthy behaviors
Reduced health distress and depression
Less pain
Reduced health care utilization (ER visits and
hospitalizations) = Cost savings
Research Findings
35Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
National Study Results
CDSMP Helps Achieve Triple Aims Goal
Better Care:
Communication with health care team
Medication compliance
Health literacy
Better Health:
Self-assessed health,
Depression,
Quality of life,
Unhealthy physical/mental days improved
Lower Costs:
Lower ER visits
Fewer hospitalizations
36Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
$364 cost savings per person after considering
cost of the program
Reaching 10% of Americans with one or more
chronic conditions could save $4.2 billon
Based on one national study.
More research needed to substantiate findings.
Estimated Cost Savings
ER Visits and Hospitalizations
37Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Lack understanding of what preventive health/health promotion
programs and services are available and what the benefits are
Lack awareness of how to access programs/services
Mistrust of the social welfare and health care system
Low self-confidence in ability to effect change in health or financial
situation
Difficulty accessing programs, especially in rural areas due to:
Social isolation
Lack of transportation
Programs not uniformly available - limited human and financial
resources
Fragmented approaches to service provision
Challenges for Older Adults
38Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
You Can Make a Difference
Find out who the CDSME program providers are in your
community
Arrange a meeting to determine how you can work
together to help older adults access programs and
services
Ask for a schedule of local workshops
Maintain ongoing relationships with CDSME staff
Provide information to older adults about the benefits
of CDSME and help them to enroll in local workshops
Communicate, Coordinate, Collaborate
39Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Get Connected through NCOA’s CHA Website
www.ncoa.org/cha
Email:
40Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Find a Healthy Aging Program
CDSME Program Locator
41Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
For More Information about Stanford Programs
http://patienteducation.stanford.edu/
42Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Nevada
Ken Napier• Medicare Benefits Counselor
• Medicare "Extra Help" Outreach Program Coordinator
• State of Nevada, Aging & Disability Services Division
• State Health Insurance Assistance Program (SHIP)
1820 E. Sahara Ave., Suite 205
Las Vegas, NV 89104
Phone: 702-486-3478 and 702- 486-4581
43Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Maryland
Sarah Bush
• Older Americans Act Program Manager
125 Virginia Ave
Cumberland, MD 21502
301-784-1710
44Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Washington
Melody Coleman• ADR/FCSP Supervisor
Northwest Regional Council
600 Lakeway Drive, Suite 100
Bellingham, WA 98225
(360) 676-6749
45Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging
Contact Us
Presenters:
Melissa Simpson
Cora Plass
www.ncoa.org
www.ncoa.org/centerforbenefits
Social media: @NCOAging