insurance.arkansas

www.insurance.arkansas.gov

Arkansas Insurance Department

Arkansas Insurance Department

The primary mission is consumer protection through insurer solvency and market conduct regulation, and fraud prosecution and deterrence.

Insurance Department Divisions• Health Insurance Premium

Rate Review• Liquidation• Life and Health• Property and Casualty• Public Employee Claims• Risk Management• Senior Health Insurance

Information Program

• Administration• Accounting• Consumer Services• Consumer Assistance

Program• Criminal Investigations• Finance • Human Resources• Legal• License• Health Benefits

Exchange

Consumer Services Division Stats

• Toll-free Phone 1-800-852-5494• Assisted Arkansans in collecting $14,006,232• Received 2,864 consumer complaints• Closed 3,164 consumer complaint files• Responded to 19,207 telephone inquiries and

assisted 299 walk-in consumers• Participated in 130 dislocated worker workshops

and 28 expos and health fairs

SHIIP Stats

• Assist Arkansans with all things MEDICARE– Assisted more than 14,500 Medicare recipients or

caregivers– 6,642 Part D comparisons of which 2,648 assisted

with enrollment– 2,132 Medigap comparison and eligibility – 2,008 Medicare Advantage comparisons

Complaints• Contact Insurance Plan/Carrier first and ask for

clarification• Insurance Department Complaints

– Claims payment concerns– Agent misconduct– Medicare Supplement Policy

• Medicare Complaints via SHIIP– Claims Payment Issues Plan False or Misleading Sales &

Marketing Practices

Patient Protection and Affordable Care Act (PPACA)

Affordable Care Act Changes• Take Care Arkansas– Temporary (until 2014) high-risk pool for those

with pre-existing conditions• Administered by Blue Cross Blue Shield

–1-800-285-6477 –WWW.TAKECAREARKANSAS.ORG

• Early Retirees (before age 65)– Temporary program to offset cost of retiree

coverage paid to employers (not retirees)

Affordable Care Act & Medicare

• Annual Election Period– EARLIER starts Oct 15 and ends Dec 7

• Medicare Claims– Maximum period for submission of Medicare

claims reduced time period– Not more than 12 months

• Preventive Services– No longer pay Part B deductible and coinsurance

for most preventative services

Affordable Care Act- Medicare

• Therapy caps extended– Physical & Speech pathology= combined $1,860

per year– Occupational therapy= $1,860 per year

Affordable Care Act- Medicare

• Power-driven wheelchairs effective Jan 2011– Medicare no longer purchase with lump-sum– Paid over 13-month period

• Increased ground ambulance rates retroactive to Jan 2010: 3% rural, 2% urban

• Hospice Reform effective Nov 2011– Face-to-face encounter is required with hospice

physician or nurse practitioner

Affordable Care Act –MA Plans

• MA Plans can not charge more than Original Medicare– Services: chemotherapy, skilled nursing facility,

dialysis, etc.

• Payments to MA frozen in 2011• MA Disenrollment Period Jan 1-Feb 14– Leave MA and go to Original Medicare with stand

alone Part D

Affordable Care Act- Part D

• Donut Hole in 2012– 50% discount on brand name drugs– 14% discount on generic drugs

• Higher income people pay higher Part D premium – Effective Jan 2011– Same thresholds as Part B premium• Modified Adjusted Gross Income• Income reported on IRS tax return 2 years ago

Medicare Preventive Services

SESSION TOPICS•What is covered•Why preventive services are important•Who is eligible•How much you pay

Centers for Disease Control and Prevention reports less than 10% of Medicare beneficiaries receive all recommended screenings and immunizations.

Medicare Preventive Services

• Medicare coverage based on– Age– Gender– Medical history

• Covered by– Part B of Original Medicare– Medicare Advantage and other Medicare plans

Medicare Preventive Services 16

Covered Screening and Preventive Services

One time “Welcome to Medicare” physical exam

Physical Exam (yearly “Wellness Exam”)

Abdominal aortic aneurysm screening*

Bone mass measurementCardiovascular disease

screeningsColorectal cancer screeningsDiabetes screenings

EKG Screening*Flu shots Glaucoma testsHepatitis B shotsHIV ScreeningMammograms (screening)Pap test/pelvic exam/clinical

breast examProstate cancer screeningPneumococcal shotsSmoking cessation


Health Reform Section

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*When referred during Welcome to Medicare physical exam

Elimination of Part B Deductible and Coinsurance Requirements in 2011

• Starting January 1, 2011• You pay nothing for most preventive services– If you get them from a doctor or other health care

provider who accepts assignment

• Services affected must have an “A” or “B” rating – By the United States Preventive Services Task Force– http://www.uspreventiveservicestaskforce.org/

uspstf/uspsabrecs.htm


Health ReformSection

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One Time “Welcome to Medicare” Physical Exam

• Covered within first 12 months of having Part B– Height, weight and body mass index– Blood pressure and end of life planning– Education, counseling, and referrals (e.g., EKG)

• In Original Medicare pay– No deductible or copayment starting

January 1, 2011


Changes in

2011

Abdominal Aortic Aneurysm Screening

• Abdominal aortic aneurysms (weak area bulges)• Risk factors include– A family history of abdominal aortic aneurysms– Men age 65 to 75 who have smoked at least 100

cigarettes in their lifetime• Ultrasound screening covered by Medicare – Referral from the “Welcome to Medicare” physical exam– Pay 20% of the Medicare-approved amount with no

Part B deductible– No deductible or copayment starting

January 1, 2011


Changes in

2011

New Annual Wellness Visit• Effective January 1, 2011• Annual Wellness Visit– Comprehensive health risk assessment– Personalized prevention plan– Health advice and referral to education and

preventive counseling– No copayment or deductible– Available every 12 months (after first 12 months of

initial Part B coverage)o But not within 12 months of receiving either a “Welcome

to Medicare” physical exam or another Annual Wellness visit



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Bone Mass Measurement


Covered if at risk for osteoporosis– Every 2 years (more often if medically necessary)

Risk factors include but aren’t limited to– Age 50 or older– Female– Family or personal history of broken bones– White or Asian

In Original Medicare pay– No deductible or copayment starting

January 1, 2011

Changes in

2011

Cardiovascular Disease Screening• Blood test for early detection– Heart disease– Stroke

• Tests for levels of– Cholesterol– Triglycerides– Lipids

• Covered every 5 years• In Original Medicare you pay nothing


Cardiac Rehabilitation

• Medicare covers cardiac programs that include – Exercise– Education– Counseling certain patients with a doctor’s referral – Intensive cardiac rehabilitation programs

• In Original Medicare, pay 20% of the Medicare-approved amount – If you get the services in a doctor’s office

• No change in 2011, is not rated “A” or “B”

• Pay a copayment in a hospital outpatient setting


Colorectal Cancer Screening• Helps find precancerous growths – Helps prevent or find cancer early

• One or more of the following tests may be covered– Fecal Occult Blood Test– Flexible Sigmoidoscopy– Colonoscopy– Barium Enema



Colorectal Cancer Screening (continued)Test and

Requirements Covered Once Every… You Pay

Fecal Occult Blood TestAge 50 or older

12 months No deductible or copayment starting January 1, 2011.

Flexible Sigmoidoscopy Age 50 or older

48 months or 120 months after a previous screening colonoscopy for those not at high risk

No deductible or copayment starting January 1, 2011.

Colonoscopy No minimum age

120 months (generally) (high risk every 24 months) or 48 months after a previous flexible sigmoidoscopy

No deductible or copayment starting January 1, 2011.

Barium EnemaAge 50 or older

48 months (high risk every 24 months) when used instead of a sigmoidoscopy or colonoscopy

Pay 20% of the Medicare-approved amount for the doctor’s services. In a hospital outpatient setting, you pay a copayment. No change in 2011.

Diabetes Risk Factors

Diabetes is a chronic condition– Body does not produce or properly use insulin

Risk Factors– High blood pressure– High cholesterol– Obesity– History of high blood sugar– At least two of the following

• Age 65 or older,• Overweight, • Family history of diabetes, or • Past gestational diabetes or having a baby over 9 pounds


Diabetes Management

• May be able to avoid or delay complications• Manage diabetes– Test blood sugar regularly– Eat a proper diet– Exercise regularly– Take medication as prescribed


Diabetes Screening

• Testing for people at risk • Includes fasting blood glucose test• Talk with your doctor about frequency– Got pre-diabetes, then screening up to twice in a

12-month period – Not diagnosed or pre-diabetic, then screening

once in 12-month period• In Original Medicare pay– No deductible or coinsurance


Covered Diabetes Services• Screening for all at risk• For people with diabetes (need prescription)– Self-management training– Medical nutrition therapy– Blood sugar testing supplies• Lancets, monitors, testing strips= Part B• Insulin, syringes, needles, alcohol swabs, gauze = Part

D– Special eye exams– Hemoglobin A1c tests


Covered Diabetes Services

• People with diabetes who need them– Insulin pumps– Special foot care– Therapeutic shoes

• In Original Medicare pay– 20% after Part B deductible– No change in 2011

• Medicare Coverage of Diabetes Supplies & Services (CMS Pub. 11022)


Glaucoma Examination• Glaucoma is caused by increased eye pressure– May gradually lose sight without symptoms

• Protect yourself with screening eye exam• Covered if high risk once every 12 months– High-risk= Family history, African American and age

50 or old, or Hispanic and age 65 or older• In Original Medicare pay– 20% of the Medicare-approved amount

• Part B deductible applies for the doctor services– A copayment in a hospital outpatient setting– No change in 2011


HIV Screening

• Medicare covers HIV screening for people – Who are pregnant or at increased risk for the infection– Includes anyone who asks for the test

• Covered once every 12 months – Up to 3 times during a pregnancy

• In Original Medicare pay– Generally pay 20% of the Medicare-approved amount

for the doctor’s visit– No deductible or copayment for the test– No change in 2011


Pap Test and Pelvic Exam with Clinical Breast Exam

• Risk factors for some cancers in woman include– Had an Abnormal Pap test– Infected with Human papilloma virus (HPV)– Began sexuality activity before age 16– Had many sexual partners

• Medicare covers– Pap test to help find cervical and vaginal cancer– Screening pelvic exam to help find fibroids/ovarian

cancers– Clinical breast exam (another way to look for breast

cancer)



• Covered for all women with Medicare– Once every 24 months for most women– Once every 12 months if• At high risk for cervical or vaginal cancer• Childbearing age and abnormal Pap test in the past 36 months



• In Original Medicare pay nothing– Nothing for Pap lab test– No Part B deductible– No copayment starting January 1, 2011



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Prostate Cancer Risks

• Risk increases with age– Age 45 – 1 in 2,500– Age 50 – 1 in 476– Age 55 – 1 in 120– Age 60 – 1 in 43– Age 65 – 1 in 21– Age 70 – 1 in 13– Age 75 – 1 in 9 Ethnicity risk: AA, White, Hispanic at highest risk Hereditary risk


Prostate Cancer Screening• Covered– For all men with Medicare– Beginning the day after 50th birthday

• Tests include– Digital rectal exam– PSA blood test

• Prostate-specific antigen

• In Original Medicare pay – Nothing for the PSA blood (lab) test– 20% after Part B deductible for digital rectal exam

• No change in 2011


Breast Cancer and Mammography

• Breast cancer in women in U.S.– Most commonly diagnosed non-skin cancer– Second leading cause of cancer death – Risk increases with age– Successfully treated when found early

• Mammogram– Checks for abnormal breast tissue– Coverage includes digital technology


Screening Mammogram

• Covered for all women with Medicare– One baseline mammogram age 35 to 39– Once a year starting at age 40

• In Original Medicare pay nothing– No Part B deductible– No deductible or copayment starting

January 1, 2011


Changes in

2011


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Diagnostic Mammogram

• Used when there are clinical findings– On physical exam– Abnormal screening mammogram

• Medicare covers as many as needed– Also covered for men

• Different payment rates if diagnostic mammograms– Usually pay 20% of Medicare approved amount

and Part B deductible applies


Smoking Cessation

• Quitting gives significant health benefits– Even older adults who smoked for years

• When services are covered– If you have an illness caused or complicated by

tobacco use• Includes smokers with heart or lung disease, stroke,

multiple cancers, weak bones, blood clots, or cataracts– If you take medication affected by tobacco use• Such as insulin, medication for high blood pressure,

blood clots, and depression


Smoking Cessation Services

• Cessation counseling– Up to 8 sessions per year– Inpatient or outpatient– Intermediate or intensive

• In Original Medicare pay– 20% after Part B deductible

• No change in 2011

• Medicare Part D prescription drug coverage – Can help pay for drug therapy

• Nicotine patches, for example


Influenza (“Flu”) Shot

• Flu can lead to pneumonia– Can be dangerous for people 50 and over

• Flu viruses are always changing– Shot updated for most current flu viruses– Recommended in fall or winter (Oct or Nov)

• Flu shot covered for all people with Medicare• Once each flu season protects for about a year• In Original Medicare pay– No deductible or copayment


H1N1 Flu Vaccine

• H1N1 flu is caused by a new strain of influenza virus

• Risk factors not as high for those over 65– Higher risk for those with certain disabilities

• Medicare covers administration of the H1N1 flu shot – You can’t be charged for the vaccine (providers get it

free)– You pay nothing if provider accepts assignment – Part B deductible and coinsurance don’t apply

• To the vaccine or its administration• You should still get the seasonal flu shot


Pneumococcal Pneumonia Shot

• Pneumonia is inflammation in the lungs– Caused by bacteria (streptococcus pneumoniae)

• One shot could be all you ever need• All people with Medicare are eligible• In Original Medicare pay nothing– No deductible or copayment


Hepatitis B Shots

• Serious disease (virus attacks the liver)– Can cause lifelong infection, cirrhosis (scarring) of

the liver, liver cancer, liver failure, or death• Covered for medium to high risk– End-stage renal disease and hemophilia– Condition that lowers resistance to infection

• In Original Medicare pay nothing– No deductible or copayment starting

January 1, 2011



4104

Changes in

2011

Medicare Education Benefit• People with Stage IV chronic kidney disease– Have advanced kidney damage and– Will likely need dialysis or a kidney transplant soon

• Medicare Part B covers – Up to six sessions of kidney disease education services

if have stage IV and doctor refers for the service• Provided to help prevent or delay the need for

dialysis– Pay 20% of the Medicare-approved amount, and the

Part B deductible applies• No change in 2011


Protecting the Medicare Trust Funds

• Centers for Medicare & Medicaid Services (CMS) has to balance how to– Pay claims on time vs. conduct reviews– Prevent/detect fraud vs. limit burden on providers

• CMS must protect the Trust Funds1.Medicare Hospital Insurance Trust Fund (Part A)2.Supplementary Medical Insurance Trust Fund (Part

B)

Medicare Hospital Insurance Trust Fund

Pays for Funded byPart A(Hospital Insurance) benefits

Payroll taxes

Income taxes paid on Social Security benefits

Interest earned on trust fund investments

Part A premiums from people who aren’t eligible for premium-free Part A

Supplementary Medical Insurance Trust Fund

Pays for Funded byPart B(Medical Insurance) and

Part D(Medicare Prescription Drug coverage) benefits

Funds authorized by Congress

Part B premiums

Part D premiums

Interest earned on trust fund investments

Medicare OverviewEach Work Day Monthly Yearly

4.4 million claims processed

From 1.5 million providers

Worth $1.1 billion

Almost 19,000 provider enrollment applications received

Over $430 billion in claims paid

Over 48 million beneficiaries

Medicare Dictionary

When someone intentionally falsifies information or deceives Medicare.

When health care providers or suppliers don’t follow good medical practices, resulting in unnecessary costs to Medicare, improper payment, or services that aren‘t medically necessary.

Fraud and Abuse Costs

$60-90 billion annuallyor

$1.6-2.6 million per day

Examples of Fraud

• Medicare/Medicaid is billed for – Services never delivered– Equipment never delivered or returned

• Unauthorized use of Medicare/Medicaid card • A company uses false information – To mislead a beneficiary into joining a Medicare

plan

Medicare Summary Notices www.MyMedicare.gov 1-800-MEDICARE Senior Medicare Patrol www.stopmedicarefraud.gov Protecting Personal Information/ID Theft Tips Part C and D Plan Marketing Fraud

Fighting Fraud

http://www.stopmedicarefraud.gov/

Medicare Summary Notice (MSN)

Part A and Part B MSNs Shows all your services or supplies

– Billed to Medicare in 3-month period– What Medicare paid – What beneficiary owes

Read it carefully – Keep receipts and bills– Keep note of appointments/

services dates– Compare them to MSN

MyMedicare.gov• Secure site to manage personal

information– Review eligibility, entitlement and

plan information– Track preventive services– Keep a prescription drug list– Complete Authorization Form

• Review claims– Don’t have to wait for MSN

Click the “Blue Button” to download your data to a text file

Medicare Part C & D Plans Marketing Rules

• Examples– Plans can’t send unwanted emails– Agent’s can’t come to uninvited to home – Can’t call beneficiaries unless already a member – Offer cash to join their plan – Give free meals while trying to sell a plan

Telemarketing Fraud• Durable Medical Equipment Telemarketing Rules– DME suppliers cannot make unsolicited sales calls

• Potential scams– Calls or visits from people saying they represent Medicare – Telephone or door-to-door selling techniques– Equipment or service is offered free and then ask for

Medicare number for “record keeping purposes”– Told that Medicare will pay for the item or service if provide

a Medicare number

Arkansas Silver Alert System

• Modeled after Amber Alert – sign up for instant email messages– https://www.ark.org/asp/alerts/mnaa/silver.php– Do not have to be missing 24 hours

• Statewide alerts for missing seniors and/or other adults with Alzheimer’s or other cognitive disorders– AR State Police– AR Sherriff‘s’ Association– AR Police Association

https://www.ark.org/asp/alerts/mnaa/silver.php

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