THE ACA THE ACA AND YOU AND YOU AND MEDICARE TOO AND MEDICARE TOO Angela Zeek Angela Zeek Bluegrass SHIP Bluegrass SHIP Coordinator Coordinator 2013 2013
Mar 26, 2015
THE ACATHE ACAAND YOUAND YOU
AND MEDICARE TOOAND MEDICARE TOO
Angela ZeekAngela Zeek
Bluegrass SHIP CoordinatorBluegrass SHIP Coordinator
20132013
Affordable Care Act Affordable Care Act (ACA)(ACA)
ACAACA
Signed into law on March 23, 2010Signed into law on March 23, 2010 Created health insurance Created health insurance
marketplaces for the uninsured to marketplaces for the uninsured to buy insurancebuy insurance
Made a number of changes to Made a number of changes to MedicareMedicare
The ACA and MedicareThe ACA and Medicare
Many believe that rate of Many believe that rate of spending on Medicare spending on Medicare cannot be sustainedcannot be sustained– The number of people
with Medicare will grow rapidly as Boomers age
10,000 people turning 65 every day for the next 20 years
– Medicare spending is increasing faster than the rest of the economy
Millions with Medicare
2013 2030
50 79
1 2
ACA Changes to Medicare Finances
Increased RevenuesIncreased Revenues– Higher payroll taxes for wealthy Higher payroll taxes for wealthy
workers ($200/$250,000)workers ($200/$250,000)– Higher Part D premiums for 5% of Higher Part D premiums for 5% of
wealthy Medicare beneficiaries wealthy Medicare beneficiaries ($85/$170,000)($85/$170,000)
Reduced SpendingReduced Spending– Slower growth in payments to Slower growth in payments to
providers (not doctors)providers (not doctors)– Reduction in over-payments to Reduction in over-payments to
Medicare Advantage plansMedicare Advantage plans– Average yearly Medicare spending Average yearly Medicare spending
increases down from increases down from 6.8% to 5.7%6.8% to 5.7%– NO CUTS NO CUTS in basic benefitsin basic benefits
Reduced Payments to Medicare Reduced Payments to Medicare Advantage PlansAdvantage Plans
MA plans were paid MA plans were paid about $1,000 more per about $1,000 more per person than people in person than people in original Medicare (14% original Medicare (14% higher)higher)
Beginning in 2012, Beginning in 2012, these overpayments these overpayments started to be gradually started to be gradually reducedreduced– Exception- higher Exception- higher
performing plans will performing plans will receive bonusesreceive bonuses
The ACA Financial Changes to The ACA Financial Changes to MedicareMedicare
Prior to the ACA, Medicare Trust Prior to the ACA, Medicare Trust Fund would be depleted by 2017. Fund would be depleted by 2017.
Trust Fund is projected to be Trust Fund is projected to be solvent until roughly 2029 due to solvent until roughly 2029 due to the changes the changes
Increased funding to improve some Increased funding to improve some Medicare benefitsMedicare benefits
How These Changes Affect How These Changes Affect YouYou
– Medicare Prescription Drug Medicare Prescription Drug ImprovementsImprovements
– Better Preventive and Chronic Better Preventive and Chronic CareCare
– Better quality of careBetter quality of care
How These Changes Affect How These Changes Affect YouYou
Improvements in Improvements in Medicare Prescription Medicare Prescription Drug CoverageDrug Coverage
– Closing the Donut Closing the Donut Hole (coverage gap)Hole (coverage gap)
Phase Out of Donut Hole for Phase Out of Donut Hole for Brand Name MedicationsBrand Name Medications
Year
Pharmaceutical Manufacturer Discount
Government Subsidy (paid through plans)
Consumer Responsibility
2013 50% 2.50% 47.50%
2014 50% 2.50% 47.50%
2015 50% 5% 45%
2016 50% 5% 45%
2017 50% 10% 40%
2018 50% 15% 35%
2019 50% 20% 30%
2020 50% 25% 25%
Phase Out for Donut Hole for Phase Out for Donut Hole for Generic MedicationsGeneric Medications
Year Government Subsidy (paid through plans) Consumer Responsibility
2013 21% 79%
2014 28% 72%
2015 35% 65%
2016 42% 58%
2017 49% 51%
2018 56% 44%
2019 63% 37%
2020 75% 25%
How These Changes Affect How These Changes Affect YouYou
Improvements in Medicare Improvements in Medicare Prescription Drug CoveragePrescription Drug Coverage
– Improved appeals for Improved appeals for coverage denialscoverage denials
– More help for people More help for people with limited means with limited means
– For certain illnesses all For certain illnesses all medications medications manufactured to treat manufactured to treat those conditions must those conditions must be added to a plan’s be added to a plan’s formulary formulary
How These Changes Affect How These Changes Affect YouYou
Better Preventive CareBetter Preventive Care– Free annual wellness visit and prevention planFree annual wellness visit and prevention plan– No more cost sharing – free preventive benefitsNo more cost sharing – free preventive benefits– More funding for prevention servicesMore funding for prevention services
How These Changes Affect How These Changes Affect YouYou
Better Chronic Care New quality New quality
improvementsimprovements Better coordination Better coordination
among doctors, among doctors, specialists, other specialists, other providersproviders
Services to reduce Services to reduce hospital readmissionshospital readmissions
Help so you can Help so you can manage your own caremanage your own care
How These Changes Affect How These Changes Affect YouYou
Changes in Medicare Changes in Medicare Advantage (MA) Plans?Advantage (MA) Plans?
– New bonuses to reward New bonuses to reward high quality carehigh quality care
– New consumer New consumer protections to limit out-protections to limit out-of-pocket costsof-pocket costs
The ACA and Health Insurance The ACA and Health Insurance MarketplacesMarketplaces
ACA created marketplaces for ACA created marketplaces for uninsured individuals and insured uninsured individuals and insured individuals with high premiums to individuals with high premiums to purchase health insurancepurchase health insurance
Insurance sold under the marketplace Insurance sold under the marketplace offered by private companies offered by private companies
Kentucky’s marketplace is called Kynect Kentucky’s marketplace is called Kynect (kynect.ky.gov)(kynect.ky.gov)
Over 600,000 Kentuckians are Over 600,000 Kentuckians are uninsureduninsured
The ACA and health insurance The ACA and health insurance marketplacesmarketplaces
Insurance plans will be placed into categories Insurance plans will be placed into categories based on level of coveragebased on level of coverage– Bronze, silver, gold and platinumBronze, silver, gold and platinum
Individuals can compare the coverage and Individuals can compare the coverage and determine which type is best for themdetermine which type is best for them
Assistance in the way of tax credits are Assistance in the way of tax credits are available to people to reduce the cost of available to people to reduce the cost of premiumspremiums– To determine approximate credit and premium To determine approximate credit and premium
amounts visit, amounts visit, http://http://kff.orgkff.org/interactive/subsidy-calculator//interactive/subsidy-calculator/
The ACA and MedicaidThe ACA and Medicaid
Governor Beshear Governor Beshear expanded Medicaid expanded Medicaid to include anyone to include anyone with income of with income of 138% fpl or below138% fpl or below
Over 300,000 Over 300,000 Kentuckians will be Kentuckians will be eligible for Medicaid eligible for Medicaid benefits under the benefits under the expansionexpansion
Family Size
Monthly Income
1 $1,321
2 $1,784
3 $2,247
4 $2,710
The ACA and health care The ACA and health care marketplacesmarketplaces
Enrollment begins October 1 and Enrollment begins October 1 and ends March 31 for the first yearends March 31 for the first year– October 1 to December 7 in 2014 and October 1 to December 7 in 2014 and
beyondbeyond Coverage is effective January 1 if Coverage is effective January 1 if
enrollment happens prior to enrollment happens prior to December 15December 15
People on Medicare are not allowed People on Medicare are not allowed to participate in the marketplaceto participate in the marketplace
Medicare UpdatesMedicare Updates
Original Medicare Original Medicare (Part A & Part B)(Part A & Part B)
Outpatient Mental Outpatient Mental Health CareHealth Care
After Part B deductibleAfter Part B deductible– For visits to diagnose conditionFor visits to diagnose condition
Beneficiaries pay 20% of Medicare-Beneficiaries pay 20% of Medicare-approved amountapproved amount
– For outpatient treatment (such as For outpatient treatment (such as psychotherapy)psychotherapy)
In this YearIn this Year Beneficiaries PayBeneficiaries Pay
20132013 35%35%
20142014 20%20%
National Mail Order Program National Mail Order Program for Diabetic Testing Suppliesfor Diabetic Testing Supplies Effective July 1, 2013Effective July 1, 2013 Includes all parts of the United States Includes all parts of the United States
including US Territoriesincluding US Territories To find a supplier, visit To find a supplier, visit http://http://
www.medicare.gov/supplierdirectory/www.medicare.gov/supplierdirectory/search.htmlsearch.html
Medicare Part C & DMedicare Part C & D
Low-Performing Medicare Low-Performing Medicare Advantage and Drug PlansAdvantage and Drug Plans
Plans that receive average Part C or Plans that receive average Part C or D summary rating of less than 3-D summary rating of less than 3-stars for 3 years in a rowstars for 3 years in a row– Indicates organization’s substantial Indicates organization’s substantial
failure to comply with its Medicare failure to comply with its Medicare contractcontract
Ratings are on Medicare Plan Finder Ratings are on Medicare Plan Finder ToolTool
Medicare & You does not have full, Medicare & You does not have full, updated ratingsupdated ratings
Low-Performing Medicare Low-Performing Medicare Advantage PlansAdvantage Plans
Changes for low-performing plans in Changes for low-performing plans in 20132013– No online enrollment for low-performing No online enrollment for low-performing
plans plans Must contact plan directly to enrollMust contact plan directly to enroll
– Enrolled beneficiaries may use Special Enrolled beneficiaries may use Special Enrollment Period to move to a higher Enrollment Period to move to a higher quality planquality plan Will receive mailing from CMSWill receive mailing from CMS
CMS has option to terminate low-CMS has option to terminate low-performing contracts starting in performing contracts starting in 20152015
2013 Calendar 2013 Calendar HighlightsHighlights
Late September- CMS mails the Medicare Late September- CMS mails the Medicare & You handbook& You handbook
September 30- Plans must provide September 30- Plans must provide Annual Notice of Change/Evidence of Annual Notice of Change/Evidence of Coverage to membersCoverage to members
October 1- Plans begin marketingOctober 1- Plans begin marketing October 1- 2014 plan data to be October 1- 2014 plan data to be
displayed on the Medicare Plan Finderdisplayed on the Medicare Plan Finder Mid-October- plan ratings updated on Mid-October- plan ratings updated on
MPFMPF October 15-Open Enrollment beingsOctober 15-Open Enrollment beings December 7- Open Enrollment endsDecember 7- Open Enrollment ends January 1- 2014 plan benefit period January 1- 2014 plan benefit period
beginsbegins
Standard Part D Standard Part D Benefit ParametersBenefit Parameters
Benefit ParametersBenefit Parameters 20132013 20142014
DeductibleDeductible $325$325 $310$310
Initial Coverage LimitInitial Coverage Limit $2970$2970 $2850$2850
Out-of-Pocket ThresholdOut-of-Pocket Threshold $4750$4750 $3605$3605
Total Covered Drug Spending at OOP Total Covered Drug Spending at OOP ThresholdThreshold
$6954.52$6954.52 $6455$6455
Minimum Cost Sharing in Catastrophic Minimum Cost Sharing in Catastrophic CoverageCoverage
$2.65/$6.60$2.65/$6.60 $2.55/$6.35$2.55/$6.35
Extra Help CopaymentsExtra Help Copayments 20132013 20142014
InstitutionalizedInstitutionalized $0$0 $0$0
Receiving Home & Community Based Receiving Home & Community Based Ser.Ser.
$0$0 $0$0
Up to or at 100% FPLUp to or at 100% FPL $1.15/$3.50$1.15/$3.50 $1.20/$3.60$1.20/$3.60
Full Extra HelpFull Extra Help $2.65/$6.60$2.65/$6.60 $2.55/$6.35$2.55/$6.35
Partial Extra Help (deductible/cost-Partial Extra Help (deductible/cost-sharing)sharing)
$66/15%$66/15% $63/15%$63/15%
Part D Coverage Gap Part D Coverage Gap Discount ProgramDiscount Program
If beneficiaries reach the coverage gap If beneficiaries reach the coverage gap in 2013in 2013– 52.5% discount on covered brand-name 52.5% discount on covered brand-name
drugsdrugs Counts toward TrOOPCounts toward TrOOP
– 21% discount on covered generic drugs21% discount on covered generic drugs– Total cost paid by beneficiary (plus the Total cost paid by beneficiary (plus the
52.5% discount) counts toward catastrophic 52.5% discount) counts toward catastrophic coveragecoverage
– Dispensing fees are not subject to the Dispensing fees are not subject to the 52.5% discount52.5% discount
Additional savings in coverage gap each Additional savings in coverage gap each year year – Until 2020Until 2020
Improved Coverage in the Improved Coverage in the Coverage GapCoverage Gap
YearYear
What Beneficiaries Pay What Beneficiaries Pay for Brand Name Drugs in for Brand Name Drugs in
the Coverage Gapthe Coverage Gap
What Beneficiaries Pay What Beneficiaries Pay for Generic Drugs in the for Generic Drugs in the
Coverage GapCoverage Gap
20132013 47.5%47.5% 79%79%
20142014 47.5%47.5% 72%72%
20152015 45%45% 65%65%
20162016 45%45% 58%58%
20172017 40%40% 51%51%
20182018 35%35% 44%44%
20192019 30%30% 37%37%
20202020 25%25% 25%25%
High Performing Medicare High Performing Medicare Drug PlansDrug Plans
5 Star Special Enrollment Period5 Star Special Enrollment Period– Plans rated 5 Stars are indicated with a Plans rated 5 Stars are indicated with a
yellow triangle with a star and the yellow triangle with a star and the number 5 located in the centernumber 5 located in the center
– SEP begins December 8 each yearSEP begins December 8 each year– Beneficiaries can enroll into a 5 Star Beneficiaries can enroll into a 5 Star
rated plan up until Nov. 30 of the rated plan up until Nov. 30 of the following yearfollowing year
– Only allowed one enrollment during the Only allowed one enrollment during the SEPSEP
– SEP is extended to individuals currently SEP is extended to individuals currently enrolled into a 5 Star planenrolled into a 5 Star plan
Notices from CMS and Notices from CMS and SSASSA SeptemberSeptember
– Social Security Notice to Review Eligibility Social Security Notice to Review Eligibility for LISfor LIS
– Plan Annual Notice of Change/Evidence of Plan Annual Notice of Change/Evidence of CoverageCoverage
– Plan LIS Rider-from plan telling how much Plan LIS Rider-from plan telling how much they get in 2014 towards Part D they get in 2014 towards Part D premium, deductibles and co-paymentspremium, deductibles and co-payments
– Creditable Coverage letters from Creditable Coverage letters from Employer/Union plansEmployer/Union plans
– Loss of Deemed Status Notice-from SSA Loss of Deemed Status Notice-from SSA stating they are no longer eligible for LISstating they are no longer eligible for LIS
– Medicare & You handbooksMedicare & You handbooks
Notices from CMS and Notices from CMS and SSASSA OctoberOctober
– Plan Non-Renewal NoticesPlan Non-Renewal Notices– Change in Extra Help Co-Payment Notice- Change in Extra Help Co-Payment Notice-
from SSA on orange paper explaining from SSA on orange paper explaining copayments levels will change in 2014copayments levels will change in 2014
– Reassignment Notices-Plan Termination-Reassignment Notices-Plan Termination-on blue paper explaining that plan is on blue paper explaining that plan is terminating and they will be reassigned to terminating and they will be reassigned to a new plana new plan
– Reassignment Notice-Premium Increase-Reassignment Notice-Premium Increase-on blue paper explaining that will be re-on blue paper explaining that will be re-assigned to a new plan due to the assigned to a new plan due to the increase in their current plan premium increase in their current plan premium which is above the benchmarkwhich is above the benchmark
Notices from CMS and Notices from CMS and SSASSA OctoberOctober
– MA Reassignment Notice-on blue paper MA Reassignment Notice-on blue paper explaining that the MA plan is terminating explaining that the MA plan is terminating and they will be re-assigned to a Medicare and they will be re-assigned to a Medicare drug plan for 2014drug plan for 2014
NovemberNovember– LIS Choosers Notice-on tan paper LIS Choosers Notice-on tan paper
explaining if they chose a Plan on their explaining if they chose a Plan on their own that the plan’s premium has own that the plan’s premium has increased above the benchmark and they increased above the benchmark and they will pay a portion of the premiumwill pay a portion of the premium
Notices from CMS and Notices from CMS and SSASSA
NovemberNovember– Non-Renewal Reminder Notice- reminds Non-Renewal Reminder Notice- reminds
people who do not get LIS that the plan is people who do not get LIS that the plan is terminatingterminating
– Social Security Income Related Adjustment Social Security Income Related Adjustment Amount Notice- tell higher income Amount Notice- tell higher income beneficiaries about the higher Part B and beneficiaries about the higher Part B and Part D premium adjustmentsPart D premium adjustments
– Social Security LIS Redetermination Social Security LIS Redetermination Decision Notice-informing beneficiaries of Decision Notice-informing beneficiaries of their LIS award for 2014their LIS award for 2014
– Social Security LIS and MSP Outreach Social Security LIS and MSP Outreach Notice-informs individuals of these two Notice-informs individuals of these two benefitsbenefits
Notices from CMS and Notices from CMS and SSASSA
DecemberDecember– Social Security Benefit Rate Change Notice- tells people Social Security Benefit Rate Change Notice- tells people
about benefit payment changes due to cost of living about benefit payment changes due to cost of living increases, premium withholdings, etc.increases, premium withholdings, etc.
– Reassign Formulary Notice- on blue paper informing Reassign Formulary Notice- on blue paper informing individuals who get LIS and were affected by reassignment individuals who get LIS and were affected by reassignment which of the Part D drugs they took in 2013 will be which of the Part D drugs they took in 2013 will be covered in their new 2014 Medicare plancovered in their new 2014 Medicare plan
JanuaryJanuary– CMS Non-Renewal Action Notice- reminds people who do CMS Non-Renewal Action Notice- reminds people who do
not get LIS and whose plan terminated to join a new drug not get LIS and whose plan terminated to join a new drug planplan
FebruaryFebruary– Consistent Poor Performer Notice- Informs people that Consistent Poor Performer Notice- Informs people that
they’re enrolled in a plan that has been identified as a they’re enrolled in a plan that has been identified as a consistent poor performer and encourages them to consistent poor performer and encourages them to explore other plan options in their areaexplore other plan options in their area
THINGS TO REMEMBERTHINGS TO REMEMBER
Medicare Open Enrollment begins October Medicare Open Enrollment begins October 15 and ends December 715 and ends December 7
Must compare your prescription drug Must compare your prescription drug and/or Medicare Advantage planand/or Medicare Advantage plan
Kynect, Kentucky’s health care Kynect, Kentucky’s health care marketplace is for uninsured individuals marketplace is for uninsured individuals and enrollment dates are different from and enrollment dates are different from Medicare Open EnrollmentMedicare Open Enrollment
Review all information received from Review all information received from Social Security or MedicareSocial Security or Medicare