Washington SHIBA Trainings CMS Region 10 Presenters Division of Financial Management & Fee for Service Operations: Lauri Tan Division of Medicare Health Plan Operations: Steve Amaro Rod Haynes George Lombard Regional External Affairs & SHIP Liaison: Julie Bannester September 2015
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Washington SHIBA Trainings CMS Region 10 Presenters Division of Financial Management & Fee for Service Operations: Lauri Tan Division of Medicare Health.
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Washington SHIBA Trainings
CMS Region 10 Presenters
Division of Financial Management & Fee for Service Operations: Lauri Tan
Division of Medicare Health Plan Operations: Steve Amaro Rod Haynes George Lombard
Program Enrollment Medicare Access and CHIP Reauthorization Act
Medicare Provisions Preventive services Medicare Secondary Payer Recovery Medicare Advantage (Part C) Medicare Prescription Drug Coverage (Part D)
July 2015 Current Topics 6
7July 2015 Current Topics
Medicare Program Enrollment
* May not add up due to rounding.
2015 Average Monthly Projected Enrollment in Millions
Medicare
Parts A and/or B 55.2
Aged 46.1
Disabled 9.1
Original Medicare Enrollment 39
Prepaid Enrollment 16.2
Medicare Advantage Enrollment 15.7
Part D (Medicare Advantage with Rx Coverage and Prescription Drug Plans) 39.6
Medicare Access and CHIP Reauthorization Act Medicare Provisions
Medicare Access and CHIP Reauthorization Act Medicare Provisions
Sustainable Growth Rate (SGR) Repeal and Medicare Provider Payment Empowering Beneficiary Choices through Continued Access to Information on
Physicians’ Services Medicare and Other Health Extenders Savings to Medicare and Medicaid programs Protecting the Integrity of Medicare Act of 2015 (PIMA) Prohibition of Inclusion of Social Security Numbers on Medicare Cards Continuing Automatic Extension Of Providers Opt Out Election Income-related Premium Adjustment for Parts B and D Extension of Probe and Educate Program of Two Midnight Rule Medigap (Medicare Supplement Insurance) Policy Changes
July 2015 Current Topics 8
MACRA
9July 2015 Current Topics
Provisions to replace the Sustainable Growth Rate (SGR) formula to provide long-term stability to the Medicare physician fee schedule• Provides stable updates for 5 years and ensures no changes are made to
the current payment system for 4 years
• Establishes a streamlined and improved incentive payment program that will focus the fee-for-service system on providing value and quality
• Consolidates the 3 existing incentive programs, continuing the focus on quality, resource use, and meaningful electronic health records (EHRs)
• Provides financial incentive(s) for professionals to participate in tests of alternative payment models (APMs)
SGR Repeal and Medicare Provider Payment Modernization
MACRA
10July 2015 Current Topics
New publicly available information on doctors and other eligible providers on items and services furnished to Medicare beneficiaries• Number of services furnished • Submitted charges and payments for such services
The information would be searchable by the specialty or type of professional; characteristics of the services furnished; and location
Information on Physician Compare by 2016
Empowering Beneficiary Choices through Continued Access to Information on Physicians’ Services
MACRA
11July 2015 Current Topics
Extends increased payments for certain low-volume and small rural hospitals, doctors, therapy services, and ambulance providers
• Through either fiscal year 2017 or calendar year 2017 Depending on Medicare’s payment system to that type of provider
Extension of therapy cap exceptions process• Until January 1, 2018, and reforms the process of medical manual
review to help support the integrity of the Medicare program Extension for specialized Medicare Advantage (MA) Plans for special needs
individuals (Special Needs Plans)• This provision extends authority for SNPs through December 31, 2018
Permanent extension of the Qualifying Individual (QI) program Extends Transitional Medical Assistance under Medicaid
Medicare and Other Health Extenders
MACRA
12July 2015 Current Topics
Significant provisions include• Higher income thresholds starting in 2018 for determining Part B
and Part D premium subsidies Beginning in 2020, more people will pay higher Part B and Part
D premiums due to a change in the indexing of income thresholds
• Payment rate updates in 2018 for skilled nursing facilities, inpatient rehabilitation facilities, home health agencies, hospices and long-term care hospitals would be limited to 1%
• Planned 3.2% increase in inpatient hospital payment rate replaced by 0.5% increase each year from 2018-2023
Savings to Medicare and Medicaid programs
MACRA
13July 2015 Current Topics
Strengthening Medicare’s ability to fight fraud and build on existing program integrity policies• Prohibiting Social Security numbers on Medicare cards (no later than 4
years after enactment)
• Preventing payments for items and services furnished to incarcerated individuals, individuals not lawfully present, and deceased individuals
• Modifying Medicare Durable Medical Equipment Face-to-Face Encounter Documentation Requirement
• Requiring Valid Prescriber National Provider Identifiers on Pharmacy Claims (starting plan year 2016)
• Option to Receive Medicare Summary Notice Electronically (starting in Fall of 2015)
Protecting the Integrity of Medicare
MACRA
14July 2015 Current Topics
Prohibits Social Security account numbers on Medicare cards starting in 2019
The new Medicare Beneficiary Identifier (MBI) will be• Recognizably different than the Medicare Health Insurance
Claim Number (HICN)
• The same length as the HICN
• Displayed on the Medicare cards
• Will be used by external partners (Beneficiary, Provider, Plans, etc.) participating in claims processing and other related activities when interacting with CMS
Prohibition of Inclusion of Social Security Numbers on Medicare Cards
MACRA
15July 2015 Current Topics
Extend Opt Out election beginning on the date the affidavit is signed to include each subsequent 2-year period • Unless the physician or practitioner provides notice not later
than 30 days before the end of the previous 2-year period
Beginning not later than February 1, 2016, make the list publicly available through website • Number and characteristics of opt-out physicians and
practitioners
Continuing Automatic Extension Of Providers Opt Out Election
MACRA
16July 2015 Current Topics
Income-related Premium Adjustment for Parts B and D
Beginning in 2020, the income thresholds would be adjusted each year by increasing the previous year’s income threshold amounts by the consumer price index for urban consumers.
Modified Adjusted Gross Income Threshold for Years Prior to 2018
Modified Adjusted Gross Income Threshold for Years Beginning in 2018
Applicable Percentage
More than $85,000 but not more than $107,000
More than $85,000 but not more than $107,000
35%
More than $107,000 but not more than $160,000
More than $107,000 but not more than $133,500
50%
More than $160,000 but not more than $214,000
More than $133,500 but not more than $160,000
65%
More than $214,000 More than $160,000 80%
MACRA
17July 2015 Current Topics
Allows CMS to continue use of the Medicare Administrative Contractor (MAC) “probe and educate” program to assess provider understanding and compliance with the “2-Midnight Rule” • On a pre-payment basis• Through September 30, 2015
Allows CMS to identify providers that have properly understood and implemented the 2-midnight benchmark, and those providers who might benefit from additional education, as evidenced by high claim error rates
Extension of Probe and Educate Program of 2-Midnight Rule
MACRA
18July 2015 Current Topics
Limitation on certain Medigap policies for people newly eligible for Medicare • On or after January 1, 2020
• Medigap policies sold to newly eligible Medicare beneficiaries Will no longer provide coverage for the Part B deductible
Newly eligible means an individual who, before January 1, 2020, is neither 65, nor has Part A
Plans C and F will become Plans D and G respectively for policies sold to those newly eligible • Policies bought before January 1, 2020, won’t be affected
Multi-target stool DNA test (Cologuard™)• Covered for certain people with Medicare every 3 years if they
Are between 50–85 Show no signs or symptoms of colorectal disease Are at average risk for developing colorectal cancer
Hepatitis C Screening • Single once-in-a-lifetime screening test
• Covered for adults who don't meet the high-risk determination
• Born from 1945 through 1965
New Medicare Preventive Services
ACA
20July 2015 Current Topics
Lung cancer screening• Low Dose Computed Tomography once per year for certain people with
Medicare
Pneumococcal vaccine update• An initial pneumococcal vaccine for all Medicare beneficiaries who’ve never
received the vaccine under Medicare Part B
• A different second pneumococcal vaccine 1 year after the first vaccine was administered (11 full months have passed following the month in which the last pneumococcal vaccine was administered)
• All people with Medicare are eligible
• No copayment or deductible for the vaccines with Original Medicare if the provider accepts assignment
Medicare Preventive Services Continued
ACA
21July 2015 Current Topics
SMART Act final rule effective April 28, 2015• Established a formal appeals process for applicable plans
where the Secretary seeks Medicare Secondary Payer (MSP) recovery directly from an applicable plan
• Applicable plan may appeal the amount of the debt and/or the existence of the debt
Medicare is required to send a notice to people with Medicare who received the items or services at issue
Strengthening Medicare and Repaying Taxpayers Act of 2012
SMART
Medicare Advantage Plans (Part C)Medicare Advantage Plans (Part C)
Expanded rewards and incentive programs Low-performing plans
22Current TopicsJuly 2015
23July 2015 Current Topics
Focus on encouraging participation in activities that promote• Improved health• Prevention of injuries and illness• Efficient use of health care resources
Can’t discriminate based on race, gender, chronic disease, institutionalization, frailty, health status, or other impairments
Must be designed so all enrollees are able to earn rewards Can’t be offered in the form of cash or other monetary
rebates or be used to target potential enrollees
Medicare Advantage OrganizationsExpanded Rewards and Incentives
Reg 4159-F
Low-Performing Health Plan (LPP) Termination
Termination of consistently low-performing plans (LPPs) on December 31, 2016• If plan receives Part C or Part D summary score of
less than 3 stars for 3 consecutive years Plans will be identified when plan ratings data
is released in early October 2015• LPPs currently have icon on Medicare Plan Finder• Affected beneficiaries will have an opportunity to
join a new plan
July 2015 Current Topics 24
Medicare Prescription Drug Coverage (Part D)Medicare Prescription Drug Coverage (Part D)
Requirements for Prescribers Low Performing Plan Terminations Improved Coverage in the Coverage Gap Access to Preferred Cost-Sharing Pharmacies
July 2015 Current Topics 25
26July 2015 Current Topics
CY 2015 final rule issued May 23, 2014 requires prescribers of Part D drugs • Be enrolled in an approved status, or
• Have a valid opt-out affidavit on file for their prescriptions to be covered under Part D
Requirement for Prescribers
CMS-4159-F
27July 2015 Current Topics
The June 1, 2015, interim final rule changed enforcement date to June 1, 2016• Requires pharmacy claims and beneficiary requests for reimbursement
for Part D prescriptions Written by prescribers other than physicians and eligible professionals
permitted by state or other applicable law to prescribe medications Not be rejected at point of sale by the plan if all other requirements
are met
• Requires plans to allow a provisional 3-month supply When prescription is written by a prescriber eligible to enroll but who
isn’t enrolled in or opted out of Medicare
Requirement for Prescribers Continued
CMS-4159-F
28July 2015 Current Topics
Plans will be required to make disclosures of their outlier status in 2016 plan marketing materials if their network analysis finds that their plans offer access to a PCSP within• 2 miles of fewer than 40% of urban beneficiaries’ residences; • 5 miles of fewer than 87% of suburban beneficiaries’
residences; or • 15 miles of fewer than 70% of rural beneficiaries’ residences.
CMS will take compliance actions if plan doesn’t provide the required disclosures
Lesson 4—Medicaid/Children’s Health Insurance Program (CHIP) Updates
Lesson 4—Medicaid/Children’s Health Insurance Program (CHIP) Updates
Medicaid and Children’s Health Insurance Program (CHIP) Enrollment
Medicare Access and CHIP Reauthorization Act CHIP provisions
July 2015 Current Topics 32
33July 2015 Current Topics
Medicaid and Children’s Health Insurance Program (CHIP) Enrollment
*Doesn’t add up due to rounding
2015 Average Monthly Projected Population in Millions*
Medicaid Total 66.7
Aged 5.5
Blind/Disabled 9.8
Children 29.3
Adults 15.1
Expansion Children .7
Expansion Adult 6.4
Children’s Health Insurance Program 6.2
34July 2015 Current Topics
Medicaid agencies are required to screen all provider applications, including initial applications, applications for a new practice location, and applications for re-enrollment or revalidation, based on a categorical risk level of “limited,” “moderate,” or “high” • Starting July 31, 2015
State Medicaid agencies must establish categorical risk levels for providers and provider categories who pose an increased financial risk of fraud, waste or abuse to the Medicaid program• When the agency determines that a provider’s categorical risk level is
“high,” or when the agency is otherwise required to do so under state law, the agency must require providers to consent to criminal background checks, including fingerprinting
Implementation of Fingerprint-Based Criminal Background Checks
42 CFR 455.414-416
35July 2015 Current Topics
Preserves and extends CHIP funding through fiscal year 2017• Would likely provide enough funds to cover some amount of
projected 2018 expenditures• CHIP program is authorized through 2019
Extension of Express Lane Eligibility (ELE) • Permits states to rely on findings, for things like income, household
size, or other factors of eligibility, from another program designated as an Express Lane agency to facilitate enrollment in health coverage. Express Lane agencies may include
SNAP, School Lunch, TANF, Head Start, and WIC Extension of Outreach and Enrollment Program
Medicare Access and CHIP Reauthorization Act CHIP provisions
MACRA
Navigating the Medicare Plan FinderNavigating the Medicare Plan Finder
April 2015
What is the Medicare Plan Finder?What is the Medicare Plan Finder?
Internet tool on Medicare.gov that let’s you • View and compare your health and drug coverage
options in your area• Identify which plans cover your prescriptions at most
affordable cost where you shop• Enroll in a Part D or Medicare Advantage Plan
Getting Started: What You Will NeedGetting Started: What You Will Need
Your Zip Code Medicare card List of prescriptions
• Strength and quantity• Use of generics
Pharmacy you use Other helpful information Other health insurance cards Subsidy eligibility Medicaid, Low Income Subsidy April 2015 Navigating the Medicare Plan Finder 38
Medicare.gov HomepageMedicare.gov Homepage
April 2015 Navigating the Medicare Plan Finder 39
Plan Finder HomepagePlan Finder Homepage
April 2015 Navigating the Medicare Plan Finder 40
Plan Finder Search OptionsPlan Finder Search Options
April 2015 Navigating the Medicare Plan Finder 41
Step 1 of 4: General Search OnlyStep 1 of 4: General Search Only
LIS Notice states what percentage the beneficiary is
expected to pay for their premium.
April 2015 Navigating the Medicare Plan Finder 42
General Search Only-Select Your Current Plan
General Search Only-Select Your Current Plan
Select Your current plan from a list of plans in your
area.
April 2015 Navigating the Medicare Plan Finder 43
Step 2: Enter Your DrugsStep 2: Enter Your Drugs
April 2015 Navigating the Medicare Plan Finder 44
Entering DrugsEntering Drugs
April 2015 Navigating the Medicare Plan Finder 45
Pop-up box to indicate dosage, quantity, frequency and where you buy
Pop-up box to indicate dosage, quantity, frequency and where you buy
Exercise 2: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Competitive Bidding Program
Exercise 3: The Health Insurance Marketplace and Medicare
Casework Exercises
Exercise 1Mr. Santos’ birthday is February 15, 1947. Mr. Santos has 40 quarters, but he continues to work and is covered by his employer group health plan. Mr. Santos decided to retire on June 30, 2015.• What is the appropriate enrollment period to use?• How long does Mr. Santos have to enroll in Medicare?• When should Mr. Santos apply for Medicare?• What if Mr. Santos takes COBRA? When should he
apply for Medicare? Why?
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Exercise 1 (cont’d)
83
Mar Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar
E E E E CE C
E CE C
E CE C
E CE C
E C
Exercise 1 (cont’d)
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar
COBRA
G E P
E
C
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Under this scenario, if the beneficiary takes COBRA and did not enroll until March (end of the GEP) will the beneficiary have a Part B late enrollment penalty (LEP) ?
Exercise 2
A dialog on
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
Competitive Bidding Program
85
Exercise 3
Mr. Gonzalez is 64 years old. He is enrolled in the WA State Health Benefit Exchange. In 4 months Mr. Gonzalez will turn 65. Mr. Gonzalez came to see you today for advice.
What are the questions that you need to ask Mr. Gonzalez?