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					2011 Current Topics
    Module 4
                     Session Objectives

         At the end of this session you will be able to
             – Recognize pertinent legislation
             – Explain updates to Medicare and Medicaid




07/27/2011                 DRAFT Medicare Current Topics   2
                          2011 Enrollment

                                                        Children’s Health
               Medicare                       Medicaid Insurance Program

  9.2M Medicare and Medicaid Eligible                         5M+
48.6M                                             67M
• 36.7M Original Medicare
• 11.9MMedicare Advantage
         For state level data
• 35.6M gethttp://www.cms.gov/ho
         – Part D Rx benefits
  o 29.4M in Part D
             me/rsds.asp
  o 6.2M through Retiree Drug
    Subsidy
  o 10.7M low-income have drug
    coverage
  07/27/2011                 DRAFT Medicare Current Topics           3
                           Lessons

             1. Pertinent Legislation
             2. Agency Priorities
             3. Medicare Updates
             4. Durable Medical Equipment,
                Prosthetics, Orthotics, and Supplies
                (DMEPOS)
             5. Electronic Health Records
             6. Medicaid Updates
07/27/2011                DRAFT Medicare Current Topics   4
                      1. Pertinent Legislation

                MMA - Medicare Modernization Act
                DRA - Deficit Reduction Act
                TRHCA -Tax Relief and Health Care Act
                MMSEA - Medicare, Medicaid, and State Children’s
                 Health Insurance Program Extension Act
                MIPPA - Medicare Improvements for Patients and
                 Providers Act
                CHIPRA - Children’s Health Insurance Program
                 Reauthorization Act
                ARRA - American Recovery and Reinvestment Act
                ACA - Affordable Care Act

07/27/2011                      DRAFT Medicare Current Topics       5
                    2. Agency Priorities

             I. Improving Care for Individuals
             II. Better Coordination of Care
             III. Fighting Fraud and Abuse




07/27/2011                DRAFT Medicare Current Topics   6
             I. Improving Care for Individuals

     Value-based Purchasing
     Focus on Hospital Acquired Conditions
     Reducing Unnecessary Hospital Readmissions
     Bonus Payments
     Preexisting Condition Insurance Plans




07/27/2011              DRAFT Medicare Current Topics   7
                                                                 ACA

             Hospital Value-Based Purchasing

 Incentive payments to acute care hospitals
   – Based either on
         1. How well a hospital performs on certain quality measures
         2. How much the hospitals' performance improves
              o On certain quality measures during baseline period
   – Effective FY 2013 for discharges on/after 10/1/2012




07/27/2011                 DRAFT Medicare Current Topics          8
                                                         ACA

        Hospital-Acquired Conditions (HACs)

 Prohibits federal payments to states
      – For Medicaid services related to certain HACs
 100K Americans die each year from HACs
 HACs increase hospital costs by $45B a year
 HAC identified based on
      – Medical record
      – Diagnosis-related group (DRG) for initial admission


07/27/2011              DRAFT Medicare Current Topics     9
                                                        ACA

 Hospital Readmission Reduction Program

 Smoother transitions for patients
    – Like follow up phone calls/home health nurse visits
 Rewards hospitals that reduce avoidable
  readmissions
 Improves quality of care
 CMS and Quality Improvement Organizations
    – Work with hospitals at local level
 Effective October 1, 2012
07/27/2011              DRAFT Medicare Current Topics   10
                                                           ACA

               HPSA Bonus Payments

 10% Medicare bonus payments
      – Primary care services
      – General surgeons in health professional shortage
        areas
 From January 1, 2011 – December 31, 2015




07/27/2011              DRAFT Medicare Current Topics      11
                                                       ACA

  Pre-Existing Condition Insurance Plans (PCIPs)

 Covers people without insurance due to a pre-
  existing condition until 2014
 Administered by state or Department of
  Health and Human Services
 Premium not higher due to your condition
      – Standardized by age
 Doesn’t base eligibility on income


07/27/2011             DRAFT Medicare Current Topics   12
                                                       ACA

             PCIP Standard Covered Benefits

 Primary and specialty care
 Hospital care
 Prescription drugs
 Home health care and hospice care
 Skilled nursing care
 Preventive health and maternity care



07/27/2011             DRAFT Medicare Current Topics   13
                                                         ACA

             Who is eligible for PCIP coverage?

 U.S. citizens or legal residents
 With a pre-existing medical condition
 Not have creditable health coverage
      – For the previous 6 months before you apply
 Your state Consumer Assistance Program (CAP)
      – Helps you enroll
      – File complaints and appeals
 Information at https://www.pcip.gov/
07/27/2011               DRAFT Medicare Current Topics   14
             II. Better Integration of Care

 Independence at Home Demonstration
 Accountable Care Organizations
 Medicare-Medicaid Coordination Office




07/27/2011            DRAFT Medicare Current Topics   15
                                                             ACA

    Independence at Home Demonstration

 Tests providing services at home
      – To certain high-need Medicare beneficiaries
      – Utilizes primary care teams
             • Directed by physician or nurse practitioner
      – Care is coordinated across all settings
      – Quality reporting required
      – Voluntary
 Effective January 1, 2012 and runs 3 years

07/27/2011                   DRAFT Medicare Current Topics   16
                                                             ACA

    Independence at Home Demonstration

 Participating beneficiaries must
      – Must be entitled to Part A and enrolled in Part B
      – Not be enrolled in a Medicare Advantage or PACE plan
      – Have two or more chronic illnesses, designated by CMS
      – Have non-elective hospital admission in past 12 months
      – Have two or more functional dependencies
         • Requiring assistance of another person
      – Meet other criteria as specified by the legislation



07/27/2011                DRAFT Medicare Current Topics      17
                                                             ACA

    Accountable Care Organizations (ACOs)

 Providers organize ACOs
      – Facilitate provider coordination and cooperation
             • Improve quality of care
             • Reduce unnecessary costs
      – Voluntarily meet quality thresholds
      – Share in cost savings achieved for Medicare
 Comment period closed
      – In listening mode

07/27/2011                   DRAFT Medicare Current Topics   18
                                                       ACA

   Medicare-Medicaid Coordination Office

 Medicare-Medicaid Coordination Office is part
  of CMS
 Focus on Medicare – Medicaid eligible
 Purpose
      – Improve quality
      – Reduce costs
      – Improve the beneficiary experience


07/27/2011             DRAFT Medicare Current Topics   19
             III. Fighting Fraud and Abuse

 Save taxpayer dollars
 New steps




07/27/2011            DRAFT Medicare Current Topics   20
              Fighting Fraud and Abuse
 Tax dollars saved
      – Over $4 billion recovered and returned in 2010
      – Over $5 billion so far in 2011
 Nine Anti-fraud Strike Force teams
      – In fraud hot spots around the country
      – Hundreds of convictions
      – Criminals had billed Medicare $100s of millions
 Senior Medicare Patrol www.smpresource.org
      – Reached 1.5 million with critical information
07/27/2011              DRAFT Medicare Current Topics     21
                                                          ACA

                Fraud and Abuse Prevention

 New steps to keep criminals on the defensive
      – Tougher screenings for health care providers
      – Site visits
      – Keep fraudulent providers out of programs
             • Medicare
             • Medicaid
             • CHIP
      – Types identified as higher risk subject to more
        thorough screening

07/27/2011                DRAFT Medicare Current Topics   22
                                                      ACA

             Fraud and Abuse Prevention

 Identify trends that indicate fraud
 Increase penalties for fraud
 Authority to suspend payments
   – When credible allegation is being investigated
 $350 million for fraud fighting resources




07/27/2011           DRAFT Medicare Current Topics    23
                    3. Medicare Updates

              Medicare
              – Original Medicare
              – Medicare Advantage (Part C)
              – Medicare Prescription Drug Coverage (Part D)




07/27/2011                  DRAFT Medicare Current Topics   24
                Original Medicare Updates

              2011 Amounts and Premiums
              Therapy Caps
              Face-to-face encounters
                –   Home Health
                –   Hospice
              Power-Driven Wheelchairs
              Preventive Services

07/27/2011                DRAFT Medicare Current Topics   25
     Part A Costs for Inpatient Hospital Stays

For each benefit
period in 2011                   You Pay
Days 1-60            $1,132 deductible
Days 61-90           $283 per day
Days 91-150          $566 per day (60 lifetime
                     reserve days)
All days after 150   All Costs

  07/27/2011         DRAFT Medicare Current Topics   26
 Part A Costs for Skilled Nursing Facility Care


For each benefit period in 2011       You Pay
Days 1-20                       $0
Days 21-100                     $141.50 per day
All days after 100              All Costs




 07/27/2011        DRAFT Medicare Current Topics   27
                     2011 Part B Amounts

    Part B Annual Deductible - $162
                 Part B Monthly Premium
    (hold harmless since no Social Security COLA in 2011)
If your income is $85K or less You pay this                   Notes
   and you paid this in 2010     in 2011
            $96.40                   $96.40
           $110.50                  $110.50           If premium deducted from
                                                      Social Security
                                  $115.40 If premium not deducted
                                                      from Social Security
                                  $115.40 If
 Nothing (not yet enrolled) DRAFT Medicare Current Topics new to Medicare in 2011
  07/27/2011                                                                 28
                Income-Related Part B Premium
     Part B premium income thresholds
          – Frozen at 2010 levels through 2019
                                                                   In 2011
                If your Yearly Income in 2009 was
                                                                  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         $299.00
above $214,000                          above $428,000            $369.10
 *Higher if you have a late enrollment penalty

   07/27/2011                     DRAFT Medicare Current Topics       29
                                                            ACA

   Extension of Therapy Cap Exceptions Process

 Ability to request exception was to end 2010
 Process of therapy caps extension extended
      – Therapy caps determined on calendar year basis
      – Exception process
             • Extended through December 2011




07/27/2011                  DRAFT Medicare Current Topics   30
                                                                       ACA

                  2011 Therapy Limits


             Type of Therapy                           Annual Limit*
Physical and                                             $1,870
Speech-Language Pathology                               Combined
Occupational Therapy                                      $1,870

*Doesn’t apply to therapy services you get in hospital
  outpatient departments or hospital emergency rooms



07/27/2011             DRAFT Medicare Current Topics                   31
New Home Health Face-to-Face Encounter

  New requirement for face-to-face encounter
       – 90 days before or 30 days after start of care
       – May include use of telehealth
             • Via communications system
  Certify
       – Skilled need
       – Homebound status


07/27/2011                  DRAFT Medicare Current Topics   32
      Home Health Face-to-Face Encounter

  Within guidelines may be conducted by
       – Physician
       – Nurse practitioner or clinical nurse specialist
       – Physician’s Assistant under physician’s supervision
       – Hospitalist
             • Doctor specialized in the care of patients in the hospital
  Implemented 3/10/11


07/27/2011                     DRAFT Medicare Current Topics           33
                                                          ACA

       New Face-to-Face Hospice Encounter

 Hospice physician or nurse practitioner
      – Meet in person prior to 180-day recertification
        • Hospice patients entering their 3rd benefit period
        • Each subsequent recertification
 No additional payment
      – Unless reasonable and necessary medical care
        provided



07/27/2011              DRAFT Medicare Current Topics     34
                                                          ACA

       New Face-to-Face Hospice Encounter

 Certifying doctor/nurse practitioner
             • Employed by hospice or
             • Work under arrangement with hospice
 Can be done anywhere
      – Patient transport covered by hospice per diem
 Telehealth may NOT be used
 Effective January 1, 2011


07/27/2011                DRAFT Medicare Current Topics   35
                                                          ACA

             Power-Driven Wheelchairs

 Eliminates up-front lump-sum payment option
  for standard power wheelchairs
 Medicare will pay over a 13-month period
 Complex rehabilitative power wheelchairs
      – Purchase option maintained
 Effective January 1, 2011
      – Does not apply to beneficiaries who live in one of
        the first 9 competitive bidding areas until January
        1, 2014

07/27/2011               DRAFT Medicare Current Topics        36
                                                        ACA
                Annual Wellness Visit

 Once every 12 months covers
      – Comprehensive health risk assessment
      – Personalized prevention plan
      – Health advice
      – Referrals for education and counseling
 No cost if doctor accepts assignment
 Can be performed by nurse practitioners and
  physician’s assistants
 Effective January 1, 2011
07/27/2011              DRAFT Medicare Current Topics   37
             When to get Your Wellness Visit


 Had Part B for at least 12 months
      – Welcome to Medicare physical not required
 Had “Welcome to Medicare” exam
      – Must wait 12 months before annual Wellness visit
 Effective January 1, 2011




07/27/2011             DRAFT Medicare Current Topics   38
              Preventive campaign summer of 2011
               – Learn about covered preventive
                  services
               – PSA’s, online ads, community events
               – Access preventive publications
             www.medicare.gov/share-the-health/
07/27/2011           DRAFT Medicare Current Topics   39
               Medicare Advantage Updates

              Enrollment Period
              Disenrollment Period
              5-Star Special Election Period
              Cost Limits/Plan Payments
              Extension of Cost Plans
              Complaint system
              Appeals

07/27/2011                  DRAFT Medicare Current Topics   40
                                                                ACA

  Medicare Advantage Enrollment Periods

 MA Open Enrollment Period eliminated
 Annual Coordinated Election Period (AEP)
      – Now October 15 – December 7
             • Enrollment effective January 1
      – Known as Open Enrollment
             • Can change plan or switch to Original Medicare




07/27/2011                    DRAFT Medicare Current Topics     41
                                                        ACA

     New MA Annual Disenrollment Period

 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
 Between January 1-February 14
      – Effective first of the month after enrollment




07/27/2011              DRAFT Medicare Current Topics   42
             New Special Enrollment Period

 Can enroll in 5-Star MA, MAPD or PDP plan
 Enroll at any point during the year
      – Once per year
 New plan starts first of month after enrolled
 Star ratings on Planfinder October 1
      – Updated yearly
 Effective December 8, 2011


07/27/2011               DRAFT Medicare Current Topics   43
                                                          ACA

             Medicare Advantage Plans

 Can’t charge more than Original Medicare
      – Chemotherapy
      – Dialysis
      – Skilled nursing facility care
      – Other certain services
 Must limit your costs for Part A/B services
 Effective January 1, 2011


07/27/2011                DRAFT Medicare Current Topics   44
                                                              ACA

   Payments to Medicare Advantage Plans

 Frozen in 2011
 Benchmarks vary
      – % Original Medicare pays on average at county level
 Phased in over 3, 5, or 7 years
      – Depending on level of payment reductions
 MA benchmarks reduced in 2012
 85% of funds must be spent on health care
      – Effective 2014

07/27/2011                 DRAFT Medicare Current Topics      45
                                                        ACA

               Extension of Cost Plans

 Cost Plans
      – Not Medicare Advantage Plans
      – Provide full Medicare package
      – Services covered by plan or Original Medicare
      – Were scheduled to end in 2010
 Cost plan contracts extended
      – In areas that have other health plan options
      – From January 1, 2010 to January 1, 2013

07/27/2011              DRAFT Medicare Current Topics   46
Medicare Prescription Drug Coverage Updates

              Enrollment Period
              Coverage Gap
              Income-related Premium
              Indian Health/AIDS Drug Assistance
              Low-Income Benchmark Premium




 07/27/2011              DRAFT Medicare Current Topics   47
                                                                 ACA

                   Open Enrollment Period

 Formerly called the Annual Election Period
 Changes in 2011
      – October 15 – December 7
      – Coverage begins January 1, 2011
             • Joined/switched Medicare Advantage Plan
             • Joined/switched Medicare Prescription Drug Plan




07/27/2011                    DRAFT Medicare Current Topics      48
             New Special Enrollment Period

 Can enroll in 5-Star MA, MAPD or PDP plan
 Enroll at any point during the year
      – Once per year
 New plan starts first of month after enrolled
 Star ratings on Planfinder October 1
      – Updated yearly
 Effective December 8, 2011


07/27/2011               DRAFT Medicare Current Topics   49
                                                            ACA

                     Part D Coverage Gap

 If you reach the coverage gap in 2011
      – You get a 50% discount on brand-name Rx drugs
             • Counts toward TROOP
      – 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

07/27/2011                  DRAFT Medicare Current Topics   50
                What You Pay for Brand                What You Pay for Generic
                 Name Drugs in the                    Drugs in the Coverage Gap
  Year             Coverage Gap
  2011                  50%                                     93%
  2012                  50%                                     86%
  2013                 47.5%                                    79%
  2014                 47.5%                                    72%
  2015                  45%                                     65%
  2016                  45%                                     58%
  2017                  40%                                     51%
  2018                  35%                                     44%
  2019                  30%                                     37%
  2020                  25%                                     25%
Note: Dispensing fees are not discounted.
07/27/2011                    DRAFT Medicare Current Topics                 51
                                                                     ACA

 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
             • Beneficiary financial information not on Planfinder
 Must pay if you have Part D coverage
 Social Security notifies beneficiary
 Effective January 1, 2011

07/27/2011                    DRAFT Medicare Current Topics          52
   Income-Related Adjustment to Part D Premium                                   ACA
  For IRS Reported Income 2 Years Prior                               You Pay
Individual Tax Return     File Joint Tax Return                 In 2011     In 2012

$85K or below           $170K or below                           Base Premium (BP)

$85K – $107K            $170,000.01 – $214,000 BP + $12.00 BP + $11.60

$107K – $160K           $214,000.01 – $320,000 BP + $31.10 BP + $29.90

$160K – $214K           $320,000.01 – $428,000 BP + $50.10 BP + $48.10

$214K and up            $428,000.01 or higher                  BP + $69.10 BP + $66.40


Note: Can be appealed to SSA (not plan or CMS)
   07/27/2011                  DRAFT Medicare Current Topics                     53
                                                          ACA

               True Out-of-Pocket Costs

 Count toward out-of-pocket TROOP threshold
      – Drug costs reimbursed by Indian Health Services
      – Drug costs reimbursed by AIDS Drug Assistance
        Programs
 Effective January 1, 2011




07/27/2011              DRAFT Medicare Current Topics     54
 Part D Low Income Benchmark Premiums

 Removes MA rebates/quality bonus payments
     – From Low Income Subsidy benchmark calculation
     – Effective January 1, 2011
 Provides for voluntary de minimis policy
     – Allows Part D plans to absorb cost difference
     – Remain a $0 premium LIS plan
     – Effective January 1, 2011




07/27/2011              DRAFT Medicare Current Topics   55
                                                       ACA

Improvement to PDP/MA-PD Complaint System

 Model form is on www.medicare.gov
      – Number and types of complaints
      – Geographic variations
      – Timeliness of responses
      – Resolution of complaints




07/27/2011             DRAFT Medicare Current Topics   56
                                                              ACA
                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
             • Via plan’s toll-free telephone number
             • On plan’s website
 Filed on or after January 1, 2012



07/27/2011                    DRAFT Medicare Current Topics   57
                        4. DMEPOS

              Durable Medical Equipment,
               Prosthetics, Orthotics and Supplies
               (DMEPOS) Competitive Bidding
               Program




07/27/2011                DRAFT Medicare Current Topics   58
                                                         MMA
    Durable Medical Equipment, Prosthetics,              MIPPA
       Orthotics and Supplies (DMEPOS)                   ACA


 Part B covered equipment and supplies
 New competitive bidding program
      – Effective 1/1/11 in 9 areas
 Must use contract supplier
      – In certain areas
      – For certain products




07/27/2011               DRAFT Medicare Current Topics     59
                                                        MMA
                                                        MIPPA
   Who the Competitive Bidding Affects

 Beneficiaries who have Original Medicare
      – Reside in Competitive Bidding Area (CBA)
      – Obtain competitive bid items while visiting a CBA
 To see if ZIP Code is in a Competitive Bidding Area
      – Call 1-800-MEDICARE
      – Visit www.medicare.gov
 Medicare Advantage enrollees use plan suppliers


07/27/2011              DRAFT Medicare Current Topics       60
                                                         MMA
                                                         MIPPA
                  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       Cincinnati, Middletown
Indiana
Pennsylvania              Pittsburgh
Texas                     Dallas-Fort Worth, Arlington

 07/27/2011              DRAFT Medicare Current Topics      61
                                                          MMA
                                                          MIPPA
        Products Included in the Program
1. Oxygen, oxygen equipment, and supplies
2. Standard power wheelchairs, scooters
3. Complex rehabilitative power wheelchairs – Group 2 only
4. 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 accessories
8. Walkers and related accessories
9. Support surfaces (Group 2 mattresses/overlays) Miami only


07/27/2011              DRAFT Medicare Current Topics          62
                                                             MMA
                                                             MIPPA
               Using Contract Suppliers

 Must use contract supplier for items/services
  included in Competitive Bidding Program
      – Living in a CBA
      – Traveling to or visiting a CBA
 Exceptions
      – Doctors/hospitals can supply certain items (ex:
        walkers)
      – Nursing facility can supply directly if a contract
        supplier
07/27/2011               DRAFT Medicare Current Topics        63
                                                       MMA
                                                       MIPPA
             Identifying Contract Suppliers

 Call 1-800-MEDICARE (1-800-633-4227)
 TTY users call 1-877-486-2048
 Visit www.medicare.gov/supplier
      – DMEPOS Supplier Locator Tool




07/27/2011             DRAFT Medicare Current Topics    64
                                                        MMA
                                                        MIPPA
                         Round 2                        ACA


 Program expands
      – 91 Metropolitan Statistical Areas
 Supplier competition begins in 2011
 Visit www.cms.gov/DMEPOSCompetitiveBid/




07/27/2011              DRAFT Medicare Current Topics    65
       5. Electronic Health Records Updates

              American Recovery and
               Reinvestment Act (ARRA) and the
               Health Information Technology for
               Economic and Clinical Health Act
               (HITECH)
              Medicare’s “Blue Button”



07/27/2011               DRAFT Medicare Current Topics   66
                                                   ARRA
                                                   HITECH
             EHR Incentive Program

 Health Information Technology for Economic
  and Clinical Health Act (HITECH)
 Provides incentive payments
 Use of electronic health records system
 Sometimes called “HITECH”




07/27/2011         DRAFT Medicare Current Topics   67
                                                        ARRA
                                                        HITECH
                    Who Is Eligible?

 Professionals who use EHRs meaningfully
      – Doctor of medicine or osteopathy
      – Doctor of dental surgery or medicine
      – Doctor of podiatry
      – Doctor of optometry
      – Chiropractor




07/27/2011              DRAFT Medicare Current Topics   68
                                                        ARRA
                                                        HITECH
                   Who Is Eligible?

 Hospitals who use EHRs meaningfully
      – In 50 states and DC
      – Paid under inpatient prospective payment system
      – Critical access hospitals
      – Can be Medicare Advantage affiliated




07/27/2011              DRAFT Medicare Current Topics   69
                                                         ARRA
                                                         HITECH
                    Meaningful Use

 Use certified EHR technology meaningfully
      – To exchange health information
      – To improve quality of health care
      – To submit clinical quality and other measures
      – So quality and quantity are measurable




07/27/2011               DRAFT Medicare Current Topics   70
                                                      ARRA
                                                      HITECH
                 Program Benefits

 Increased data confidentiality
 Streamlined clinician workflow
 Improved quality of care
 For information and registration
      – www.cms.gov/EHRIncentivePrograms/




07/27/2011            DRAFT Medicare Current Topics   71
             NEW: Medicare’s “Blue Button”

    On www.MyMedicare.gov
         – Helps you manage your health information online
         – Download your Medicare claims
         – Download self-entered information
             •   Emergency contacts
             •   Names of pharmacies and providers
             •   Self-reported allergies
             •   Medical conditions
             •   Prescription drugs

07/27/2011                    DRAFT Medicare Current Topics   72
                    6. Medicaid Updates

              New Eligibility Group
              Medicaid Drug Changes
              Medicaid Health Homes
              State Balancing Incentive Program




07/27/2011                DRAFT Medicare Current Topics   73
                                                        ACA

   Coverage of Individuals Under Medicaid

 New eligibility group (VIII)
      – Must be covered as of January 2014
      – States have option to begin covering April 1, 2010
      – Fills the gaps in existing Medicaid eligibility
      – Very-low income individuals not otherwise eligible
         • Income can’t exceed 133% FPL
         • No asset test



07/27/2011              DRAFT Medicare Current Topics    74
                                                        ACA

   Coverage of Individuals Under Medicaid

 New eligibility group (VIII) includes those not
      – Age 65 or older
      – Pregnant
      – Entitled to or enrolled in Medicare Part A
      – Enrolled under Medicare Part B
      – In any other mandatory group
 States may elect to phase-in coverage


07/27/2011              DRAFT Medicare Current Topics   75
                                                       ACA

              Medicaid Drug Changes

 Removed from Medicaid’s excluded list in 2014
      – Smoking cessation drugs
      – Barbiturates
      – Benzodiazepines



Note: This change takes place for Medicare in 2013



07/27/2011             DRAFT Medicare Current Topics   76
                   Medicaid Health Homes

 Creates a new Medicaid state option
 Certain Medicaid enrollees with multiple
  chronic illnesses
      – Can designate a provider as a health home
      – Coordinates medical/behavioral health care
 States taking up the option receive
      – 90% federal matching payments
             • For two years for health home-related services
 Effective January 1, 2011
07/27/2011                    DRAFT Medicare Current Topics     77
                        Medicaid

 Creates State Balancing Incentive Program
      – Provides enhanced Federal matching payments
      – Increase non-institutionalized long-term care svcs
 Creates Community First Choice Option
      – Provides community-based attendant support svcs
      – For certain people with disabilities
 Effective October 1, 2011


07/27/2011              DRAFT Medicare Current Topics    78
                                         Current Topics Resource Guide

                              Resources                                              Medicare Products
Centers for Medicare &                     State Health Insurance Assistance     Medicare & You Handbook
Medicaid Services (CMS)                    Programs (SHIPs)*                     CMS Product No. 10050)
1-800-MEDICARE
(1-800-633-4227)                           *For telephone numbers call CMS       Your Medicare Benefits
(TTY 1-877-486-2048)                       1-800-MEDICARE (1-800-633-4227)       CMS Product No. 10116
www.medicare.gov                           1-877-486-2048 for TTY users
www.cms.gov                                                                      Choosing a Medigap Policy: A Guide to
                                                                                 Health Insurance for People with
Social Security                                                                  Medicare
1-800-772-1213                                                                   CMS Product No. 02110
TTY 1-800-325-0778
www.socialsecurity.gov                                                           Closing the Coverage Gap – More
                                                                                 Prescription Drugs Are Becoming
Railroad Retirement Board                                                        Affordable
1-877-772-5772                                                                   CMS Product No. 11493
www.rrb.gov
                                                                                 To access these products:
Pre-Existing Condition Insurance Plans
                                                                                 View and order single copies at
www.pcip.gov
                                                                                 www.medicare.gov

                                                                                 Order multiple copies (partners only)
                                                                                 at productordering.cms.hhs.gov. You must
                                                                                 register your organization.


      07/27/2011                                 DRAFT Medicare Current Topics                                     79
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