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					The New Health Care
     Reform:

Explaining Changes To
Medicare Beneficiaries
      On March 23, 2010,

President Obama Signed Into Law

   THE PATIENT PROTECTION

  AND AFFORDABLE CARE ACT
Followed Closely On Its Heels Was

     THE HEALTH CARE AND

EDUCATION RECONCILATION ACT

 Signed Into Law March 30, 2010
     Taken Together

These Pieces of Legislation

      Represent the

Current Health Care Reform
  After nearly two years of public debate,

            demonstration, and

     intensive lobbying, we now have

    the most comprehensive change in

the American Health Care System since the

enactment of Medicare & Medicaid in 1965.
New Legislation Contains Far Reaching
Provisions Aimed At:
•Reducing the number of Americans
 without health coverage

•Expanding eligibility for Medicaid

•Reforming insurance eligibility standards

•Sponsoring a system of State Based
 Insurance Exchanges through which individual
 consumers and small employers can gain access
 to health insurance at better/reduced rates
            Provisions in Effect for 2010
  •Health insurers cannot eliminate existing coverage
     based on discovery of a pre-existing condition

 •Health insurers cannot deny new coverage to children
            because of a pre-existing condition

   •Health insurers are required to permit dependent
children to remain on health insurance plans up to age 26

•Lifetime caps on health insurance benefits are prohibited

•Requires emergency services that are out of network be
               billed at in network rates
               Provisions in Effect for 2014
•Private insurers will no longer be able to turn away adult individuals
  with pre-existing conditions or charge higher premium rates based
                           on those conditions

                   •Health Insurance Exchanges
  These are state based insurance markets enabling individuals and
           small businesses to purchase health insurance

  •Employer Mandated Health Insurance Coverage for Employees

             •Individual Mandated Insurance Coverage

           •Federally Funded Health Insurance Subsidies

               •Small Business Health Care Assistance
                  High Risk Pools
temporary provisions (effective 2010)
have been made to provide coverage for adults who have
been excluded by insurers due to pre-existing conditions.

These pools will expire in 2014 when the pre-existing
condition ban goes into effect.
                 High Risk Pools
To qualify:
individuals must demonstrate that they:
•Have been uninsured for at least 6 months
•Have been denied coverage due to pre-existing
 conditions

Monthly costs:
•WILL be based on the costs for general health
 insurance population
•WILL NOT be able to vary more than 4 to 1
•Out of pocket expenses are capped at
 $5,950 annually for an individual and
 $11,900 annually for a family
         Provisions in Effect for 2014

Health Insurance Exchanges
•State –based insurance markets based
 on Massachusetts “Health Connector System”
•Transparency in benefits and pricing for
 individuals and small businesses
•At least one guaranteed low cost selection
 option
            Provisions in Effect for 2014
Employer Mandate
•Business with 50 employees or more will be required
 to provide insurance coverage or face a $2,000
 penalty per employee not covered
Individual Mandate
•Most Americans will be required to have insurance
 coverage or face fines
•$95 annually for 2014
•$695 or 25% of (?) whichever is less by 2016
•Low income individuals are exempt if lowest insurance
 plan cost exceeds 8% of individual’s income – these
 individuals will likely be eligible for Medicaid
           Provisions in Effect for 2014

Health Insurance Subsidies
•Subsidies will be available to help individuals and
 families afford the mandatory insurance premiums
•Subsidies will be on a graduated scale – lower incomes
 receiving larger subsidies
•Example – family of 4 with a total income of $88,000
 or less will be eligible for subsidies
            Provisions in Effect for 2014

Small Business Health Care Assistance
States will be required to set up Small Business
Health Plan Option Programs (SHOP) in which small
business will be able to pool together to buy insurance
Small business are defined as no more than 100
employees – however states can limit SHOP to
employers with 50 employees or less
Effective 2010 – Small business are provided with
federal tax credit until SHOP is implemented in 2014
        Provisions in Effect for 2014
Nursing Home/Long Term Care Facilities
Transparency & Improvement Program
•Expanding existing requirements for
 Nursing/LTC facilities to provide information
 to the state government on their operations:
   •Staff levels
   •Operation schedules
   •Wages
   •Organization structure
   •Ownership disclosure
             Provisions in Effect for 2014
Nursing Home/Long Term Care Facilities
Transparency & Improvement Program
•Nursing/LTC facilities must include dementia management
program following federal guidelines

•Nursing/LTC facilities must provide dementia care and abuse
prevention training for all existing employees and new hires
•Establishes extended guidelines for national background
checks for employees of Nursing/LTC facilities that have direct
patient access

•Nursing/LTC facilities will be required to report incidents of
patient abuse
         Provisions in Effect for 2014

CLASS Program
provides a public, voluntary, long term
program that working individuals can
purchase.
The program would cover home care, respite
care, home modifications,
transportation, and assistive technologies.
         Provisions in Effect for 2014

CLASS Program
•Buy-in program funded entirely by participants
 who make voluntary salary withholding from
 their gross wages
•Participants are entitled to guaranteed benefit
 payouts of at least $50 per day for the cost of
 LTC
How Does the
 New Law
  Impact
 Medicare?
The New Health Care Reform
     Impacts Medicare
   in a Number of Ways:
 Some Provisions are directed at

   HEALTH CARE PROVIDERS :

how Reimbursements and Subsidies

  are Determined and Dispersed
  Some Provisions affect

 MEDICARE BENEFICIARIES

 and the Benefit Services

they receive under Medicare
    Some Provisions

  fall within the area of

Improving the Quality and
      Performance

of the Health Care System
     Changes Effective In 2010
•Nursing Home Compare Medicare Website
  Links to state nursing home survey and
  certification programs, model complaint forms,
  summary of complaints and information on
  criminal violations
     Changes Effective In 2010
•Hospital Payment Rates
  Reduces payments to inpatient acute care
  hospitals, LTC hospitals, psychiatric hospitals
  and rehabilitation hospitals

•Therapy Cap Exceptions
  Extends the process for allowing exceptions to
  the payment caps for physical speech and
  occupational therapy until 12/31/2010.
  Providers must submit claims for an exception.
   Changes Effective In 2010
•Medicare Part B Premiums
  Freezes the income threshold for
  beneficiaries who pay a higher Part B
  premium. Will be frozen at the 2010 income
  levels through 2019

•Special Needs Plans (SNP)
 Extends the SNP program until 2014.
 CMS will apply “frailty payment adjustments”
 for dual SNP beneficiaries
     Changes Effective In 2010
•Closing the Part D Prescription Drug
 Coverage Gap (the Donut Hole)
  For 2010, the new law creates a one time $250
  rebate for beneficiaries whose costs for Part D
  prescription drugs exceeds the coverage gap
  threshold
      Eventual Elimination of the
            “Donut Hole”
•2010 – New law provides $250 rebate for
 individuals in the “Donut Hole”

•2011 – 50% rebate will apply to brand name
 prescription drugs for individuals in the “Donut
 Hole”

•2020 – complete elimination of the coverage gap
What is the “Donut Hole”

   and How do I Know

    If I’ve Reached It?
Typical Medicare Prescription Drug Plan

 Catastrophic       Plan Pays 95%

  Coverage       Beneficiary Pays 5%

                                        $4,550.00
No Coverage        Coverage Gap:
“DOUGHNUT       Beneficiary Pays 100%
  HOLE”
                                        $2,830,00
                   Plan Pays 75%
   Partial      Beneficiary pays 25%
  Coverage
                  Coverage Gap
Medicare Prescription Drug Plans (Medicare D Plans)
have a gap in coverage sometimes called the “Donut Hole”

During the Coverage Gap a beneficiary is responsible for
paying 100% of their drug costs.

For (2010) the Coverage Gap begins when the total cost for
prescription drugs purchased through the plan reaches
$2,830. The coverage gap ends when the individual’s own
expenditures reaches $4,550.00.

About 390,00 Medicare Beneficiaries in Pennsylvania hit
the “Donut Hole” each year – the annual cost to individuals
that reach the “donut hole “ averages over $4,000.
    2010
Coverage Gap
   Rebate
            $250 REBATE
•For Individuals that reach the
 “Donut hole” during 2010

•One time payment only

•And only for 2010 year
Approximately three months after the end of the quarter
in which an individual reaches the “Donut Hole”
Medicare will automatically send out the rebate check

•Quarter # 1 Ends March 31 –
 Check will be mailed in June

•Quarter #2 ends June 30 –
 Check will be mailed in September

•Quarter #3 ends September 30 –
 Check will be mailed in December

•Quarter #4 ends December 31 –
 Check will be mailed in March
What does a qualified individual
    need to do to get this
       Rebate Check?


         Nothing…
   Qualied individuals will
  automatically receive their
    check from Medicare
      How will Medicare know
      an individual reached the
            “Donut Hole”?
At the end of each quarter, all insurance
companies that provide Prescription Drug
plans will submit a report to Medicare
listing every individual that has entered
the Coverage Gap during that quarter
   What if I Don’t Get the
Rebate Check When I Should?

      Contact Medicare
       1-800-633-4227
             Or
Visit www.healthreform.gov
the US government web site
Managed by the Department
Of Health & Human Services
Coming in 2011……
  Continues to close the
coverage gap by reducing
the percentage of cost for
      beneficiaries.
•2011
 New Health Care Legislation will require
 Pharmaceutical Manufacturers to provide
 a 50% discount on prescriptions filled for
 individuals in the Coverage Gap. (federal
 government will provide a 7% discount on
 generics for individuals in the coverage gap)
 The % amount of the discount will gradually
 increase each year until…

•2020
 Complete elimination of the Coverage Gap
    Changes Effective In 2011
•Annual Enrollment Period (AEP)
  •Changes the AEP to October 15 – December 7
  •Change begins October 15, 2011

•Medicare Advantage Disenrollment Period
  Provides a 45 day period (1/1 – 2/15) to
  Medicare Advantage enrollees, during which
  time they can disenroll from Medicare
  Advantage plan and return to Original
  Medicare.
   Changes Effective In 2011
•Physician Compare Website
  Requires the Secretary of HHS to develop a
  “Physician Compare” website by 1/1/2011.

•Preventative Benefits
  Eliminate all cost sharing for certain
  preventative screening services.
     Changes Effective In 2011
•Payment Rates to
 Medicare Advantage Plans
  Freezes payment rates for 2011 at the 2010
  payment levels

•Cost Sharing Requirements
  Requires Medicare Advantage plans that provide
  extra benefits to give priority to cost
  Sharing reductions
    Changes Effective In 2011
•Cost Sharing Restrictions
  Prohibits Medicare Advantage plans from
  imposing higher cost sharing for some
  Medicare covered benefits such as
  chemotherapy, dialysis, and skilled nursing
  care.
  Can not charge more than Original Medicare
    Changes Effective In 2011
•Higher Premiums
  •Medicare beneficiaries with annual incomes
   will pay higher Part D plan premiums
     •$85,000 + single
     •$170,000 + married
  •Less than 5% of the Medicare population is
   subject to income-related premium
   adjustments
    Changes for 2012 and Beyond
•Exceptions and Appeals
  •PDPs and MA-PDs are required to utilize a
   single uniform exceptions/appeals process.
   Plans are to provide instant access to the
   process via the web or toll free number

•Medicare Advantage Payment Rates
  •Reductions in payments to MA plans will be
   phased in over 3 to 7 years. Plans must
   still provide all benefits guaranteed by
   Medicare
     Changes for 2012 and Beyond
•Medicare Part D Cost Sharing
  •Eliminates Part D cost sharing for dual
   eligible beneficiaries receiving services under
   a Home and Community Based Waiver

•Medicare Part D Formulary
  •By 2014 Part D will cover Benzodiazepines
   and Barbiturates
     Changes for 2012 and Beyond
Nursing Home/Long Term Care Facilities
Transparency & Improvement Program
•Expanding existing requirements for
 Nursing/LTC facilities to provide information
 to the state government on their operations:
   •Staff levels
   •Operation schedules
   •Wages
   •Organization structure
   •Ownership disclosure
      Changes for 2012 and Beyond
Nursing Home/Long Term Care Facilities
Transparency & Improvement Program
•Nursing/LTC facilities must include dementia management
program following federal guidelines

•Nursing/LTC facilities must provide dementia care and abuse
prevention training for all existing employees and new hires
•Establishes extended guidelines for national background
checks for employees of Nursing/LTC facilities that have direct
patient access

•Nursing/LTC facilities will be required to report incidents of
patient abuse

				
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