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Medicare Improvement for Patients and Providers Act of 2008. Preliminary Summary of Beneficiary and Plan Provisions July 14 th , 2008. Beneficiary Improvements. Initial Preventive Exam Eligibility extended from 6 months to one year after entry to Medicare Not subject to the deductible
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Medicare Improvement for Patients and Providers Act of 2008 Preliminary Summary of Beneficiary and Plan Provisions July 14th, 2008
Beneficiary Improvements • Initial Preventive Exam • Eligibility extended from 6 months to one year after entry to Medicare • Not subject to the deductible • “End of Life” / Advance Directives planning added • Mental Health Co-Pays Equalized • Benzodiazepines and barbiturates covered by Part D
Medicare Low Income Programs • QI eligibility extended through 2009 • LIS/MSP assets equalized for January, 2010 • SSA funded to eliminate processing and application barriers; transmit data to states; states process as MSP application • No Part D late penalties for LIS eligibles • No estate recovery for Medicare Savings Program • In-kind income excluded • Life Insurance not considered an asset • State Health Insurance (SHIPs), AAAs and ADRC’s Programs funded for outreach
Special Needs Plans Provisions • SNP authority extended one more year • through plan year 2010; expires1/1/2011 • moratorium lifted; dual plans have new criteria • CMS prohibited from “designating” a plan as a SNP; all plans must apply. • 100% of new enrollees must be in the targeted enrollment category. • The plan may not impose higher cost sharing on the duals than permitted under Medicaid • Provisions effective in 2010
SNP Provisions: Quality • Care Management • Evidenced based model of care • Appropriate network of providers and specialists • Initial and annual assessment of physical, psychosocial and functional needs • Individual plan of care identifying goals, objectives, measureable outcomes and specific benefits • Care management included in CMS periodic audit • Quality Reporting • Plans must provide data to “measure health outcomes and other measures of quality“ • All data shall be at the plan level • May be based on claims data
SNP Provisions: Dual SNPs • Plan provides prospective enrollees a written statement describing • Benefits and cost sharing protections under Medicaid • Which Medicaid and cost sharing protections are covered by the plan • Plan has a contract with the state to provide benefits or arrange for Medicaid benefits to be provided. • Dual SNPs without a contract may operate, but cannot expand during 2010. • CMS must designate “staff and resources” to assist state coordination with SNPs • States are not required to contract with SNPs
SNP Provisions: Institutional SNPs • I-SNP members in the community must be assessed as needing an institutional level of care • Assessed by an entity other than the organization • Using the assessment tool of the state of residence
Chronic SNPs • “Chronic and disabling” definition amended • co-morbid and medically complex condition(s) • substantially disabling or life threatening • high risk of hospitalization or significant adverse outcome • require care across domains of care • HHS to convene a panel to determine which conditions meet this definition; AHRQ must serve on the panel.
Marketing Restrictions • Effective January,1 2009 • Contains all provisions of CMS’ proposed rules re: cold calling, cross selling, limitations on meals, gifts and incentives ( ACAP still reviewing ) • Strengthens State Oversight • Agents and brokers must be licensed • Plans must cooperate with state information requests.
MedPAC Studies • Chronic Care Demonstration • Feasibility of a standing Chronic Care Practice Network • Report due June 15, 2009 . • Quality Measurement • Recommend how comparable measures of performance and patient experience can be collected and reported by 2011 that compare quality across plans AND compare FFS to MA plans • Report Due March 31, 2010 on findings and recommended legislation and administrative actions • Medicare Advantage payments • Costs plans incur as reflected in their bids • Ways to improve the estimates of county level per capita spending including use of VA services by Medicare beneficiaries • Alternate payment approaches • Report Due March 31, 2010 on findings and recommended legislation and administrative actions
The “Pay-For” Provisions CBO Estimates Savings for All Provisions as $12.5b for 2009-2013; $47.5b for the 2009-2018; overall MA enrollment down 2.3 m from 2013 projections • Small changes in FFS; delay home oxygen volume purchase • Phase-out of indirect medical education (IME) • Plan year 2010 MA rates reduced by .06 • Reduced an additional .06 each subsequent year till phased out • PACE programs excluded • Adjustment to the Medicare Advantage stabilization fund. • Removes all but one dollar from the fund • PFFS Required to Have Networks • Areas with less than 2 network plans exempted • Network requirements assumed to reduce enrollment