Medicare Updates

1. Medicare Updates

2. Medicare Enrollment: Minnesota • Total Medicare beneficiaries (2011): 791,566 (15% of total population) • Total Medicare Advantage enrollment (2011): 349,715 (44% of Medicare population) • Part D Low-Income Subsidy enrollees (2010): 134,119 • Number of Medicare Rx Drug Plans (2011): 30 Getting Started

3. Medicare Enrollment : Minnesota • Part D Rx Drug Coverage Gap Discounts as of August 5, 2011: • 12,922 Minnesota beneficiaries with gap discount • $522 = average gap discount amount per beneficiary • $6,750,209 = total discount amount in MN Getting Started

4. Preventive Services Update • Covered by Medicare Part B • Covered by Original Medicare, MA and other plans • Find problems early, when treatment works best • Coverage based on • Age • Gender • Medical history 7

5. Paying for Preventive Services in 2011 • Original Medicare • Pay nothing from provider who accepts assignment • May require coinsurance for office visit • May pay more from provider who does not accept assignment • Medicare Advantage or other Medicare plans may require copayment 7

6. Paying for Preventive Services • Original Medicare – Part B deductible/copayment for these screenings eliminated (certain coverage criteria apply) • Bone mass measurement • Cervical cancer screening, including Pap smear tests & pelvic exams • Cholesterol and other cardiovascular screenings • Colorectal cancer screening (except for barium enemas) • Diabetes screening • Flu shot, pneumonia shot, and the hepatitis B shot • HIV screening for people at increased risk or who ask for the test • Mammograms • Medical nutrition therapy to help people manage diabetes or kidney disease • Prostate cancer screening (except digital rectal examinations)

7. Annual Wellness Visit • New in 2011 • Available every 12 months • Blood pressure, height and weight measurements • Personalized prevention plan • Written screening schedule • Health advice • Referrals for health education and preventive counseling

8. Influenza (“Flu”) Vaccine • Flu can lead to pneumonia • Dangerous for people 50 and over • Flu viruses are always changing • Shot updated annually for most current flu viruses • Flu shot covered for all people with Medicare • No copayment or deductible with Original Medicare Getting Started

9. Part C: How MA Plans Work • You get Medicare-covered services through the plan • All Part A and Part B covered services • Some plans may provide additional benefits • Most plans include prescription drug coverage • Part D • You may have to go to network doctors or hospitals • MA may be different than Original Medicare • Benefits and cost-sharing Medicare Advantage Plans and Other Medicare Plans

10. MA – New for 2011 Health Reform • If you are accepted as a participant in an approved clinical research study • Your costs may be lower • Some costs may be covered by your plan (Section 2101) • MA Plans can’t charge more than Original Medicare • For certain services, e.g., chemotherapy, dialysis, and skilled nursing facility care (Section 3202) • MA Plans must limit your out-of-pocket costs • For Part A and part B covered services (Section 3202) Medicare Advantage Plans and Other Medicare Plans

11. 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

12. When you can Join or Switch MA Plans • Can leave an MA plan and switch to Original Medicare • Between January 1–February 14 • Coverage begins the first of the month after you switch • If you make this change you also may join a Medicare Prescription Drug Plan to add drug coverage • Between January 1-February 14 • Drug coverage begins the first of the month after the plan gets enrollment form Health Reform Section 3204 Medicare Advantage Plans and Other Medicare Plans

13. 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 • Effective December 8, 2011

14. Star Ratings for Health Plans • 5 Stars Excellent performance • 4 Stars Above average performance • 3 Stars Average performance • 2 Stars Below average performance • 1 Star Poor performance Medicare Advantage Plans and Other Medicare Plans

15. Authority to Deny Plan Bids • Secretary not required to accept any or every bid submitted by an MA organization • Secretary can deny a bid • Proposes significant increases in cost-sharing or • Decreases benefits offered by the plan • Applies to bids from prescription PDP sponsors • Effective for contract years on/after January 1, 2011 ACA Section 3209

16. Medicare Prescription Drug Coverage • Medicare Part D • Drug plans approved by Medicare • Run by private companies • Available to everyone with Medicare • Must be enrolled in a plan to get coverage • Coverage provided through • Medicare Prescription Drug Plans (PDPs) • Medicare Advantage (MA-PDs) and other Medicare plans with Rx coverage

17. ACA Part D Coverage Gap • If you reach the coverage gap in 2011 • You get a 50% discount on brand-name Rx drugs • 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

18. Manufacturer Discount Program • Must occur at point-of-sale Discounts can be provided at POS only if the entity adjudicating the electronic pharmacy claim has the information necessary to determine at that point in time: • the drug is a discountable drug; • the beneficiary is eligible for the discount; • the claim is wholly or partially in the coverage gap; and • The amount of the discount, taking into consideration plan supplemental benefits that pay first.

19. Brand Benefit • In addition to the 50 % manufacturer’s discount, beginning in 2013 plans will start providing an additional brand benefit • Increases incrementally over 7 years • Along with the manufacturer discount, this brand benefit looks to increase the total brand discount to 75% during the coverage gap by the year 2020

20. Brand-Name Prescription Drug Savings in the Coverage Gap

21. Closing the Coverage Gap: Generics • The coinsurance under basic prescription drug coverage will be reduced for generic covered Part D drugs purchased during the coverage plan gap phase • Coinsurance charged to beneficiary will be 93% of generic drug cost in 2011

22. Generic Drug Cost Sharing: 2010-2020 http://www.kff.org/healthreform/upload/8059.pdf

23. Summary of Gap Coverage

24. Prescription Drug Benefit without Health Reform http://www.kff.org/healthreform/upload/8059.pdf

25. Prescription Drug Benefit with Health Reform http://www.kff.org/healthreform/upload/8059.pdf

26. Pre-existing Condition Insurance Plan • Health insurance coverage for individuals under 65 with a pre-existing condition • May be a valuable option for family member or spouse who is not yet 65 • Eligibility criteria • Uninsured for at least 6 months • Have a pre-existing condition • US citizen or legal resident • Visit www.pcip.gov for more information Getting Started