Navigating Medicare in 2020

1. Navigating Medicare in 2020 Carmen Irwin Health Insurance Specialist/ Rural Health Coordinator CMS Dallas Regional Office October 3, 2019

2. Current Topics CMS Priorities and Strategic Initiatives We’re transforming the healthcare system to deliver better value and results for patients through competition and innovation.

3. CMS’ Strategic Initiatives Current Topics

4. Current Topics CMS’ 16 Strategic Initiatives

5. Current Topics

6. Current Topics Highlights • Expanded online self-service, including ability to print your own replacement Medicare card and make online premium payments • Launched “What’s Covered” mobile app • Launched a targeted campaign to encourage adoption of Medicare eResources instead of paper • Redesigning Medicare.gov homepage and Medicare Plan Finder to improve user experience for next Open Enrollment • Work underway to update and align individual tools for finding and comparing providers and facilities

7. Current Topics Blue Button • Established in 2010 as a joint effort of CMS and the VA • Used by more than one million beneficiaries to download their CMS information as .txt or .pdf files, via the MyMedicare.gov portal • Patients are increasingly using and sharing their data to improve health outcomes • This drives the need for easier data interoperability

8. Current Topics Blue Button 2.0 • Enhances CMS’ current Blue Button service to provide a developer-friendly, standards-based data API • Enables beneficiaries to connect to and share their Medicare claims data with the applications, services, and research programs they trust • Contains 4 years of Medicare Part A, Part B and Part D data for 53 million Medicare beneficiaries • Beneficiaries can find Blue Button 2.0 info and apps at Medicare.gov/manage-your-health/medicares-blue-button-blue-button-20 • Identity and authorization controlled via MyMedicare.gov

9. Current Topics • Proposed End-Stage Renal Disease (ESRD) Treatment Choices (ETC) Model • Encourage greater use of kidney transplants and home dialysis for Medicare beneficiaries with ESRD • Preserve or enhance quality of care • Reduce Medicare expenditures • Certain ESRD facilities and Managing Clinicians would be required to participate in the ETC Model based on their location in randomly selected geographic areas

10. Current Topics Medicare Updates • Program Enrollment • New Medicare Card • Round 2021 of the Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program • Income-Related Monthly Adjustment Amount (IRMAA) for 2019 • 2020 Medigap Changes • Therapy Caps for 2019 • Telehealth Services

11. Medicare Enrollment Numbers Current Topics

12. Current Topics Medicaid Enrollment as of March 2019

13. Current Topics New Medicare Card • New Medicare Card mailing completed • Medicare Beneficiary Identifier (MBI), not Social Security Number • Can print copies from MyMedicare.gov • Can use old card (number) until January 1, 2020 • Claims filed without the MBI will be rejected MACRA

14. Current Topics Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP): Temporary Gap Period • DMEPOS CBP contracts expired on December 31, 2018 • As of January 1, 2019, there’s a temporary gap in the DMEPOS CBP • Expected to last until December 31, 2020 • During the temporary gap, any Medicare-enrolled DMEPOS supplier may furnish DMEPOS items and services to people with Medicare • In most cases, people with Medicare won’t need to switch suppliers BBA

15. Current Topics Round 2021 Updates • Competitive Bidding Areas (CBAs) • CMS consolidated CBAs from round 2 Recompete and Round 1 – 2017, into a single round of competition for Round 2021 • Total 130 CBAs • Round 2021 contracts effective January 1, 2021, and extend to December 31, 2023 • Product Categories • Shifting some items to different, smaller product categories to accommodate the lead item pricing methodology • 16 product categories in Round 2021 • Items newly included are off-the-shelf (OTS) back braces, OTS knee braces, and non-invasive ventilators BBA

16. Current Topics DMEPOS—Round 2021 Updates (continued) • National Mail-Order (NMO) • Not including a national mail-order program for diabetes testing supplies in Round 2021  • Round 2021 Precluded Suppliers • Precluded suppliers aren’t permitted to participate in Round 2021 • Suppliers received a letter as a reminder that they are precluded from participating BBA

17. Current Topics Monthly Part B Standard Premium—Income-Related Monthly Adjustment Amount (IRMAA) for 2019 Chart is based on your yearly income in 2017 (for what you pay in 2019) NOTE: You may pay more if you have a Part B late enrollment penalty (LEP). BBA

18. Current Topics 2020 Medigap Changes • On or after January 1, 2020, Medigap carriers cannot sell policies that provide coverage of the Part B deductible • Carriers are prohibited from selling standardized Plans C or F to people “newly eligible” for Medicare • Turning 65 as of January 1, 2020, or later • Entitled to Part A on the basis of age, disability, or ESRD as of January 1, 2020, or later • A person who isn’t “newly eligible” for Medicare can apply with a carrier to purchase a Plan C or F and the carrier wouldn’t be precluded from selling the policy • Carriers may sell Plans C or F to those getting Medicare retroactively with Part A start date before January 1, 2020 MACRA

19. Current Topics 2020 Medigap Changes (continued) • Plans C and F will remain in force for people who already had them • Plans C and F are guaranteed renewable • Unless the premiums aren’t paid • No federal guaranteed issue right to transfer from Plans C or F to other plan types • Check with your state NOTE: Plans C and F may continue to be offered to people who became eligible for Medicare prior to January 1, 2020 MACRA

20. Current Topics Therapy Caps for 2019 • Bipartisan Budget Act of 2018 repealed the therapy caps • Annual dollar limit ($2,040 for 2019)  for physical therapy and speech-language pathology combined • $2,040 for occupational therapy • The limit remains as a threshold above which claims must include the KX modifier as a confirmation that services are medically necessary (just as it was before) • Retains the targeted medical review process, but at a lower threshold amount or $3,000 (instead of $3,700) through 2028

21. Current Topics Telehealth Services for Substance Use Disorder Treatment • The Recovery and Treatment (SUPPORT) for Patients and Communities Act removes the originating site geographic conditions and adds an individual’s home as a permissible originating telehealth services site for treatment of a substance use disorder or a co-occurring mental health disorder for services furnished on or after July 1, 2019 • Requires that no originating site facility fee will be paid in instances when the individual’s home is the originating site • Practitioners would be responsible for assessing whether individuals have an SUD diagnosis SUPPORT Act

22. Current Topics Medicare Advantage (MA) • MA Update • New MA Supplemental Benefits • Medicare Advantage Open Enrollment Period (MA OEP) • Plans with Low Enrollment • Innovations in Health Plan Design • CY 2020 Voluntary and Mandatory Maximum Out-of-Pocket (MOOP) Range Amounts by Plan Type • End-Stage Renal Disease (ESRD) and Enrollment

23. Current Topics NEW Expanded Health Related Extra Benefits • Beginning calendar year 2019, CMS reinterpreted the meaning of “primarily health related” to consider an item or service as primarily health related if it is used to • Diagnose, prevent, or treat an illness or injury • Compensate for physical impairments • Improve the functional/psychological impact of injuries or health conditions • Reduce avoidable emergency and health care use • Benefit must focus on enrollee’s health care needs and be recommended by a licensed medical professional as part of a care plan, if not provided by one

24. Current Topics NEW Allowable Extra Benefits • Adult Day Care Services • Home-Based Palliative Care • In-Home Support Services • Support for Caregivers of Enrollees • Medically-Approved Non-Opioid Pain Management • Stand-alone Memory Fitness Benefit • Home & Bathroom Safety Devices & Modifications • Non-emergency Transportation • Over-the-Counter (OTC) Benefits

25. Current Topics NEW Expanded Health Related Extra Benefits (continued) • 12 parent organizations with 160 plans are providing enrollees with access to expanded health related extra benefits in 2019 • More than 778,000 projected enrollees will have access to these benefits, with in-home support and support for caregivers being the most popular • Adult-day care services • Home-based palliative care • In-home support services • Support for caregivers of enrollees • Therapeutic massage • There are 20 states that have plans offering expanded health related extra benefits: AR, AZ, CT, GA, IL, IN, KY, MO, MS, NC, NJ, OR, RI, SC, TN, TX, VA, WA, WI and WV

26. Current Topics 2019 Benefits at Reduced Extra Benefits/Cost-Sharing for Enrollees with Certain Health Conditions • There are 19 parent organizations with 113 plans (717,000 projected enrollees) that have at least one supplemental benefits package for people with certain disease states • Diabetes is the most popular disease state package offered, followed by Congestive Heart Failure • Some plan-defined packages included Cardiovascular Disorders, Chronic Pain Syndrome, Chronic Kidney Disease, and Opiate Use Disorder • There are 11 states that have plans offering benefits at reduced cost-sharing and additional benefits for enrollees with certain conditions:  HI, ID, LA, MA, ME, MN, NE, NH, OK, PA and VT

27. Current Topics NEW-2020 Non-Opioid Pain Management Extra Benefits • CMS encourages MA Plans to consider extra benefits that address medically-approved non-opioid pain management and complementary and integrative treatments • Peer support services to facilitate recovery and assist in navigating health care resources as part of pain management treatment • Psychosocial services/cognitive behavioral therapy can be included in counseling services • Non-Medicare covered chiropractic services • Acupuncture • Therapeutic massage

28. Current Topics NEW-2020 Special Benefits for the Chronically Ill • MA Plans may offer additional benefits that aren’t “primarily health-related” benefits only to enrollees who are “chronically ill enrollees” as defined by Medicare statute and only when the additional benefits have a reasonable expectation of improving or maintaining the health or overall function of the chronically ill enrollee • CMS won’t require extra benefits to be primarily health related when they are provided to chronically ill BBA

29. Current Topics Non-Primarily Health Related Items or Services Examples “Non-primarily health related” item or service examples that may meet the criteria if the statute requirements are met

30. Current Topics NEW-2020 Physical Exam Extra Benefit for Special Needs Plans (SNPs) • Beginning CY 2020, SNPs may offer the Physical Exam extra benefit • Currently available to Non-SNP MA Plans • Provide services beyond those services required to be provided in the Annual Wellness Visit • Provide services beyond what is required as part of the SNP’s regular care coordination and disease management responsibilities • The exam would be provided by a qualified physician or qualified non-physician practitioner

31. Current Topics New Enrollment Changes • Regulation CMS-4182-F, published April 16, 2018, included new enrollment provisions • Impacts MA and Part D Plans • Effective January 1, 2019 • Subregulatory guidance issued July 31, 2018

32. Current Topics MA Open Enrollment Period • MA Disenrollment Period ended 2018 • Medicare Advantage Open Enrollment Period (MA OEP) began in 2019 • January 1 – March 31 each year • Must be in MA Plan on January 1 to use MA OEP • New Medicare beneficiaries who enroll in MA during IEP have 3 months to use MA OEP to make a change Cures Act

33. Current Topics MA Open Enrollment Period (continued) • People in an MA Plan on January 1 can use the MA OEP to do the following: • Switch MA Plans (excluding MSA plans, Cost Plans, or PACE Plans) • Leave MA to join Original Medicare • There’s a coordinating Part D Special Enrollment Period (SEP), during which MA enrollees changing MA Plans or going to Original Medicare can add or drop Part D • Can’t switch from one standalone PDP to another standalone PDP • Can’t join MA if in Original Medicare

34. Current Topics Plans With Low Enrollment • Plans with low enrollment can’t renew for 2020 • Non-SNPs that had fewer than 500 enrollees • SNPs that had fewer than 100 enrollees • In existence for 3 or more years as of March 2019 • Excludes plans • With low enrollment operating in service areas that don’t have a sufficient number of competing options • Section 1876 Cost Plans, employer plans, or MSA plans • Upon receipt of CMS notification, organizations • Confirm each of the low enrollment plans identified by CMS will be eliminated or consolidated with another of the organization’s plans for CY 2020, or • Provide a justification to CMS for renewal

35. Current Topics Innovations in Health Plan Design • Value-Based Insurance Design (VBID) Model Test • Tests whether the additional flexibilities provided under the model allow and incentivize plans to develop and offer interventions that improve health outcomes and lower expenditures MA enrollees • Part D Enhanced Medication Therapy Management (MTM) Model • Tests whether providing Part D sponsors with additional payment incentives and regulatory flexibilities will lead to improved outcomes and lower costs • Part D Payment Modernization Model • Tests the impact of a revised Part D program design and incentive alignment on overall Part D prescription drug spending and beneficiary out-of-pocket costs

36. Current Topics Expansion of Telehealth Benefits • Starting in 2020, MA Plans can include “additional telehealth benefits”in their bids for basic benefits • Beyond what Original Medicare allows • MA enrollees may get Part B healthcare services from places like their homes • Rather than a healthcare facility • MA Plans have broader flexibility in how they pay and expand telehealth services BBA

37. Current Topics CY 2020 Voluntary and Mandatory Maximum Out-of-Pocket (MOOP) Range Amounts by Plan Type

38. Current Topics End-Stage Renal Disease (ESRD) and Enrollment • Currently, most people with ESRD can’t join an MA Plan • Effective January 1, 2021, people with ESRD will no longer be prohibited from enrolling in an MA Plan • Cost of acquiring organs shift from the MA Plans to Original Medicare Cures Act

39. Current Topics Part D Updates • Coverage Gap • True Out-of-Pocket (TrOOP) Costs • Income-Related Monthly Adjustment Amount (IRMAA) • Formulary Changes • The Preclusion List • Elimination of Gag Clauses • 2020 Specialty Tiers Threshold • Low Enrollment

40. Current Topics Improved Coverage in the Coverage Gap BBA

41. Current Topics True Out-of-Pocket (TrOOP) Costs • Expenses that count toward your out-of-pocket threshold ($5,100 in 2019) • After threshold you get catastrophic coverage • You pay only small copayment or coinsurance for covered drugs • Explanation of Benefits (EOB) shows TrOOP costs to date • TrOOP transfers if you switch plans mid-year

42. Current Topics Monthly Part D Standard Premium—Income-Related Monthly Adjustment Amount (IRMAA) for 2019 Chart is based on your yearly income in 2017 (for what you pay in 2019) *IRMAA is adjusted each year. It is calculated on the annual beneficiary base premium.

43. Current Topics NEW Formulary Changes • A Medicare drug plan may • Remove a brand-name drug from its Part D formulary, or • Change the brand-name drug's preferred or tiered cost-sharing, so long as a plan • Adds a therapeutically equivalent generic drug to its formulary • Couldn’t have previously included such drug on its formulary because such generic drug wasn’t yet available on the market • Provides general notice to all current and prospective enrollees • Provides advance general notice to CMS

44. Current Topics NEW The Preclusion List • List of individuals and entities currently revoked from Medicare, are under reenrollment bar, or could be revoked if they had been enrolled in Medicare because of OIG exclusions, felony convictions, and other misconduct, and if CMS determines that the underlying conduct that led to the revocation is detrimental to the best interest of the Medicare Program • Individuals and entities are notified of their potential inclusion on the list and their applicable appeal rights • One Preclusion List with subsequent updates - Initial list available January 1, 2019 • Updates made every 30 days (first business day of each month) • Visit CMS.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/PreclusionList.html for Preclusion List resources • Medicare Advantage Plans and Part D plans must • Reject claims or deny payments for Part D drugs and Medicare Advantage services and items prescribed or furnished by an individual or entity on the preclusion list • Notify enrollees who got care in the last 12 months from a contracted provider or a prescription from a provider who’s included on the list

45. Current Topics NEWThe Preclusion List—Beneficiary Notice • Medicare enrollees get 60-day advance notice before payment is denied or pharmacy claims are rejected • Plans could begin payment denials and claims rejections on April 1, 2019, for the January 1, 2019, Preclusion List • Allowing 30 days for plans to review the list and notify Medicare enrollees, but no later than 30 days from the posting of the list and an additional 60 days for enrollees to prepare • Follow the same process for monthly updates to the Preclusion List as they did for the initial list

46. Current Topics NEW Elimination of Gag Clauses • Know the Lowest Price Act of 2018 • Prohibits PDPs, MA Plans, and MA-PDs from restricting or penalizing a pharmacy for disclosing price information to an enrollee • Allows pharmacies to disclose difference between the negotiated price and a lower price without using any health insurance coverage • Applies to plan years beginning on or after January 1, 2020 • Enrollees pay cash at the pharmacy and submit claim to plan for reimbursement and TrOOP counting Know the Lowest Price Act of 2018

47. Current Topics 2020 Specialty Tiers Threshold • Part D sponsors may exempt a formulary tier from its tiering exceptions process • Sponsor-negotiated price must exceed a dollar-per-month threshold established by CMS • 2020 specialty tier threshold is $670 for the full cost of a 30-day supply

48. Current Topics Low Enrollment Plans (Stand-alone PDPs only) • CMS will terminate low enrollment plans for 2020 • Below 1,000 enrollees • In the lowest 5th of enrollment within the specific PDP region • For 3 consecutive years • CMS notified affected low enrollment plans in the Spring of 2019 • Option to consolidate or non-renew the plan • May alternatively submit a strategic plan that describes how enrollment will be increased

49. New Medicare Plan Finder