Barbara Childers, MSW Centers for Medicare & Medicaid Services

Barbara Childers, MSW Centers for Medicare & Medicaid Services
Medicare Advanced Barbara Childers, MSW Centers for Medicare & Medicaid Services Health Reform

Session Topics Changes to Medicare as a result of healthcare reform
Low Income Subsidy Program (Extra Help with Drug Plan Costs) Coordination of Benefits

Session A: Changes to Medicare as a result of healthcare reform
Overview and Highlights Medicare Updates Original Medicare Medicare Advantage Medicare Prescription Drug Coverage DMEPOS

Medicare Statistics In 2009
46.3 million people were covered by Medicare 38.7 million aged 65 and older 7.6 million with a disability About 24% in Part C (Medicare Advantage) $502 billion - Total benefits paid DRAFT

New Legislation – Health Reform
Patient Protection and Affordable Care Act (PPACA) Signed into law H.R on March 23, 2010 Makes numerous statutory changes to Medicare program The Health Care and Education Reconciliation Act of 2010 (HCERA) Signed into law H.R on March 30, 2010 Modifies PPACA and adds several new provisions Together called the Affordable Care Act DRAFT

Highlights of Affordable Care Act
Closes prescription drug coverage “Donut Hole” Strengthens the financial health of Medicare Invests in fighting waste, fraud, and abuse Will extend the financial health of Medicare by 12 years Changes annual enrollment period for MA and PDP Improves preventive services coverage Promotes better care after a hospital discharge Creates the Center for Medicare & Medicaid Innovation DRAFT

Highlights of Affordable Care Act (continued)
Help for early retirees (before age 65) Temporary program to offset cost of expensive premiums Extends dependent coverage to age 26 Eliminates limits on benefits Provides $11B for Federally Qualified Health Centers Outpatient primary care and preventive services “Safety net” providers Community health centers Public housing centers Outpatient programs funded by the Indian Health Service Programs serving migrants and the homeless ACA Section 1001 DRAFT

Pre-Existing Condition Insurance Plan (PCIP)
A new health coverage option created by the Affordable Care Act (ACA) Provides coverage for individuals with pre-existing conditions until the Health Insurance Exchanges are available in 2014 A person applying for PCIP must: Reside within the service area of the PCIP; Be a U.S. citizen or reside in the U.S. legally; Have been without health coverage for a minimum of 6 months before applying; and Have a pre-existing condition, as defined by the PCIP and approved by HHS. To learn more about this program, including how to apply in your state, go to “Find Your State” at or call (TTY ) which is open from 8 AM to 11 PM EST To request more information, resources (drop-in articles, facts sheets, etc), presentation for your staff or for questions, please

Original Medicare Updates
Medicare Claims Limit 2011 Amounts Preventive Services Face-to-Face Meeting Rules Therapy Caps Power-driven Wheelchairs Medigap Policies DRAFT

Medicare Claims Limit Maximum period for submission of Medicare claims
Reduced time period Now not more than 12 months Effective January 1, 2010 ACA Section 6404 DRAFT

2011 Part A Amounts For inpatient hospital stays in 2011
Each benefit period you pay $1,132 total deductible for days 1 – 60 $283 co-payment per day for days 61 – 90 $566 co-payment per day for days 91 – 150 (60 lifetime reserve days) All costs for each day beyond 150 days For Skilled Nursing Facility Care $ per day for days

2011 Part B Amounts Part B Annual Deductible - $162
Part B Monthly Premium (hold harmless) If your income is $85K or less and you paid this in 2010 You pay this in 2011 Notes $96.40 $110.50 If premium deducted from Social Security $115.40 If premium not deducted from Social Security $0 If new to Medicare in 2011 DRAFT

Income-Related Part B Premium
Effective January 1, 2011, Part B premium income thresholds frozen at 2010 levels through 2019 ACA Section 3402 If your Yearly Income in 2009 was In 2011 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. DRAFT

Preventive Services Medicare covers preventive services to help
Find health problems early, when treatment works best Prevent certain diseases or illnesses/avoid complications To encourage use and increase accessibility Part B Deductible and Coinsurance eliminated Services affected must have an “A” or “B” rating By the United States Preventive Services Task Force New Annual Wellness Visit ACA Section 4104 ACA Section 4103 DRAFT

New Home Health Rules Doctor must meet patient in person
90 days before the start of care or 30 days after May be conducted by hospitalist Even if another doctor will continue the care/care plan ACA Section 6407 DRAFT

New Hospice Rules Doctor must meet patient in person
Within 30 days of recertification Starting on the third benefit period Doctor must be employed by or working under arrangement with hospice ACA Section 3132 DRAFT

Extension of Therapy Cap Exceptions Process
Medicare limits coverage for outpatient therapy Physical and speech-language pathology Combined $1,860 per year Occupational therapy $1,860 per year Ability to request exception was to end 2009 Process of therapy caps extension extended Therapy caps determined on calendar year basis All patients began a new cap year on January 1, 2010 ACA Section 3103 DRAFT

Power-Driven Wheelchairs
Medicare will no longer purchase power-driven wheelchairs with lump-sum payment Medicare will pay over a 13-month period Purchase option is maintained for complex rehabilitative power wheelchairs Effective January 1, 2011 ACA Section 3136 DRAFT

Medigap Updates Makes hospice coverage a basic benefit
MIPPA Medigap Updates Makes hospice coverage a basic benefit Deletes preventive services coverage Deletes at-home recovery coverage Creates new Plans D & G, and M & N Eliminates E, H, I, and J Plans DRAFT

2010 Medigap Changes (* denotes new plans and benefits)
MIPPA 2010 Medigap Changes (* denotes new plans and benefits) Basic Benefits Deleted Coverage Deleted Plans Plan D Plan G Plan M * Plan N * Add Hospice Coverage- Part A coinsurance* (Part A coinsurance days; Part B coinsurance or copayments for outpatient; blood, first 3 pints per year) Preventive Services; No In-Home Recovery E, H, I, J Basic, including 100% Part B Coinsurance Skilled Nursing Facility coinsurance Part A Deductible Foreign Travel Emergency (In-Home recovery deleted) Skilled Nursing Facility Coinsurance 100% Part B Excess * (In-Home Recovery deleted) 50% Part A Deductible Basic, including 100% Part B Coinsurance (except up to $20 office visit copayment; up to $50/ER) DRAFT

Medicare Advantage Updates
Enrollment Period Disenrollment Period Cost limits/Plan Payments Complaint system Appeals DRAFT

Medicare Advantage Enrollment Periods
2011 and beyond New dates for AEP – October 15 – December 7 Change plans or switch to Original Medicare MA Open Enrollment Period eliminated ACA Section 3204 DRAFT

New MA Annual Disenrollment Period
New in 2011 January 1 – February 14 Leave MA plan and switch to Original Medicare Coverage begins first day of following month May join Part D plan Coverage begins first of month after plan gets form To disenroll and switch to Original Medicare Make a request directly to MA organization Call MEDICARE Enroll in a standalone prescription drug plan ACA Section 3204 DRAFT

MA – New for 2011 MA Plans can’t charge more than Original Medicare
For certain services, e.g., chemotherapy, dialysis, and skilled nursing facility care MA Plans must limit your out-of-pocket costs For Part A and Part B covered services ACA Section 3202 DRAFT

Payments to Medicare Advantage Plans
Frozen in 2011 Benchmarks vary Phased in over 3, 5, or 7 years depending on level of payment reductions Medicare Advantage benchmarks reduced in 2012 By 2014, 85% of funds plans receive must go to health care ACA Section 3203 DRAFT

Improvement to PDP/MA-PD Complaint System
Secretary to develop easy-to use complaint system Allows for collection and maintenance of complaints Received through any source or by any mechanism Against PDPs and MA-PD plans Must report and initiate appropriate interventions Must monitor and guide quality improvement Model form on medicare.gov Secretary to report to Congress annually ACA Section 3311

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 Toll-free telephone number Internet website Exceptions and appeals filed on/after January 1, 2012 ACA Section 3312

Medicare Prescription Drug Coverage Updates Income-related Premium
Low-Income Benchmark Premium Coverage Gap DRAFT

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 Must pay if you have Part D coverage Effective January 2011 DRAFT

Income-Related Adjustment to Part D Premium
ACA Section 3308 Base beneficiary Part D premium increases People with incomes above the thresholds used to compute income-related adjustment to Part B premiums If your Yearly Income in 2009 was In 2011 You Pay File Individual Tax Return File Joint Tax Return $85,000 or below $170,000 or below Base Premium (BP) $85, – $107,000 $170, – $214,000 BP + $12.00 $107, – $160,000 $214, – $320,000 BP + $31.10 $160, – $214,000 $320, – $428,000 BP + $50.10 $214, or higher $428, or higher BP + $69.10 DRAFT

Part D Low Income Benchmark Premiums
Removes MA rebates/quality bonus payments from calculation of Low Income Subsidy benchmark Effective January 1, 2011 Provides for voluntary de minimis policy Regional benchmark for WV is $34.07 (2011) Allows Part D plans to absorb cost difference Remain a $0 premium LIS plan ACA Section 3302 ACA Section 3303 DRAFT

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

Medicare’s Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program DRAFT

DMEPOS—What You Need to Know
DMEPOS stands for Durable Medical Equipment, Prosthetics, Orthotics and Supplies Equipment /supplies covered under Medicare Part B New competitive bidding program Effective 1/1/11 If you live in affected area and need certain products You must use contract supplier, or Medicare won’t cover DRAFT

DMEPOS—What You Need to Know
Expected to save Medicare and Beneficiaries $28 billion over 10 years $17 billion in Medicare expenditures $11 billion in Beneficiary coinsurance and monthly premium payments DRAFT

Who will Competitive Bidding Affect?
Beneficiaries who have Original Medicare and Permanently reside in a ZIP Code in a CBA Obtain competitive bid items while visiting a CBA To find out if a ZIP Code is in a Competitive Bidding Area Call MEDICARE Visit medicare.gov Medicare Advantage enrollees can use suppliers designated by their plan DRAFT

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 Indiana - Cincinnati, Middletown Pennsylvania - Pittsburgh Texas - Dallas-Fort Worth, Arlington DRAFT

Products Included in the Program
Oxygen, oxygen equipment, and supplies Standard power wheelchairs, scooters Complex rehabilitative power wheelchairs – Group 2 only Mail-order diabetic supplies Enteral nutrients, equipment, and supplies Continuous Positive Airway Pressure (CPAP) devices and Respiratory Assist Devices (RADs) Hospital beds and related accessories Walkers and related accessories Support surfaces (Group 2 mattresses/overlays) Miami only DRAFT

Using Contract Suppliers
Must use contract supplier Item and services included in Competitive Bidding Program living in a CBA Traveling to or visiting a CBA Exceptions Providers can supply certain items (ex: walkers) Nursing facility can supply directly if a contract supplier DRAFT

Identifying Contract Suppliers
Call MEDICARE ( ) TTY users call Visit medicare.gov/supplier DMEPOS Supplier Locator Tool DRAFT

Points to Remember The Competitive Bidding Program does NOT affect which physician or hospital you use May need to change DMEPOS supplier to continue your Medicare coverage May stay with current supplier if “grandfathered” If in Medicare Advantage plan, check with your plan DRAFT

Round 2 Expands program to 91 Metropolitan Statistical Areas
Request for bids begin in 2011 Visit cms.gov/DMEPOSCompetitiveBid/ DRAFT

Session B: Extra Help with Drug Plan Costs
What it is How to qualify Enrollment Continuing eligibility Your costs with Extra Help

What is “Extra Help” Sometimes called the Low-Income Subsidy (LIS)
For people with lowest income and resources Pay no premiums or deductibles & small or no copayments Those with slightly higher income and resources Pay reduced deductible and a little more out of pocket No coverage gap for people who qualify for LIS

Qualifying for Extra Help
You automatically qualify for Extra Help if You get full Medicaid benefits You get Supplemental Security Income (SSI) Medicaid helps pay your Medicare premiums All others must apply with Social Security Online at or Call (TTY ) Ask for “Application for Help with Medicare Prescription Drug Plan Costs” (SSA-1020)

Income and Resource Limits
Below 150% Federal poverty level $1, per month for an individual* or $1, per month for a married couple* Based on family size Resources Up to $12,640 (individual) Up to $25,260 (married couple) Resources include money in a checking or savings account, stocks, and bonds. Resources don’t include your home, car, burial plot, burial expenses up to your state’s limit, furniture, or other household items, wedding rings or family heirlooms. 2011 amounts 2011 amounts *Higher amounts for Alaska and Hawaii

Medicare and Full Medicaid
You are auto-enrolled in a plan unless You are already in a Part D plan You choose and join a plan on your own You call the plan or MEDICARE to opt out You are covered 1st month you are covered by Medicaid and are entitled to Medicare Will get auto-enrollment letter on yellow paper You have a continuous Special Enrollment Period

Others Qualified for Extra Help
Facilitated into a plan unless You already are in a Part D plan You choose and join own plan You’re enrolled in employer/union plan receiving subsidy You call the plan or MEDICARE to opt out Coverage is effective 2 months after CMS notifies Will get facilitated enrollment letter on green paper Have continuous Special Enrollment Period

People New to Extra Help
You can apply for Extra Help any time If denied, can reapply if circumstances change If in a Medicare drug plan and later qualify Plan is notified you qualify for Extra Help Plan refunds costs back to effective date of Extra Help Deductibles/Premiums Cost-sharing assistance

LI-NET Limited Income Newly Eligible Transition Program (LI-NET)
Combined auto-enrollment and Point-of-Sale Facilitated Enrollment For full duals and SSI-only beneficiaries Provides Part D coverage for all uncovered Full duals and SSI-only beneficiaries retroactively LIS eligible beneficiaries on a current basis

Access to LI-NET Three ways to access the LI-NET program
Auto‐Enrollment by CMS 2. Point of Service (POS) Use Submitting a receipt (Rx already paid out-of-pocket) During eligible periods

LI-NET Coverage and Enrollment
Full Dual/SSI-only up to 36 months Partial Dual/LIS Applicants up to 30 days Unconfirmed up to 7 days Enrolled in LI NET for temporary coverage In Standard PDP for future coverage Open Formulary, No Prior Authorization, No Pharmacy Restrictions Standard PDP Rights for Enrollees, Eligibility Reviews for Non-Enrollees

Auto- and Facilitated Enrollment
CMS identifies and enrolls people each month Randomly assigned to plans Premiums at or below regional low-income premium subsidy amount May join MA plan meeting special needs If you are already enrolled in an MA plan You’ll be enrolled in the same plan with Rx coverage (MA-PD) If offered by your current plan

Enrollment Notices CMS notifies people of enrollment in a PDP
Auto-enrollment letter on yellow paper Facilitated enrollment letter on green paper Denotes either full or partial subsidy Includes list of area plans at/below regional low- income premium subsidy amount MA plan sends notice if enrollment in MA-PD See Guide to Consumer Mailings handout

Re-establishing Eligibility for People Who Automatically Qualify
CMS re-establishes eligibility in the Fall For next calendar year If you no longer automatically qualify CMS sends letter in September on gray paper Includes SSA application If you automatically qualify & your copayment changed CMS sends letter In early October on orange paper

Continuing Eligibility
People who are already qualified Four types of redetermination processes Initial Cyclical or recurring Subsidy-changing event (SCE) Other event (change other than SCE)

Extra Help in 2011 – What You Pay
Group 1 Group 2 Group 3 Premium $0* $0 Sliding scale based on income Yearly deductible $310/year $60 Coinsurance up to $4,550 out of pocket $1.10/$3.20 copay $2.40/$6.00 copay Up to 15% coinsurance Catastrophic coverage *If you join a basic plan with a premium at or below the regional low-income premium subsidy amount.

Session C: Coordination of Benefits
Overview Health Coverage Coordination Prescription Drug Coverage Coordination Information Sources

Coordination of Benefits (COB)
The goal of COB is to ensure proper payment Identify the available health benefits Coordinate the payment process Prevent mistaken payment of Medicare benefits

COB Benefits Everyone Individuals and their caregivers
Less stress Healthcare providers Identifies all available health and drug benefits Streamlines the payment process Supports Part D plans in tracking true out-of-pocket costs Provides quality customer service Healthcare system Protects the Medicare trust fund

What Is MSP? Medicare Secondary Payer mandates Medicare is primary
Certain insurance pays health care bills first Medicare pays second Identify other insurance that may pay first Medicare is primary In the absence of other insurance States play a crucial role in MSP in some issues Workers’ Compensation Liability insurance

Identifying the Appropriate Payer
Possible coverage combinations Medicare may be primary payer Medicare may be secondary payer Medicare may not make payment Data sources include Initial Enrollment Questionnaire (IEQ) Doctors and other providers Group health plans Employers

COB Systems IRS/SSA/CMS Data Match
Databases maintained by multiple stakeholders Federal agencies States Plans Pharmacies Assistance programs

COB Contractors Group Health Incorporated (GHI) RelayHealth
Consolidates activities to support Collection, management and reporting of other coverage Coordinates the payment process to prevent mistaken payment of Medicare benefits Doesn’t process claims, recovery, or claim specific inquiries Centralizes COB for Medicare Secondary Payer RelayHealth Centralizes COB for Medicare Part D Acts as TrOOP facilitator

2. Health Coverage Coordination
Other Health Care Payers Determining Who Pays First

Other Possible Health Care Payers

Other Possible Health Care Payers
No-fault or liability insurance Workers’ compensation Federal Black Lung Program COBRA continuation coverage Employer/retiree group health plans Federal Employee Health Benefits Program Military coverage through veterans’ benefits VA TRICARE For Life Others

No-Fault Insurance Pays regardless of who is at fault
Medicare is secondary payer Medicare may make conditional primary payment If claim not paid promptly Usually within 120 days Person won’t have to use own money to pay bill Must be repaid when claim is resolved

Liability Insurance Protects against certain claims
Negligence, inappropriate action, or inaction Medicare is secondary payer Health care professionals must attempt to collect before billing Medicare Medicare may make conditional payment If the liability insurer will not pay promptly Usually within 120 days Medicare recovers conditional payment

Workers’ Compensation
Medicare will not pay for health care related to workers’ compensation claims If workers’ compensation claim denied Claim may be filed for Medicare payment Medicare may make conditional payment

Federal Black Lung Program
Lung disease caused by coal mining Services under this program Considered workers’ compensation claims Not covered by Medicare Information Federal Black Lung Program

COBRA Employees and dependents can keep health coverage after leaving their EGHP If private or state/local government employer with 20 or more employees Called “continuation coverage” Continues for 18, 29, or 36 months Depending on the qualifying event Person must pay entire premium

COBRA and Medicare Medicare is usually primary
Medicare is secondary during 30-month coordination period for End-Stage Renal Disease (ESRD) State Health Insurance Assistance Program (SHIP) counselors can help West Virginia SHIP:

Bankruptcy of Former Employer
COBRA rules may offer protection May require continued coverage by another company under same corporate structure May be able to get “COBRA-for-life” Benefits can change Cost of coverage can go up

Federal Employee Health Benefits Program (FEHBP)
An Employer Group Health Plan (EGHP) Pays secondary when person retires Pays first If person with Medicare or covered spouse still working For person or spouse during first 30 months of eligibility due to ESRD

VA Benefits People with Medicare and VA benefits Generally
Can obtain treatment under either program Must choose which benefit to use each time Generally Medicare cannot pay for service authorized by VA VA cannot pay for service covered by Medicare VA member could be subject to a penalty For enrolling "late" for Medicare Part B

TRICARE For Life (TFL) TRICARE's Medicare-wraparound coverage
Available to all Medicare-eligible TRICARE beneficiaries Medicare is primary TRICARE acts as secondary payer Minimizes out-of-pocket expenses Benefits cover Medicare's coinsurance and deductible MUST have Medicare Parts A and B

How TRICARE For Life Works with Medicare
Use Medicare provider Medicare provider will file claims with Medicare Medicare pays its portion and forwards claim to TFL TFL pays provider directly for TRICARE-covered services Services covered by both Medicare and TRICARE Medicare pays first TFL pays remaining Services covered by TRICARE but not by Medicare TFL pays first Medicare pays nothing

Determining Who Pays First – Health Coverage

When Medicare is Primary
Medicare is the only insurance Other source of coverage is Medigap policy Medicaid Retiree benefits Indian Health Service Veterans benefits and TRICARE for Life COBRA continuation coverage Except 30-month coordination period for people with End-Stage Renal Disease (ESRD)

Medicare is Secondary To employer group health plans (EGHP)*
65+ and still working: EGHP 20 or more employees Disability: EGHP 100 or more employees ESRD: Any size EGHP after initial 30-months To non-EGHP involving Workers’ Compensation (WC) Black Lung Program No-fault/liability insurance

Page 6 - Medicare and Other Health Benefits: Your Guide to who Pays First, CMS Pub. #02179

Page 7 - Medicare and Other Health Benefits: Your Guide to who Pays First, CMS Pub. #02179

Employer Group Health Plans
Offered by many employers and unions Current employees Retirees Spouse or family members May be fee-for-service plan May be managed care plan Can choose to keep or reject

EGHP and Working Aged Age 65 or older and
Working and covered by EGHP or Covered by working spouse’s EGHP Medicare is generally secondary payer If employer has 20 or more employees For self-employed, if covered by EGHP of employer with 20 or more employees

LGHP and Medicare Due to Disability
Medicare based on disability and Working and covered by large EGHP (LGHP) or Covered by LGHP of working spouse Or other family member Medicare is secondary payer If employer has 100 or more employees or Self-employed, if covered by LGHP of employer with 100 or more employees

EGHP and End-Stage Renal Disease
Medicare and ESRD and covered by EGHP of any size Coverage through self or family member Need not be based on current employment Medicare is secondary payer During 30-month coordination period Unless Medicare already primary to retiree plan

EGHP and ESRD EGHP primary payer for first 30 months
Medicare becomes primary after 30 months Separate 30-month coordination periods Each time eligible for Medicare based on ESRD Applies only to people with ESRD For details

Retiree Health Plans Medicare pays first Retiree coverage pays second
Might offer additional benefits Prescription drug coverage Routine dental care Refer to plan’s benefits booklet Coverage for spouse Employer/union may change benefits, change premiums, or cancel coverage

3. Coordination of Prescription Drug Benefits
Other Possible Drug Coverage Identifying the Appropriate Payer

Other Possible Drug Coverage

Other Possible Drug Coverage
Medicaid programs State Pharmacy Assistance Programs (SPAPs) Patient Assistance Programs (PAPs) and charities AIDS Drug Assistance Programs (ADAPs) Safety-net providers Indian Health Service coverage Personal health savings accounts Part B drug coverage FEHBP VA TRICARE

Identifying the Appropriate Prescription Drug Coverage Payer

Part D COB Contractors Group Health Inc. (GHI) and Relay Health
GHI - Centralizes COB for Medicare Relay Health is the TrOOP Facilitator (True Out-of-Pocket costs)

Medicare Part D Medicare usually primary
Part D plan pays first Situations involving Employer Group Health Plans Part D plan denies primary claims Non-group health plan situations Part D plan makes conditional primary payment To ease burden on enrollee Medicare is reimbursed

Other Drug Coverage and Part D Enrollment Considerations
Current coverage is creditable Coverage as good as Medicare drug coverage Can keep it as long as still offered Won’t pay penalty if enroll in Part D later Current coverage NOT creditable Coverage not as good as Medicare drug coverage Can enroll in Part D 10/ /7 in 2011 Late enrollment may result in penalty

Part D and Medicaid People with both Medicare and Medicaid
Get drug coverage from Medicare Get low-income assistance (“Extra Help”) States may opt to cover non-Part D drugs Does not count toward TrOOP COB between plans, states, and pharmacies Not required Part D plans may choose to share data Some Special Needs Plans coordinate services for Medicaid recipients

Qualified SPAP Coverage secondary to Part D
Contributions count toward TrOOP May opt to participate in COB and TrOOP facilitation, to help Effectively wrap around Part D Speed up reimbursement of erroneous payments Facilitate timely access to prescriptions Some may enroll members in Part D Must be non-discriminatory

Patient Assistance Programs and Charities
Sponsored by Pharmaceutical manufacturers Other entities Provide for low-income patients Financial assistance Cost-sharing or premiums Free products Incomes below 200% Federal poverty level No prescription drug coverage Insufficient prescription drug coverage

AIDS Drug Assistance Programs
Help pay for HIV/AIDS drug treatments Contributions do count toward TrOOP Effective January 1, 2011 Can choose to participate in COB either Electronically at point-of-sale or By submitting paper claims to TrOOP contractor Health Reform Section 3314

Safety-Net Providers Serve low-income communities Examples include
Federally Qualified Health Centers Rural Health Clinics Critical Access Hospitals Offer services through a “closed pharmacy” Many in 340B Drug Pricing Program Allows them to buy prescription drugs at lower prices

Employer/Union Drug Plan Options
EGHP options Take Retiree Drug Subsidy Become a Medicare drug plan Wrap around Medicare drug coverage Pay enrollees’ Medicare drug plan premium May change at any time during year Not required to make changes during specific enrollment period

Important Considerations for People with Retiree Coverage
Most retiree plans offer generous coverage for entire family Employer/union must disclose how its plan works with Medicare drug coverage Talk to benefits administrator for more information People who drop retiree drug coverage May lose other health coverage May not be able to get it back Family members may lose coverage

People With Retiree Coverage Who Qualify for Extra Help
Those with limited income and resources Income at or below 150% of Federal poverty level Pay very little for prescriptions in a Part D Plan CMS automatically enrolls people with Medicare and full Medicaid benefits Including those with retiree drug coverage May have to choose between Medicare drug coverage and retiree coverage

Retiree Coverage and Extra Help
CMS encourages employers/unions to Allow those disenrolling by mistake to re-enroll Allow separate package for family members Add supplemental coverage option Help retirees who choose to opt out of Medicare drug coverage Coordinate with state Medicaid or other assistance programs

How Prescription Assistance Programs and Charities Work with Part D
Charities can wrap around the Part D benefit Charities can participate in COB either Electronically at point-of-sale or Submitting paper claims to TrOOP contractor Manufacturer-sponsored PAPs can choose to operate outside the Part D benefit No interaction with TrOOP PAPs should still coordinate with Part D plans

How Safety-Net Providers Work with Part D
Part D plans encouraged to contract with safety-net providers Contributions by safety-net providers Generally do not count toward TrOOP Count toward TrOOP if unadvertised AND either Offered in non-routine manner Offered to Extra Help recipients

Personal Health Savings Accounts
Contributions count toward TrOOP when not structured as group health plan Health Savings Accounts Flexible Spending Accounts Medicare Medical Savings Accounts Contributions do not count toward TrOOP When structured as group health plan Health Reimbursement Arrangements Must participate in COB

Medicare Part B and Part D
Systems do not automatically coordinate Guidelines help differentiate Part B-covered drugs Part D-covered drugs Details available on CMS website

How FEHB Works with Part D
FEHB considered creditable drug coverage As good as Medicare drug coverage People can have both FEHB and Part D Adding Part D provides little, if any, savings Unless qualify for Extra Help COB contractor captures/maintains enrollment data

How VA Works with Part D VA offers creditable drug coverage
As good as Medicare drug coverage People can choose which benefit to use VA Medicare Single prescription cannot be covered by both COB contractor captures/maintains enrollment data

How TRICARE for Life Works with Part D
TFL considered creditable drug coverage As good as Medicare drug coverage People can have both TFL and Part D Adding Part D may benefit people who qualify for Extra Help COB contractor captures/maintains enrollment data

4. Information Sources

Information Sources COBRA Contacts EGHP benefits administrator
Department of Labor USA-DOL ( ) State department of insurance Medicare Coordination of Benefits Contractor CMS Health Insurance Hotline , extension

Information Sources Coordination of Benefits Contractor
(TTY ) To get information on who pays first To report changes in your insurance information Medicare Coordination of Benefits

Information Sources Medicare and Other Health Benefits: Your Guide to Who Pays First

Information Sources Medicare/TRICARE Benefit Overview
Department of Defense (To get information about the TRICARE Pharmacy Program (TTY ) Department of Veterans Affairs (TTY ) Medicare Secondary Payer Recovery Contractor (TTY )

Information Sources Office of Personnel Management (for FEHBP)
(TTY ) U. S. Department of Labor Federal Black Lung Program COBRA

Introduction to Medicare Resource Guide
Resources Medicare Products Centers for Medicare & Medicaid Services (CMS) 1-800-MEDICARE ( ) (TTY ) Social Security 1‑800‑772‑1213 TTY 1‑800‑325‑0778 Railroad Retirement Board State Health Insurance Assistance Programs (SHIPs)* *For telephone numbers call CMS 1-800-MEDICARE ( ) for TTY users Affordable Care Act Medicare & You Handbook CMS Product No ) Your Medicare Benefits CMS Product No Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare CMS Product No To access these products View and order single copies at Order multiple copies (partners only) at productordering.cms.hhs.gov. You must register your organization.

Barbara Childers, MSW Centers for Medicare & Medicaid Services

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