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Medicare Advanced Barbara Childers, MSW Centers for Medicare & Medicaid Services.

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Presentation on theme: "Medicare Advanced Barbara Childers, MSW Centers for Medicare & Medicaid Services."— Presentation transcript:

1 Medicare Advanced Barbara Childers, MSW Centers for Medicare & Medicaid Services

2 Session Topics A.Changes to Medicare as a result of healthcare reform B.Low Income Subsidy Program (Extra Help with Drug Plan Costs) C.Coordination of Benefits 2

3 Session A: Changes to Medicare as a result of healthcare reform 1.Overview and Highlights 2.Medicare Updates  Original Medicare  Medicare Advantage  Medicare Prescription Drug Coverage  DMEPOS 3

4  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 4 Medicare Statistics

5  Patient Protection and Affordable Care Act (PPACA) – Signed into law H.R. 3590 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. 4872 on March 30, 2010 – Modifies PPACA and adds several new provisions  Together called the Affordable Care Act 5 New Legislation – Health Reform

6 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 6

7 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 7 ACA Section 1001

8 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 1-866-717-5826 (TTY 1- 866-561-1604) which is open from 8 AM to 11 PM  To request more information, resources (drop-in articles, facts sheets, etc), presentation for your staff or for questions, please email

9 9 Original Medicare Updates  Medicare Claims Limit  2011 Amounts  Preventive Services  Face-to-Face Meeting Rules  Therapy Caps  Power-driven Wheelchairs  Medigap Policies

10 Medicare Claims Limit  Maximum period for submission of Medicare claims – Reduced time period – Now not more than 12 months  Effective January 1, 2010 10 ACA Section 6404

11 11 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 – $141.50 per day for days 21 - 100

12 2011 Part B Amounts  Part B Annual Deductible - $162  Part B Monthly Premium (hold harmless) 12 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 $110.50$115.40If premium not deducted from Social Security $0$115.40If new to Medicare in 2011

13 Income-Related Part B Premium  Effective January 1, 2011, Part B premium income thresholds frozen at 2010 levels through 2019 ACA Section 3402 13 If your Yearly Income in 2009 was In 2011 You Pay* File Individual Tax ReturnFile 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 $214,000above $428,000$369.10 *Higher if you have a late enrollment penalty.

14 14 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

15 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 15 ACA Section 6407

16 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 16 ACA Section 3132

17 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 17 ACA Section 3103

18 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 18 ACA Section 3136

19 19 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 MIPPA

20 20 2010 Medigap Changes (* denotes new plans and benefits) Basic Benefits Deleted Coverage Deleted Plans Plan DPlan GPlan M *Plan N * Add Hospice Coverage- Part A coinsurance* (Part A coinsurance + 365 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) Basic, including 100% Part B Coinsurance Skilled Nursing Facility Coinsurance Part A Deductible 100% Part B Excess * Foreign Travel Emergency (In-Home Recovery deleted) Basic, including 100% Part B Coinsurance Skilled Nursing Facility Coinsurance 50% Part A Deductible Foreign Travel Emergency Basic, including 100% Part B Coinsurance (except up to $20 office visit copayment; up to $50/ER) Skilled Nursing Facility coinsurance Part A Deductible Foreign Travel Emergency MIPPA

21 21 Medicare Advantage Updates  Enrollment Period  Disenrollment Period  Cost limits/Plan Payments  Complaint system  Appeals

22 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 22

23 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 1-800-MEDICARE – Enroll in a standalone prescription drug plan ACA Section 3204 23

24 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 24 ACA Section 3202

25 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 25 ACA Section 3203

26 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  Secretary to report to Congress annually ACA Section 3311

27 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

28 28 Medicare Prescription Drug Coverage Updates  Income-related Premium  Low-Income Benchmark Premium  Coverage Gap

29 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 29

30 Income-Related Adjustment to Part D Premium  Base beneficiary Part D premium increases – People with incomes above the thresholds used to compute income-related adjustment to Part B premiums 30 If your Yearly Income in 2009 wasIn 2011 You Pay File Individual Tax ReturnFile Joint Tax Return $85,000 or below$170,000 or belowBase Premium (BP) $85,000.01 – $107,000$170,000.01 – $214,000BP + $12.00 $107,000.01 – $160,000$214,000.01 – $320,000BP + $31.10 $160,000.01 – $214,000$320,000.01 – $428,000BP + $50.10 $214,000.01 or higher$428,000.01 or higherBP + $69.10 ACA Section 3308

31 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 – Effective January 1, 2011 31 ACA Section 3302 ACA Section 3303

32 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 32

33 33 Medicare’s Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program

34 34 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

35 35 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

36 36 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 1-800-MEDICARE – Visit  Medicare Advantage enrollees can use suppliers designated by their plan

37 37 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

38 38 Products Included in the Program 1.Oxygen, oxygen equipment, and supplies 2.Standard power wheelchairs, scooters 3.Complex rehabilitative power wheelchairs – Group 2 only 4.Mail-order diabetic supplies 5.Enteral nutrients, equipment, and supplies 6.Continuous Positive Airway Pressure (CPAP) devices and Respiratory Assist Devices (RADs) 7.Hospital beds and related accessories 8.Walkers and related accessories 9.Support surfaces (Group 2 mattresses/overlays) Miami only

39 39 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

40 40 Identifying Contract Suppliers  Call 1-800-MEDICARE (1-800-633-4227)  TTY users call 1-877-486-2048  Visit – DMEPOS Supplier Locator Tool

41 41 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

42 42 Round 2  Expands program to 91 Metropolitan Statistical Areas  Request for bids begin in 2011  Visit

43 Session B: Extra Help with Drug Plan Costs  What it is  How to qualify  Enrollment  Continuing eligibility  Your costs with Extra Help 43

44 44 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

45 45 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, – Call 1-800-772-1213 (TTY 1-800-325-0778) Ask for “Application for Help with Medicare Prescription Drug Plan Costs” (SSA-1020)

46 Income and Resource Limits 46  Income –Below 150% Federal poverty level $1,361.25 per month for an individual* or $1,838.75 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 * Higher amounts for Alaska and Hawaii

47 47 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 1-800-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

48 48 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 1-800-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

49 49 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

50 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 50

51 Access to LI-NET  Three ways to access the LI-NET program 1.Auto‐Enrollment by CMS 2. Point of Service (POS) Use 3.Submitting a receipt (Rx already paid out-of-pocket) – During eligible periods 51

52 LI-NET Coverage and Enrollment  Coverage – 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 52

53 53 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

54 54 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

55 55 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

56 56 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)

57 57 Extra Help in 2011 – What You Pay Group 1Group 2Group 3 Premium$0*$0Sliding scale based on income Yearly deductible $310/year $0*$0$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 $0 $2.40/$6.00 copay *If you join a basic plan with a premium at or below the regional low-income premium subsidy amount.

58 Session C: Coordination of Benefits 1.Overview 2.Health Coverage Coordination 3.Prescription Drug Coverage Coordination 4.Information Sources 58

59 59 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

60 60 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

61 61 What Is MSP?  Medicare Secondary Payer mandates – 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

62 62 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

63 63 COB Systems  IRS/SSA/CMS Data Match  Databases maintained by multiple stakeholders – Federal agencies – States – Plans – Pharmacies – Assistance programs

64 64 COB Contractors  Group Health Incorporated (GHI) – 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

65 2. Health Coverage Coordination  Other Health Care Payers  Determining Who Pays First 65

66 Other Possible Health Care Payers 66

67 67 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

68 68 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

69 69 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

70 70 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

71 71 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 – 1-800-638-7072

72 72 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

73 73 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: 877-987-4463

74 74 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

75 75 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

76 76 VA Benefits  People with Medicare and VA benefits – 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

77 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 77

78 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 78

79 Determining Who Pays First – Health Coverage 79

80 80 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)

81 81 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

82 Page 6 - Medicare and Other Health Benefits: Your Guide to who Pays First, CMS Pub. #02179 82

83 83 Page 7 - Medicare and Other Health Benefits: Your Guide to who Pays First, CMS Pub. #02179

84 84 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

85 85 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

86 86 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

87 87 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

88 88 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 –

89 89 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

90 3. Coordination of Prescription Drug Benefits  Other Possible Drug Coverage  Identifying the Appropriate Payer 90

91 Other Possible Drug Coverage 91

92 92 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

93 Identifying the Appropriate Prescription Drug Coverage Payer 93

94 94 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)

95 95 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

96 96 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 10/15 - 12/7 in 2011 – Late enrollment may result in penalty

97 97 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

98 98 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

99 99 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

100 100 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

101 101 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

102 102 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

103 103 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

104 104 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

105 105 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

106 106 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

107 107 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

108 108 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

109 109 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

110 110 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

111 111 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

112 112 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

113 4. Information Sources 113

114 114 Information Sources  COBRA Contacts – EGHP benefits administrator – Department of Labor 1-866-4-USA-DOL (1-866-487-2365) State department of insurance – Medicare Coordination of Benefits Contractor 1-800-999-1118 – CMS Health Insurance Hotline 410-786-1565 1-877-267-2323, extension 6-1565

115 115 Information Sources  Coordination of Benefits Contractor – 1-800-999-1118 (TTY 1-800-318-8782 ) – To get information on who pays first – To report changes in your insurance information  Medicare Coordination of Benefits – –

116 116 Information Sources  Medicare and Other Health Benefits: Your Guide to Who Pays First –

117 117 Information Sources  Medicare/TRICARE Benefit Overview –  Department of Defense (To get information about the TRICARE Pharmacy Program – 1-877-363-1303 (TTY 1-877-540-6261)  Department of Veterans Affairs – 1-800-827-1000 (TTY 1-800-829-4833 )  Medicare Secondary Payer Recovery Contractor – 1-866-677-7220 (TTY 1-866-677-7294)

118 118 Information Sources  Office of Personnel Management (for FEHBP) – 1-888-767-6738 (TTY 1-800-878-5707)  U. S. Department of Labor – Federal Black Lung Program – COBRA

119 119 Introduction to Medicare Resource Guide ResourcesMedicare Products Centers for Medicare & Medicaid Services (CMS) 1-800-MEDICARE (1-800-633-4227) (TTY 1-877-486-2048) Social Security 1 ‑ 800 ‑ 772 ‑ 1213 TTY 1 ‑ 800 ‑ 325 ‑ 0778 Railroad Retirement Board 1-877-772-5772 State Health Insurance Assistance Programs (SHIPs)* *For telephone numbers call CMS 1-800-MEDICARE (1-800-633-4227) 1-877-486-2048 for TTY users Affordable Care Act es/patient_protection_affordable_car e_act_as_passed.pdf Medicare & You Handbook CMS Product No. 10050) Your Medicare Benefits CMS Product No. 10116 Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare CMS Product No. 02110 To access these products View and order single copies at Order multiple copies (partners only) at You must register your organization.

120 This training module provided by the For questions about training products, e-mail To view all available NMTP materials or to subscribe to our listserv, visit NationalMedicareTrainingProgram

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