1. www.insurance.arkansas.gov Arkansas Insurance Department

2. The primary mission is consumer protection through insurer solvency and market conduct regulation, and fraud prosecution and deterrence.

3. Insurance Department Divisions Health Insurance Premium Rate Review Liquidation Life and Health Property and Casualty Public Employee Claims Risk Management Senior Health Insurance Information Program Administration Accounting Consumer Services Consumer Assistance Program Criminal Investigations Finance Human Resources Legal License Health Benefits Exchange

4. Consumer Services Division Stats Toll-free Phone 1-800-852-5494 Assisted Arkansans in collecting $14,006,232 Received 2,864 consumer complaints Closed 3,164 consumer complaint files Responded to 19,207 telephone inquiries and assisted 299 walk-in consumers Participated in 130 dislocated worker workshops and 28 expos and health fairs

5. SHIIP Stats Assist Arkansans with all things MEDICARE – Assisted more than 14,500 Medicare recipients or caregivers – 6,642 Part D comparisons of which 2,648 assisted with enrollment – 2,132 Medigap comparison and eligibility – 2,008 Medicare Advantage comparisons

6. Complaints Contact Insurance Plan/Carrier first and ask for clarification Insurance Department Complaints – Claims payment concerns – Agent misconduct – Medicare Supplement Policy Medicare Complaints via SHIIP – Claims Payment Issues Plan False or Misleading Sales & Marketing Practices

7. Patient Protection and Affordable Care Act (PPACA)

8. Affordable Care Act Changes Take Care Arkansas – Temporary (until 2014) high-risk pool for those with pre-existing conditions Administered by Blue Cross Blue Shield – 1-800-285-6477 – WWW.TAKECAREARKANSAS.ORG Early Retirees (before age 65) – Temporary program to offset cost of retiree coverage paid to employers (not retirees)

9. Affordable Care Act & Medicare Annual Election Period – EARLIER starts Oct 15 and ends Dec 7 Medicare Claims – Maximum period for submission of Medicare claims reduced time period – Not more than 12 months Preventive Services – No longer pay Part B deductible and coinsurance for most preventative services

11. Affordable Care Act- Medicare Therapy caps extended – Physical & Speech pathology= combined $1,860 per year – Occupational therapy= $1,860 per year

12. Affordable Care Act- Medicare Power-driven wheelchairs effective Jan 2011 – Medicare no longer purchase with lump-sum – Paid over 13-month period Increased ground ambulance rates retroactive to Jan 2010: 3% rural, 2% urban Hospice Reform effective Nov 2011 – Face-to-face encounter is required with hospice physician or nurse practitioner

13. Affordable Care Act –MA Plans MA Plans can not charge more than Original Medicare – Services: chemotherapy, skilled nursing facility, dialysis, etc. Payments to MA frozen in 2011 MA Disenrollment Period Jan 1-Feb 14 – Leave MA and go to Original Medicare with stand alone Part D

14. Affordable Care Act- Part D Donut Hole in 2012 – 50% discount on brand name drugs – 14% discount on generic drugs Higher income people pay higher Part D premium – Effective Jan 2011 – Same thresholds as Part B premium Modified Adjusted Gross Income Income reported on IRS tax return 2 years ago

15. Medicare Preventive Services SESSION TOPICS What is covered Why preventive services are important Who is eligible How much you pay Centers for Disease Control and Prevention reports less than 10% of Medicare beneficiaries receive all recommended screenings and immunizations.

16. Medicare Preventive Services Medicare coverage based on – Age – Gender – Medical history Covered by – Part B of Original Medicare – Medicare Advantage and other Medicare plans Medicare Preventive Services16

17. Covered Screening and Preventive Services  One time “Welcome to Medicare” physical exam  Physical Exam (yearly “Wellness Exam”)  Abdominal aortic aneurysm screening*  Bone mass measurement  Cardiovascular disease screenings  Colorectal cancer screenings  Diabetes screenings  EKG Screening*  Flu shots  Glaucoma tests  Hepatitis B shots  HIV Screening  Mammograms (screening)  Pap test/pelvic exam/clinical breast exam  Prostate cancer screening  Pneumococcal shots  Smoking cessation Medicare Preventive Services17 Health Reform Section 4103 *When referred during Welcome to Medicare physical exam

18. Elimination of Part B Deductible and Coinsurance Requirements in 2011 Starting January 1, 2011 You pay nothing for most preventive services – If you get them from a doctor or other health care provider who accepts assignment Services affected must have an “A” or “B” rating – By the United States Preventive Services Task Force – http://www.uspreventiveservicestaskforce.org/uspst f/uspsabrecs.htm Medicare Preventive Services18 Health Reform Section 4104

19. One Time “Welcome to Medicare” Physical Exam Covered within first 12 months of having Part B – Height, weight and body mass index – Blood pressure and end of life planning – Education, counseling, and referrals (e.g., EKG) In Original Medicare pay –No deductible or copayment starting January 1, 2011 Medicare Preventive Services19 Changes in 2011

20. Abdominal Aortic Aneurysm Screening Abdominal aortic aneurysms (weak area bulges) Risk factors include – A family history of abdominal aortic aneurysms – Men age 65 to 75 who have smoked at least 100 cigarettes in their lifetime Ultrasound screening covered by Medicare – Referral from the “Welcome to Medicare” physical exam – Pay 20% of the Medicare-approved amount with no Part B deductible – No deductible or copayment starting January 1, 2011 Medicare Preventive Services20 Changes in 2011

21. New Annual Wellness Visit Effective January 1, 2011 Annual Wellness Visit – Comprehensive health risk assessment – Personalized prevention plan – Health advice and referral to education and preventive counseling – No copayment or deductible – Available every 12 months (after first 12 months of initial Part B coverage) o But not within 12 months of receiving either a “Welcome to Medicare” physical exam or another Annual Wellness visit Medicare Preventive Services21 Health Reform Section 4103

22. Bone Mass Measurement Medicare Preventive Services22  Covered if at risk for osteoporosis –Every 2 years (more often if medically necessary)  Risk factors include but aren’t limited to –Age 50 or older –Female –Family or personal history of broken bones –White or Asian  In Original Medicare pay –No deductible or copayment starting January 1, 2011 Changes in 2011

23. Cardiovascular Disease Screening Blood test for early detection – Heart disease – Stroke Tests for levels of – Cholesterol – Triglycerides – Lipids Covered every 5 years In Original Medicare you pay nothing Medicare Preventive Services23

24. Cardiac Rehabilitation Medicare covers cardiac programs that include – Exercise – Education – Counseling certain patients with a doctor’s referral – Intensive cardiac rehabilitation programs In Original Medicare, pay 20% of the Medicare- approved amount – If you get the services in a doctor’s office No change in 2011, is not rated “A” or “B” Pay a copayment in a hospital outpatient setting Medicare Preventive Services24

25. Colorectal Cancer Screening Helps find precancerous growths – Helps prevent or find cancer early One or more of the following tests may be covered – Fecal Occult Blood Test – Flexible Sigmoidoscopy – Colonoscopy – Barium Enema Medicare Preventive Services25

26. Medicare Preventive Services26 Colorectal Cancer Screening (continued) Test and Requirements Covered Once Every… You Pay Fecal Occult Blood Test Age 50 or older 12 monthsNo deductible or copayment starting January 1, 2011. Flexible Sigmoidoscopy Age 50 or older 48 months or 120 months after a previous screening colonoscopy for those not at high risk No deductible or copayment starting January 1, 2011. Colonoscopy No minimum age 120 months (generally) (high risk every 24 months) or 48 months after a previous flexible sigmoidoscopy No deductible or copayment starting January 1, 2011. Barium Enema Age 50 or older 48 months (high risk every 24 months) when used instead of a sigmoidoscopy or colonoscopy Pay 20% of the Medicare-approved amount for the doctor’s services. In a hospital outpatient setting, you pay a copayment. No change in 2011.

27. Diabetes Risk Factors  Diabetes is a chronic condition – Body does not produce or properly use insulin  Risk Factors – High blood pressure – High cholesterol – Obesity – History of high blood sugar – At least two of the following Age 65 or older, Overweight, Family history of diabetes, or Past gestational diabetes or having a baby over 9 pounds Medicare Preventive Services27

28. Diabetes Management May be able to avoid or delay complications Manage diabetes – Test blood sugar regularly – Eat a proper diet – Exercise regularly – Take medication as prescribed Medicare Preventive Services28

29. Diabetes Screening Testing for people at risk Includes fasting blood glucose test Talk with your doctor about frequency – Got pre-diabetes, then screening up to twice in a 12-month period – Not diagnosed or pre-diabetic, then screening once in 12-month period In Original Medicare pay – No deductible or coinsurance Medicare Preventive Services29

30. Covered Diabetes Services Screening for all at risk For people with diabetes (need prescription) – Self-management training – Medical nutrition therapy – Blood sugar testing supplies Lancets, monitors, testing strips= Part B Insulin, syringes, needles, alcohol swabs, gauze = Part D – Special eye exams – Hemoglobin A1c tests Medicare Preventive Services30

31. Covered Diabetes Services People with diabetes who need them – Insulin pumps – Special foot care – Therapeutic shoes In Original Medicare pay – 20% after Part B deductible – No change in 2011 Medicare Coverage of Diabetes Supplies & Services (CMS Pub. 11022) Medicare Preventive Services31

32. Glaucoma Examination Glaucoma is caused by increased eye pressure – May gradually lose sight without symptoms Protect yourself with screening eye exam Covered if high risk once every 12 months – High-risk= Family history, African American and age 50 or old, or Hispanic and age 65 or older In Original Medicare pay – 20% of the Medicare-approved amount Part B deductible applies for the doctor services – A copayment in a hospital outpatient setting – No change in 2011 Medicare Preventive Services32

33. HIV Screening Medicare covers HIV screening for people – Who are pregnant or at increased risk for the infection – Includes anyone who asks for the test Covered once every 12 months – Up to 3 times during a pregnancy In Original Medicare pay – Generally pay 20% of the Medicare-approved amount for the doctor’s visit – No deductible or copayment for the test – No change in 2011 Medicare Preventive Services33

34. Pap Test and Pelvic Exam with Clinical Breast Exam Risk factors for some cancers in woman include – Had an Abnormal Pap test – Infected with Human papilloma virus (HPV) – Began sexuality activity before age 16 – Had many sexual partners Medicare covers – Pap test to help find cervical and vaginal cancer – Screening pelvic exam to help find fibroids/ovarian cancers – Clinical breast exam (another way to look for breast cancer) Medicare Preventive Services34

35. Pap Test and Pelvic Exam with Clinical Breast Exam Covered for all women with Medicare – Once every 24 months for most women – Once every 12 months if At high risk for cervical or vaginal cancer Childbearing age and abnormal Pap test in the past 36 months Medicare Preventive Services35

36. Pap Test and Pelvic Exam with Clinical Breast Exam In Original Medicare pay nothing – Nothing for Pap lab test – No Part B deductible – No copayment starting January 1, 2011 Medicare Preventive Services36 Health Reform Section 4104

37. Prostate Cancer Risks Risk increases with age – Age 45 – 1 in 2,500 – Age 50 – 1 in 476 – Age 55 – 1 in 120 – Age 60 – 1 in 43 – Age 65 – 1 in 21 – Age 70 – 1 in 13 – Age 75 – 1 in 9  Ethnicity risk: AA, White, Hispanic at highest risk  Hereditary risk Medicare Preventive Services37

38. Prostate Cancer Screening Covered – For all men with Medicare – Beginning the day after 50th birthday Tests include – Digital rectal exam – PSA blood test Prostate-specific antigen In Original Medicare pay – Nothing for the PSA blood (lab) test – 20% after Part B deductible for digital rectal exam No change in 2011 Medicare Preventive Services38

39. Breast Cancer and Mammography Breast cancer in women in U.S. – Most commonly diagnosed non-skin cancer – Second leading cause of cancer death – Risk increases with age – Successfully treated when found early Mammogram – Checks for abnormal breast tissue – Coverage includes digital technology Medicare Preventive Services39

40. Screening Mammogram Covered for all women with Medicare – One baseline mammogram age 35 to 39 – Once a year starting at age 40 In Original Medicare pay nothing – No Part B deductible – No deductible or copayment starting January 1, 2011 Medicare Preventive Services40 Changes in 2011 Health Reform Section 4104

41. Diagnostic Mammogram Used when there are clinical findings – On physical exam – Abnormal screening mammogram Medicare covers as many as needed – Also covered for men Different payment rates if diagnostic mammograms – Usually pay 20% of Medicare approved amount and Part B deductible applies Medicare Preventive Services41

42. Smoking Cessation Quitting gives significant health benefits – Even older adults who smoked for years When services are covered – If you have an illness caused or complicated by tobacco use Includes smokers with heart or lung disease, stroke, multiple cancers, weak bones, blood clots, or cataracts – If you take medication affected by tobacco use Such as insulin, medication for high blood pressure, blood clots, and depression Medicare Preventive Services42

43. Smoking Cessation Services Cessation counseling – Up to 8 sessions per year – Inpatient or outpatient – Intermediate or intensive In Original Medicare pay – 20% after Part B deductible No change in 2011 Medicare Part D prescription drug coverage – Can help pay for drug therapy Nicotine patches, for example Medicare Preventive Services43

44. Influenza (“Flu”) Shot Flu can lead to pneumonia – Can be dangerous for people 50 and over Flu viruses are always changing – Shot updated for most current flu viruses – Recommended in fall or winter (Oct or Nov) Flu shot covered for all people with Medicare Once each flu season protects for about a year In Original Medicare pay – No deductible or copayment Medicare Preventive Services44

45. H1N1 Flu Vaccine H1N1 flu is caused by a new strain of influenza virus Risk factors not as high for those over 65 – Higher risk for those with certain disabilities Medicare covers administration of the H1N1 flu shot – You can’t be charged for the vaccine (providers get it free) – You pay nothing if provider accepts assignment – Part B deductible and coinsurance don’t apply To the vaccine or its administration You should still get the seasonal flu shot Medicare Preventive Services45

46. Pneumococcal Pneumonia Shot Pneumonia is inflammation in the lungs – Caused by bacteria (streptococcus pneumoniae) One shot could be all you ever need All people with Medicare are eligible In Original Medicare pay nothing – No deductible or copayment Medicare Preventive Services46

47. Hepatitis B Shots Serious disease (virus attacks the liver) – Can cause lifelong infection, cirrhosis (scarring) of the liver, liver cancer, liver failure, or death Covered for medium to high risk – End-stage renal disease and hemophilia – Condition that lowers resistance to infection In Original Medicare pay nothing – No deductible or copayment starting January 1, 2011 Medicare Preventive Services47 Health Reform Section 4104 Changes in 2011

48. Medicare Education Benefit People with Stage IV chronic kidney disease – Have advanced kidney damage and – Will likely need dialysis or a kidney transplant soon Medicare Part B covers – Up to six sessions of kidney disease education services if have stage IV and doctor refers for the service Provided to help prevent or delay the need for dialysis – Pay 20% of the Medicare-approved amount, and the Part B deductible applies No change in 2011 Medicare Preventive Services48

49. Protecting the Medicare Trust Funds Centers for Medicare & Medicaid Services (CMS) has to balance how to –Pay claims on time vs. conduct reviews –Prevent/detect fraud vs. limit burden on providers CMS must protect the Trust Funds 1.Medicare Hospital Insurance Trust Fund (Part A) 2.Supplementary Medical Insurance Trust Fund (Part B)

50. Medicare Hospital Insurance Trust Fund Pays forFunded by Part A (Hospital Insurance) benefits  Payroll taxes  Income taxes paid on Social Security benefits  Interest earned on trust fund investments  Part A premiums from people who aren’t eligible for premium-free Part A

51. Supplementary Medical Insurance Trust Fund Pays forFunded by Part B (Medical Insurance) and Part D (Medicare Prescription Drug coverage) benefits  Funds authorized by Congress  Part B premiums  Part D premiums  Interest earned on trust fund investments

52. Medicare Overview Each Work DayMonthlyYearly  4.4 million claims processed  From 1.5 million providers  Worth $1.1 billion  Almost 19,000 provider enrollment applications received  Over $430 billion in claims paid  Over 48 million beneficiaries

53. Medicare Dictionary When someone intentionally falsifies information or deceives Medicare. When health care providers or suppliers don’t follow good medical practices, resulting in unnecessary costs to Medicare, improper payment, or services that aren‘t medically necessary. Fraud and Abuse Costs $60-90 billion annually or $1.6-2.6 million per day

54. Examples of Fraud Medicare/Medicaid is billed for – Services never delivered – Equipment never delivered or returned Unauthorized use of Medicare/Medicaid card A company uses false information – To mislead a beneficiary into joining a Medicare plan

55.  Medicare Summary Notices  www.MyMedicare.gov  1-800-MEDICARE  Senior Medicare Patrol  www.stopmedicarefraud.gov www.stopmedicarefraud.gov  Protecting Personal Information/ID Theft  Tips  Part C and D Plan Marketing Fraud Fighting Fraud

56. Medicare Summary Notice (MSN)  Part A and Part B MSNs  Shows all your services or supplies –Billed to Medicare in 3-month period –What Medicare paid –What beneficiary owes  Read it carefully –Keep receipts and bills –Keep note of appointments/ services dates –Compare them to MSN

57. MyMedicare.gov Secure site to manage personal information – Review eligibility, entitlement and plan information – Track preventive services – Keep a prescription drug list – Complete Authorization Form Review claims – Don’t have to wait for MSN Click the “Blue Button” to download your data to a text file

58. Medicare Part C & D Plans Marketing Rules Examples – Plans can’t send unwanted emails – Agent’s can’t come to uninvited to home – Can’t call beneficiaries unless already a member – Offer cash to join their plan – Give free meals while trying to sell a plan

59. Telemarketing Fraud Durable Medical Equipment Telemarketing Rules – DME suppliers cannot make unsolicited sales calls Potential scams – Calls or visits from people saying they represent Medicare – Telephone or door-to-door selling techniques – Equipment or service is offered free and then ask for Medicare number for “record keeping purposes” – Told that Medicare will pay for the item or service if provide a Medicare number

60. Arkansas Silver Alert System Modeled after Amber Alert – sign up for instant email messages – https://www.ark.org/asp/alerts/mnaa/silver.php https://www.ark.org/asp/alerts/mnaa/silver.php – Do not have to be missing 24 hours Statewide alerts for missing seniors and/or other adults with Alzheimer’s or other cognitive disorders – AR State Police – AR Sherriff‘s’ Association – AR Police Association