mippa: more medicare changes for minnesota

MIPPA: More Medicare

Changes for Minnesota

Kelli Jo

Greiner

MN Board

on Aging

Medicare Improvement for Patients and Providers Act of 2008 (MIPPA)

• Congress overrode President’s veto on July 15, 2008

• MIPPA contains provisions that affect Medicare Part A, Medicare Part B, Medicare Advantage and Medicare Part D

• Major Medicare legislation

MIPPA Part A Key Provisions• Extend Medicare Rural Hospital Flexibility

Program (FLEX) through 9/30/10• Provide new authority for states to improve

access to mental health services for veterans in crisis and other residents of rural areas.

• Establish a demo for development and testing of new community health integration models in certain rural counties

• Increases payments to Community Health Centers

MIPPA Part B Key Provisions: Physician

• Cancelled 10.6 cut in physician reimbursement (18 month reprieve but issue will return; potential 21% cut in 2010)

• Increase bonuses paid to providers who measure and report on quality of care (PQRI)

• Physicians use e-prescribing will receive a 2% Medicare payment bonus in 2010 and 2011; phased down after 2011.

• Physicians who do not use e-prescribing by 2012 will be penalized by decrease in payments (1% in 2012; 1.5 % in 2013 and 2% in 2014 and beyond)

• Development of a physician feedback program by CMS

MIPPA Part B Key Provisions: Value Based Purchasing

and E-prescribing• Develop a plan to transition to a value-based purchasing program for

Medicare professional services.• Physicians using e-prescribing will receive a 2% Medicare payment

bonus in 2010 and 2011; phased down after 2011.• Physicians who do not use e-prescribing by 2012 will be penalized by

decrease in payments (1% in 2012; 1.5 % in 2013 and 2% in 2014 and beyond)

MIPPA Part B Key Provisions:Welcome to Medicare Physical

• Waives Medicare Part B deductible• Extends time frame for physical from 6

months to 1 year following Part B enrollment

• Adds new services to the Welcome to Medicare physical including additional preventive services (to be determined) and end of life planning.

MIPPA Part B Key Provisions: Preventive Benefits

• Provides Medicare coverage for “additional preventive services” that identify medical conditions or risk factors recommended by the U.S Preventive Services Task Force.

MIPPA and Part B Key Provisions: Mental Health Parity

• Beginning in 2010, over a 5 year period, Medicare coinsurance for mental health services will be reduced to the same level as other Medicare outpatient services (from 50% to 20%)

MIPPA and Part B Key Provisions

• Provides an 18 month extension (through 2009) of the exceptions process for annual limit on Medicare PT, OT and ST services. – Current limit is $1,810

• Delays implementation of the Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) to 1/1/10

MIPPA and Part B Key Provisions

• Reinstates add-on payment for ground ambulance services from 7/1/08-12/31/09– 3% rural and 2% urban

• Repeals the competitive bidding demonstration for clinical lab services

• Provides funding for kidney disease education and awareness programs

MIPPA and Chronic Disease Provisions

• MedPAC is required to study and report on improving chronic care programs.

• Development of a program to fight chronic kidney disease• Increase payments for renal dialysis services• Bundle payments for dialysis drugs, testing supplies and

other items used in the treatment of ESRD• Expand the number of eligible telehealth sites in rural

areas• MedPAC to conduct a study on the merits of establishing a

Medicare Chronic Care Practice Research Network to test new models of care coordination

• Adds new funding to the Medical Home Demonstration Project

MIPPA and Medicare Advantage (Part C):

• Prohibits marketing of plans in physician offices• Each MA plan will have to indicate the type of plan

in plan name ( ex: Advantage Silver will have to be renamed to Advantage PFFS Plan)

• Directs MedPAC to study and make recommendations concerning alternate payment formulas for MA plans

• By March 2010, MedPAC to study how MA plans and Original Medicare can be compared based on performance and patient experience.


• Beginning January 2011, require MA-PFFS plans to have adequate health care provider networks in counties where 2 or more non-PFFS plans exist

• Employer PFFS plans will be required in 2011 to do this regardless of other plans

• Requires MA-PFFS and MSA plans to have Quality Improvement Programs in place


• Prohibit MA-PFFS plans from deeming without negotiating an actual contract for payment and care with the provider.

• Beginning January 2010, prohibits Medicare Advantage and Part D plans from – Door to door sales– Cold calling– Free meals– Cross selling of non health-related products– Limitations on commissions and gifts


• Extends existing MA-SNP through 2010 but prohibits designating new MA-SNPs.

• In 2010, all SNPs must have evidence based model of care– Initial assessment– Annual reassessment– Plan that identifies goals and objectives, including

measurable outcomes, specific services and benefits to be provided

• MA-SNPs must also provide for the collection, analysis and reporting of data to measure health outcomes and other measures of quality.

• For duals,in 2010, prohibits MA-SNPs from requiring additional bene cost sharing above what they would pay if they remained in Original Medicare and Medicaid

MIPPA Medicare Key Provisions: Low income beneficiaries

• Extends the QI Medicare Savings Program through 12/31/10 (ARRA)

• Increases the Medicare Savings Program asset limitation to Part D LIS resource amount which changes annually

– In MN, MSP asset limit is $10,000 single/$20,000 couple• Eliminates estate recovery for Medicare Savings Programs• Translates the Medicare Savings Program model application

form into 10 non-English languages• Requires SSA to provide Medicare Savings Program

applications to individuals applying for Medicare, includes providing assistance in completing applications.

MIPPA Medicare Part D Key Provisions: Low income Subsidy

• Removes Part D late enrollment penalties for people found eligible for the LIS

• Exempts life insurance and in-kind support and maintenance (ISM) from income and resources when determining LIS eligibility (questions will be removed from LIS application)

• Provides a beneficiary’s right to federal court review for denials of LIS

MIPPA Medicare Part D Key Provisions

• Beginning January 2012, Medicare Part D coverage for barbiturates and benzodiazepines will be permitted

• Codifies the requirement for Part D plans to cover most drugs in certain important classes of drugs

– Anti-cancer– Immunosuppresants– HIV/AIDS drugs– Anti-convulsants– Anti-psychotics– Anti-depressants

• Requires CMS to define any exceptions to this policy

MIPPA Medicare Part D Key Provisions

• Requires drug plans to pay “clean claims” submitted electronically within 14 days; non electronic claims must be paid within 30 days. Claims paid after that time will be subject to interest

• Requires drug plans to update drug pricing standards for pharmacy reimbursement at least weekly. An initial update on January 1 of each year is required to accurately reflect the market price of acquiring the drug.

• Effective in 2009, clarifies that a “medically accepted indication” for Part D covered drug is defined as any use that is supported by one or more citations in drug compendia or such use is medically accepted based upon supportive clinical evidence in peer reviewed medical literature.

Other Key MIPPA Provisions • Two new types of Medicare Supplements

(Medigap) will be offered• Cardiac and Pulmonary rehabilitation services will

be covered• Within 2 years, requires the OIG to report on the

extent to which Medicare providers follow rules regarding discrimination against beneficiaries with LEP

• Providers conducting MRI, CT and nuclear medicine/PET must be accredited by 1/1/12

2010 Medicare Update

• Up-to-date information!

PLEASE NOTE

• 2010 Medicare Part A and Part B cost sharing information has not been made public yet

• 2010 Part D benchmark and premiums have not been made public yet

2010 Medicare Part D Preview

10/1/09: Mailings and Marketing begin

11/15/09: Open Enrollment begins 12/31/09: Open Enrollment ends

Annual Coordinated Election Period (AEP)

• People can join, drop, or switch – Prescription drug plans– Medicare Advantage plans– Medicare Advantage plans with prescription drug

coverage

Minnesota Amounts for 2010

• National Average Part D Basic Premium: $?• MN Benchmark amount: $?• MA capitation rate in MN

– Ranges from $? per month per bene

What Color is the Letter?

• GREY: Loss of Extra Help (Sept. 2009) CMS• ORANGE: Change in co-payment level (October 2009) CMS• BLUE version 1: Reassignment due to plan leaving market CMS

– (October 30, 2009) CMS will reassign to new plan• BLUE version 2: Current plan above benchmark in 2009; CMS

– CMS will reassign to new benchmark plan for 2010• TAN: LIS who chose plan on own and will no longer be benchmark plan; CMS

– CMS will not reassign to a new benchmark plan for 2010• PURPLE: Deemed Status for 2010 approved CMS• YELLOW: Auto-enrollment notice (ongoing) CMS• GREEN: Facilitated enrollment (ongoing) CMS

Part 2: Mailings From the Plans

• October 1, 2009: Plans begin marketing to beneficiaries• By October 2, 2009: Plans leaving market in 2008 issue

termination letters to current enrollees.• By October 31, 2009: Plans notify beneficiaries of formulary,

benefit and premium changes for 2009

Medicare Part D Standard Benefit2006 2007 2008 2009 2010

Deductible $250 $265 $275 $295 $310

Initial Coverage Limit

$2,250 $2,400 $2,510 $2,700 $2,830

Out of pocket (OOP) threshold

$3,600 $3,850 $4,050 $4,350 $4,550

Total Covered Drugs at OOP

$5,100 $5,451.25 $5,726.25 $6,153.75 $6,440

Copays at Catastrophic Level

$2/generic$5/brand

$2.15/generic$5.35/brand



$2.50/generic $6.30/brand

5%95% Catastrophic Benefit

100%

75%25%

$295 Deductible

Monthly Premium

$2,830.01 - $6,440

$310.01 - $2,830

$.01 - $310

Over $6,440 (copays of $2.50/$6.30)

Drug Costs

Beneficiary CostsPart D Plan

2010Part D Standard Benefit

No Extra Help (LIS)

Catastrophic BenefitCo-Pays $2.50/$6.30

15% 85%

$60 Deductible

Sliding Scale Premiums

$62.01- $6,440

$.01 -$62

Over $6,440

Drug Costs

Beneficiary Costs

Part D Plan

2010Part D Partial Extra Help (LIS)

•Lower Premiums•Lower Deductible

•Lower Coinsurance•No Doughnut Hole

will vary

Benchmark• A prescription drug plan with a monthly premium at or

below the low income premium subsidy amount.• MN Benchmark amount in 2009 = $33.19• Dual eligible premiums for these plans are completely

covered by Extra Help– Duals can enroll in non-benchmark plans but will

have out of pocket costs for premium

Catastrophic Benefit100% PlanNo co-pays

Co-Pays

Co-Pays

$1.10/$3.30 <100% FPL

$2.50/$6.30 >100% FPL

No premiumsNo deductibles

$.01 - $6,440

Over $6,440

Beneficiary Costs

Part D Plan

2010 Part D Full Extra Help (LIS)No Premiums if in Benchmark PlanNo DeductibleNo CoinsuranceNo Doughnut HoleNo monthly cap on co-pays

Drug Costs

Full Dual Eligible Co-pays2006 2007 2008 2009 2010

Copays for institutionalized FBDE (SNF and ICF/MR) does not apply to assisted living

$0 $0 $0 $0 $0

Income < 100% FPG

$1/generic$3/brand name

$1/generic$3.10/brand

name


name


name


name

Income > 100% FPG

$2/generic$5/brand name


name


name


name


name

REGION 19

Medicare Advantage in MN

• Coordinated Care Plans (Local HMOs and PPO)• Cost Based Plans with Part D• Regional Preferred Provider Organizations• Private Fee-for-Service• Special Needs Plans• Medicare Medical Savings Accounts

Medicare Advantage Option 1 in Minnesota (Medicare A, B and D benefits)

• These plans provide:

– Medicare A benefits– Medicare B benefits– Medicare Part D benefits

• Option 1 includes:– Medicare Advantage HMO/Point of Service– Cost plans– Medicare Advantage Private-Fee-For- Service– Medicare Advantage Regional Preferred Provider

Organization

Medicare Advantage Option 2 in Minnesota (Medicare A and B benefits)

• These plans provide

– Medicare A

– Medicare B

– No part D• May enroll in a stand alone PDP only under Cost plan and PFFS

• Option 2 includes:

– Medicare Advantage HMO/Point of Service

– Cost plans

– Medicare Advantage Private-Fee-For Service

Medicare Advantage Option 3 in Minnesota (Medicare A, B, D and all Medicaid)

• These plans provide all

– Medicare A benefits– Medicare B benefits– Medicare Part D benefits– Most Medicaid benefits

• Option 3 includes:– Medicare Advantage Special Needs

Plans (MA-SNP: MSHO and MnDHO)

Medicare Advantage Option 4 in Minnesota

• These plans provide all– Medicare A benefits– Medicare B benefits– Medicare Part D benefits– Some Medicaid benefits

• Only available to beneficiaries age 18-64

• Option 4 includes– Medicare Advantage Special Needs Basic

Care Plans (MA-SNBC)

Medicare Advantage Option 5 in Minnesota (Medicare A and B, deductible must be paid first)

• These plans will pay for Medicare A and B services once a high annual deductible is met

– Deductible amount varies from plan– Once deductible is reached , the MSA plan will

cover most costs of Part A and B services– No Part D coverage

• Option 5 includes

– Medicare Advantage Medical Savings Accounts (MA-MSA)

MA Open Enrollment Period Limits

If coverage is Can use OEP to get Cannot use OEP to get

Medicare Advantage with prescription drug coverage (MA-PD)

A different MA-PD or Original Medicare + PDP or MA-PFFS + PDP

MA-only or Original Medicare only (cannot drop drug coverage)

Medicare Advantage with no prescription drug coverage (MA-only)

A different MA-only or Original Medicare only

MA-PD or Original Medicare + PDP (cannot add drug coverage)

MA-only PFFS + PDP MA-PD or different MA-only PFFS and same PDP or Original Medicare and same PDP

MA-only or Original Medicare only (cannot drop drug coverage)

Original Medicare and a prescription drug plan (PDP)

MA-PD or MA-PFFS and the same PDP

MA-only or A different PDP to use with Original Medicare (cannot drop drug coverage)

Original Medicare only MA-only MAPD or Original Medicare + PDP (cannot add drug coverage)

MSA N/A The MA OEP does not apply to enroll into or disenrollment from an MSA plan

Minnesota: The Numbers (July 2009)

• Total MN Medicare population = 746,505– 282,008 enrolled in Medicare Advantage plan– 38,786 enrolled in a Special Needs

Medicare Advantage Plan (38,635 are dually eligible)

– 43% of MN Medicare population enrolled in a Medicare Advantage option as of July, 2009

2010 Proposed Changes

• Specialty Tier Threshold• Transition Notices in LTC• Posting of Prior Authorization and Step Therapy• Medication Therapy Management Program

Requirements• Reference Based Pricing• Reassignment of LIS • Retroactive Auto-enrollment of

full benefit dual eligibles demo

2010 Possibilities

• Some MA-PFFS plans may leave the market• Some MA-SNP may no longer include Medicare benefits• Some Part D plans may leave the market• Some new plans may enter the market• Premiums may increase• Benchmark may increase• Formulary changes

What is the SHIP?• State Health Insurance Assistance Program• 400 certified volunteers• Medicare Experts located in your community• State based program that provides

– One to one counseling and assistance to people with Medicare and their families

– Free service provided through phone, in person, community events and media activities

– Grants provided by CMS– MBA Senior LinkAge Line®

has been the designated SHIP for MN since 1993– Available in all 87 counties of Minnesota– 54 SHIPs in United States

• Most are in State Units on Aging• Some are located within State Insurance Dept.

HELP IS HERE

• Senior LinkAge Line® (Federally designated MN SHIP)– 1-800-333-2433– Health Care Choices produced by MN Board on Aging

• Disability Linkage Line®– 1-866-333-2466

• www.cms.hhs.gov• www.Medicare.gov• Live Chat now available at www.minnesotahelp.info

http://www.cms.hhs.gov/

http://www.medicare.gov/

http://www.minnesotahelp.info/

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Need more Information, Answers or Help?

• Senior LinkAge Line® 1-800-333-2433• Disability Linkage Line ® 1-866-333-2466• Veterans Linkage Line 1-888-546-5838 (LinkVet)• www.cms.hhs.gov• www.Medicare.gov 1-800-MEDICARE• www.socialsecurity.gov 1-800-772-1213• www.MinnesotaHelp.info

http://www.cms.hhs.gov/

http://www.medicare.gov/

http://www.socialsecurity.gov/

http://www.minnesotahelp.info/

QUESTIONS?

• CONTACT INFORMATION– Kelli Jo Greiner– 651-431-2581– [email protected]

mippa: more medicare changes for minnesota

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