Medicare AdvancedBarbara Childers, MSW

Centers for Medicare & Medicaid Services

Session TopicsA.Changes to Medicare as a

result of healthcare reformB.Low Income Subsidy Program

(Extra Help with Drug Plan Costs)

C.Coordination of Benefits

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Session A: Changes to Medicare as a result of healthcare reform

1.Overview and Highlights2.Medicare Updates

Original Medicare Medicare Advantage Medicare Prescription Drug

Coverage DMEPOS

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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

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Medicare Statistics

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

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New Legislation – Health Reform

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

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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

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ACA Section

1001

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 www.pcip.gov or call 1-866-717-5826 (TTY 1-866-561-1604) 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 email PCIPro3@cms.hhs.gov

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

Medicare Claims Limit

Maximum period for submission of Medicare claims – Reduced time period– Now not more than 12 months

Effective January 1, 2010

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ACASection

6404

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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

2011 Part B Amounts

Part B Annual Deductible - $162 Part B Monthly Premium (hold harmless)

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If your income is $85K or less and you paid this in 2010

You pay this in 2011

Notes

$96.40 $96.40$110.50 $110.50 If premium deducted from

Social Security$110.50 $115.40 If premium not deducted

from Social Security$0 $115.40 If new to Medicare in 2011

Income-Related Part B Premium

Effective January 1, 2011, Part B premium income thresholds frozen at 2010 levels through 2019

ACASection

3402

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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 $299.00above $214,000 above $428,000 $369.10*Higher if you have a late enrollment penalty.

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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

ACASection

4104

ACASection

4103

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

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ACASection

6407

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

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ACASection

3132

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

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ACASection

3103

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

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ACASection

3136

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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

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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 + 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

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Medicare Advantage Updates

Enrollment Period Disenrollment Period Cost limits/Plan Payments Complaint system Appeals

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

ACASection

3204

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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

ACASection

3204

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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

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ACASection

3202

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

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ACASection

3203

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

ACASection

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

ACASection

3312

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Medicare Prescription Drug Coverage UpdatesIncome-related PremiumLow-Income Benchmark PremiumCoverage Gap

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

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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

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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)

$85,000.01 – $107,000 $170,000.01 – $214,000 BP + $12.00

$107,000.01 – $160,000 $214,000.01 – $320,000 BP + $31.10

$160,000.01 – $214,000 $320,000.01 – $428,000 BP + $50.10

$214,000.01 or higher $428,000.01 or higher BP + $69.10

ACASection

3308

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

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ACASection

3302

ACASection

3303

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

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

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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

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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

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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.gov

Medicare Advantage enrollees can use suppliers designated by their plan

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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

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Products Included in the Program

1. Oxygen, oxygen equipment, and supplies2. Standard power wheelchairs, scooters 3. Complex rehabilitative power wheelchairs – Group 2 only4. 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 accessories8. Walkers and related accessories9. Support surfaces (Group 2 mattresses/overlays) Miami only

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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

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Identifying Contract Suppliers

Call 1-800-MEDICARE (1-800-633-4227) TTY users call 1-877-486-2048 Visit medicare.gov/supplier

– DMEPOS Supplier Locator Tool

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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

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Round 2

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

Session B: Extra Help with Drug Plan CostsWhat it isHow to qualifyEnrollmentContinuing eligibilityYour costs with Extra Help

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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

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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 www.socialsecurity.gov, or – Call 1-800-772-1213 (TTY 1-800-325-0778)

• Ask for “Application for Help with Medicare Prescription Drug Plan Costs” (SSA-1020)

Income and Resource Limits

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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

2011 amounts

*Higher amounts for Alaska and Hawaii

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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

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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

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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

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Access to LI-NET

Three ways to access the LI-NET program1. Auto Enrollment by CMS‐2. Point of Service (POS) Use3. Submitting a receipt (Rx already paid out-of-pocket)

– During eligible periods

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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

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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

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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

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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

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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)

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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

$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 $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.

Session C: Coordination of Benefits

1.Overview2.Health Coverage Coordination3.Prescription Drug Coverage

Coordination4.Information Sources

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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

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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

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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

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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

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COB Systems

IRS/SSA/CMS Data Match Databases maintained by multiple stakeholders

– Federal agencies– States– Plans– Pharmacies– Assistance programs

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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

2. Health Coverage Coordination

Other Health Care Payers Determining Who Pays First

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Other Possible Health Care Payers

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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

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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

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Determining Who Pays First – Health Coverage

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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)

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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

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

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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

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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

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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

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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

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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

– www.cms.gov/ESRDGeneralInformation

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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

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Other Possible Drug Coverage

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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

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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)

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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

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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

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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

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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

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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

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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 ReformSection

3314

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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

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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

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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

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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

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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

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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

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

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

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

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

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

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

113

114

Information Sources

COBRA Contacts– EGHP benefits administrator– Department of Labor

• 1-866-4-USA-DOL (1-866-487-2365)• www.dol.gov/dol/topic/health-plans/cobra.htm• 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• www.cms.gov/COBRAContinuationofCov

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– www.cms.gov/COBGeneralInformation/– www.cms.gov/COBAgreement/

116

Information Sources

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

– www.medicare.gov/Publications/Pubs/pdf/02179.pdf

117

Information Sources

Medicare/TRICARE Benefit Overview– www.tricare.mil/mybenefit/home/overview/Plans

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

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

• http://www.dol.gov/compliance/laws/comp-blba.htm

– COBRA• www.dol.gov/dol/topic/health-plans/cobra.htm

119

Introduction to Medicare Resource GuideResources Medicare Products

Centers for Medicare & Medicaid Services (CMS)1-800-MEDICARE(1-800-633-4227)(TTY 1-877-486-2048)www.medicare.gov

www.CMS.gov

Social Security1 800 772 1213 ‑ ‑ ‑TTY 1 800 325 0778 ‑ ‑ ‑http://www.socialsecurity.gov/

Railroad Retirement Board1-877-772-5772http://www.rrb.gov/

State Health Insurance Assistance Programs (SHIPs)*

*For telephone numbers call CMS1-800-MEDICARE (1-800-633-4227)1-877-486-2048 for TTY users

http://www.medicare.gov/caregivers/

http://www.HealthCare.gov

http://www.pcip.gov

http://www.Benefits.gov

http://www.Insurekidsnow.gov

Affordable Care Act www.healthcare.gov/center/authorities/patient_protection_affordable_care_act_as_passed.pdf

Medicare & You HandbookCMS Product No. 10050)

Your Medicare Benefits CMS Product No. 10116

Choosing a Medigap Policy: A Guide to Health Insurance for People with MedicareCMS Product No. 02110

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View and order single copies at www.medicare.gov

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