Transcript Bio Presentation - Michigan Poverty Law Program

Health Care Reform &
Medicare: The Basics
(and a little more)
Leslie Fried, Esq.
ABA Commission on Law & Aging
October 1, 2010
Leslie Fried, ABA Commission on Law
& Aging
Brief Legislative History of Patient Protection
& Affordable Care Act of 2010
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Over a year of various proposals and debate
Senate passed it on December 24, 2009
House passed Senate version 3/21/10
President signed into law, 3/23/10
House passed Reconciliation bill and sent to
Senate on 3/21/10
Senate made a couple of changes, sent back to
House, which passed it again on 3/25/10
President signed the reconciliation into law
3/30/10
October 1, 2010
Leslie Fried, ABA Commission on Law
& Aging
2010 & 2011: Medicare Overview
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Part D: Rebate (2010) and beginning gradual
closure of the coverage gap (2011)
Annual wellness visit and personalized
prevention assessment plan; eliminate cost
sharing on some preventive services (2011)
Restructure payments to Medicare Advantage
(MA) plans (2011)
Reduce market basket updates to institutional
providers, including nursing facilities (2010)
Establish new Center for Innovation (2011)
October 1, 2010
Leslie Fried, ABA Commission on Law
& Aging
Part D: Phased in subsidies of the
coverage gap
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Phased in subsidies in the coverage gap
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2010 only - $250 rebate
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2011-2020 - phased in subsidies
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Generic drugs: government subsidy 7% in 2011 increases to
75% by 2020.
Brand drugs:
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October 1, 2010
50 percent discount from pharmaceutical manufacturers
beginning 2011.
2013-2020 - government subsidy of 2.5% in 2013
increases to 25% by 2020
Leslie Fried, ABA Commission on Law
& Aging
$250 Rebate Check
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Who is eligible? Beneficiaries who are:
 Enrolled in a Part D drug plan
 Enters the coverage gap in 2010
 Not receiving LIS or Medicaid benefits
Beneficiaries do not have to do anything to get
the check.
Lag time of 45 days to 4 months; Paper checks
mailed to address on file with the SSA
October 1, 2010
Leslie Fried, ABA Commission on Law
& Aging
Medicare’s “Standard” Drug Benefit in 2020
5% paid by
enrollee
15% paid by plan; 80% paid by Medicare
25%
paid by
enrollee
Catastrophic
coverage
Brands:
50% discount
25% paid by plan
Generics:
75% paid by plan
Initial coverage
limit
25%
paid by
enrollee
75%
paid by
plan
100% paid by enrollee
Deductible
SOURCE: Kaiser Family Foundation illustration of standard Medicare drug benefit for 2020 under the Patient Protection
and Affordable Care Act (P.L. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010.
Cost Sharing for Brand-Name Drugs in the
Medicare Part D Coverage Gap, 2010-2020
minus
$250
rebate
SOURCE: Kaiser Family Foundation analysis of the standard Medicare drug benefit under the Patient Protection and
Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010.
Cost Sharing for Generic Drugs in the
Medicare Part D Coverage Gap, 2010-2020
SOURCE: Kaiser Family Foundation analysis of the standard Medicare drug benefit under the Patient Protection and
Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010.
The Weeds
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Definition of covered Part D drug will
change:
All Part D drugs must be covered by a
manufacturer discount agreement with
Secretary
 Agreement applies to all manufacturers for all
its drugs
 Exceptions (CMS hopes not to apply this authority)
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Essential to the health of Part D enrollees
 Extenuating circumstances for 2011
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October 1, 2010
Leslie Fried, ABA Commission on Law
& Aging
More Weeds
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Covered in the “discount” – negotiated price of
the drugs, including sales tax and vaccine
administration.
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Not the dispensing fee except for straddle claims
Discount will be provided at the pharmacy
counter (Point of Service)
Manufacturers will make discount payments
directly to plans within 14 days of invoice from
CMS contractor
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CMS cannot touch the money
October 1, 2010
Leslie Fried, ABA Commission on Law
& Aging
Getting the Discount
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To get the discount during the coverage
gap:
Enrolled in a PDP or MA-PD plan
 Drug must be on the formulary, or the
enrollee obtained an exception
 The enrollee is not LIS or Medicaid
 Enrollee is partly or wholly in the coverage
gap
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October 1, 2010
Leslie Fried, ABA Commission on Law
& Aging
Access to Information
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For Prescribers: if a manufacturer does not sign
an agreement, none of its drugs are Part D
drugs
At Pharmacy: Enrollees should receive better
information on what is covered, how much is
discounted
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Confusing if a straddle claim; or if enrollee has
supplemental coverage which will pay first, before
discount; or if other health benefits (eg SPAP) which
pays after discount
Coverage Determinations and Appeals apply
October 1, 2010
Leslie Fried, ABA Commission on Law
& Aging
Important Issues for
Patient/Beneficiary Advocates
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Messaging: Need to provide information in
simple and understandable language
New and improved EOB: enrollees can
follow status of TrOOP
Accuracy of Information: especially about
drug prices
Privacy: important that enrollees
information is protected
October 1, 2010
Leslie Fried, ABA Commission on Law
& Aging
Annual Wellness Visit &
Preventive Services
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Provides an annual wellness visit and personalized
prevention plan services as of 1/2011
Every 12 months, starting 12 months after Welcome to
Medicare exam
No cost-sharing for visit
Includes personal risk assessment & prevention plan
services
(exam for height, weigh, BMI, blood pressure, detection for cognitive
impairment, updates for medical and family history, lost of risk factors, screening
schedule for 5-10 years and more)
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Eliminates cost-sharing for some preventive services,
effective 1/2011
October 1, 2010
Leslie Fried, ABA Commission on Law
& Aging
Medicare 2011 Part D Plans
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Open enrollment for 2011 play year is November
15 – December 31
Average PDP plans premium increased by $1
Average MA-PDP plans decreased by 1%
Reduction in plans this year
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1.2 million individuals affected by non-renewals and
will have an SEP until 1/21/11
600,000 LIS will have to be re-assigned
For state by state fact sheets, go to
www.cms.gov/center/openenrollment.asp
October 1, 2010
Leslie Fried, ABA Commission on Law
& Aging
New: Medicare Disenrollment
Period
January 1 – February 14, 2011
 Medicare beneficiaries can disenroll
from Medicare Advantage plans and
return to Original Medicare
 Beneficiaries will be able to join a
Medicare PDP at this time
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October 1, 2010
Leslie Fried, ABA Commission on Law
& Aging
2011: Cost Containment
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New Center for Medicare & Medicaid Innovation
within CMS
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Will test, evaluate and expand different payment
structures to foster patient-centered care and care
coordination across treatment centers and slow cost
growth
Freeze income threshold for income-related Part
B premiums at 2010 level; Ties Medicare Part D
premiums to income for those with incomes
above $85K individual/$170K couple
October 1, 2010
Leslie Fried, ABA Commission on Law
& Aging
2011: Medicare Advantage
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Prohibits MA plans from imposing higher cost
sharing for some Medicare covered benefits
Restructure payment to plans by phasing
payments to different percentages of Medicare
FFS
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2010 average is 114% of FFS
Medicare 2011 payments to plans frozen at 2010
rates
Cuts in MA payments but not in mandated
services (could result in cut in extra/optional
benefits)
October 1, 2010
Leslie Fried, ABA Commission on Law
& Aging
2012 and beyond
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Annual Part D and MA plan enrollment period shifts
backward to October 15 – December 7, 2011 for 2012
plan year
A variety of models, demonstration and pilot programs,
to promote quality care and cared coordination including
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Accountable Care Organizations – take responsibility for costs
and quality of care of patients
Medical homes for individuals with chronic conditions
Medicare Hospice Concurrent Care Demo
Medicare Independence at Home demo. Which provides highneed beneficiaries with primary care services in their homes
Bundled payments per episode of care pilot
Medicare Shared Savings Program to coordinate services under
Parts A and B
October 1, 2010
Leslie Fried, ABA Commission on Law
& Aging
Independent Payment
Advisory Board
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15 members, leading experts, appointed by the
president for 6-year terms, and 3 HHS officials
Membership on IPAB is a full-time job
Makes recommendations to Congress to reduce
Medicare spending if spending exceeds target
growth rate; which Congress must consider
under an expedited procedure
Makes annual detailed reports to Congress on
health care costs, access and more
October 1, 2010
Leslie Fried, ABA Commission on Law
& Aging
Changes for Nursing Facility
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Requires nursing home disclose their owners
Establishes Quality Assurance Performance
Improvement Program to improve quality
assurance standards
Report information about how well nursing
homes are staffed and direct care staff costs
Provides training for workers who care for
residents with dementia and to prevent abuse
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Initial training of 75 hours
October 1, 2010
Leslie Fried, ABA Commission on Law
& Aging
Equal Justice Act
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Establishes Elder Justice Coordinating Council to
coordinate activities (govt and private agencies)
relating to elder abuse, neglect and exploitation
Additional funding for Adult Protective Services
(APS) and LTC Ombudsman programs
Establish and support forensic centers relating to
elder abuse, neglect and exploitation
Grants to enhance LTC staffing
October 1, 2010
Leslie Fried, ABA Commission on Law
& Aging
CLASS Act
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Establishes new public LTC insurance
program
Purchase of community living assistance
services and supports by individuals with
functional impairments
Financed through voluntary payroll
deductions or contributions; automatic
enrollment with opt-out
5 year vesting
October 1, 2010
Leslie Fried, ABA Commission on Law
& Aging
CLASS Act
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Enrollees eligible for benefits after meeting
disability criteria that is expected to last at least
90 days
If eligible, a cash benefit will be paid based on
functional ability, averaging not less than $50 a
day
Secy of HHS required to establish premiums to
ensure solvency for 75 years
Treated in same manner as a LTC insurance
policy
October 1, 2010
Leslie Fried, ABA Commission on Law
& Aging
Final Thoughts about Health
Reform
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Implementation through guidance and
regulations is where the rubber hits the
road
CBO Projections – extends the Medicare
Trust fund by 12 years to 2029 and will
save $124 billion over 10 years
Important provisions for older adults and
provide support for the continuum of care
for seniors
October 1, 2010
Leslie Fried, ABA Commission on Law
& Aging
Hot Issue: Hospital
Observation Cases on the Rise
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Observation status are patients who are in
the hospital but treated as outpatient
rather than inpatient
Should be limited to 24 – 48 hours but
increasing trend of much longer
Results in higher cost-sharing for patient
Outpatient time doesn’t count toward 3
days for SNF care
October 1, 2010
Leslie Fried, ABA Commission on Law
& Aging
Hot Issue: Improvement
Standard
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For years, individuals with chronic,
debilitating and degenerative conditions
denied skilled therapy if patient’s condition
won’t “improve”
Federal law supports coverage of
maintenance therapy; restoration not
required
Center for Medicare Advocacy is looking
for plaintiffs for a lawsuit
October 1, 2010
Leslie Fried, ABA Commission on Law
& Aging