Medicare Improvement for Patients and Providers Act of 2008

Preliminary Summary of Beneficiary and Plan Provisions

July 14th, 2008

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Beneficiary Improvements

Initial Preventive Exam– Eligibility extended from 6 months to one year

after entry to Medicare– Not subject to the deductible – “End of Life” / Advance Directives planning added

Mental Health Co-Pays Equalized Benzodiazepines and barbiturates covered by

Part D

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Medicare Low Income Programs

QI eligibility extended through 2009 LIS/MSP assets equalized for January, 2010 SSA funded to eliminate processing and application barriers;

transmit data to states; states process as MSP application No Part D late penalties for LIS eligibles No estate recovery for Medicare Savings Program In-kind income excluded Life Insurance not considered an asset State Health Insurance (SHIPs), AAAs and ADRC’s

Programs funded for outreach

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Special Needs Plans Provisions SNP authority extended one more year

– through plan year 2010; expires1/1/2011

– moratorium lifted; dual plans have new criteria CMS prohibited from “designating” a plan as a SNP;

all plans must apply. 100% of new enrollees must be in the targeted

enrollment category. The plan may not impose higher cost sharing on the

duals than permitted under Medicaid Provisions effective in 2010

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SNP Provisions: Quality Care Management

– Evidenced based model of care– Appropriate network of providers and specialists– Initial and annual assessment of physical, psychosocial and functional

needs– Individual plan of care identifying goals, objectives, measureable

outcomes and specific benefits – Care management included in CMS periodic audit

Quality Reporting – Plans must provide data to “measure health outcomes and other

measures of quality“– All data shall be at the plan level – May be based on claims data

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SNP Provisions: Dual SNPs

Plan provides prospective enrollees a written statement describing – Benefits and cost sharing protections under Medicaid– Which Medicaid and cost sharing protections are covered by the plan

Plan has a contract with the state to provide benefits or arrange for Medicaid benefits to be provided.– Dual SNPs without a contract may operate, but cannot expand during

2010.– CMS must designate “staff and resources” to assist state

coordination with SNPs

– States are not required to contract with SNPs

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SNP Provisions: Institutional SNPs

I-SNP members in the community must be assessed as needing an institutional level of care – Assessed by an entity other than the

organization – Using the assessment tool of the state of

residence

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Chronic SNPs

“Chronic and disabling” definition amended – co-morbid and medically complex condition(s)– substantially disabling or life threatening– high risk of hospitalization or significant adverse

outcome– require care across domains of care

HHS to convene a panel to determine which conditions meet this definition; AHRQ must serve on the panel.

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Marketing Restrictions

Effective January,1 2009 Contains all provisions of CMS’ proposed rules re:

cold calling, cross selling, limitations on meals, gifts and incentives ( ACAP still reviewing )

Strengthens State Oversight– Agents and brokers must be licensed– Plans must cooperate with state information

requests.

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MedPAC Studies Chronic Care Demonstration

– Feasibility of a standing Chronic Care Practice Network – Report due June 15, 2009 .

Quality Measurement– Recommend how comparable measures of performance and patient experience can be

collected and reported by 2011 that compare quality across plans AND compare FFS to MA plans

– Report Due March 31, 2010 on findings and recommended legislation and administrative actions

Medicare Advantage payments– Costs plans incur as reflected in their bids – Ways to improve the estimates of county level per capita spending including use of VA

services by Medicare beneficiaries – Alternate payment approaches – Report Due March 31, 2010 on findings and recommended legislation and

administrative actions

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The “Pay-For” Provisions

CBO Estimates Savings for All Provisions as $12.5b for 2009-2013; $47.5b for the 2009-2018; overall MA enrollment down 2.3 m from 2013 projections

Small changes in FFS; delay home oxygen volume purchase Phase-out of indirect medical education (IME)– Plan year 2010 MA rates reduced by .06– Reduced an additional .06 each subsequent year till phased out – PACE programs excluded

Adjustment to the Medicare Advantage stabilization fund.– Removes all but one dollar from the fund

PFFS Required to Have Networks– Areas with less than 2 network plans exempted – Network requirements assumed to reduce enrollment

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