Total Medicare beneficiaries (2011): 791,566 (15% of total population)

Total Medicare Advantage enrollment (2011): 349,715 (44% of Medicare population)

Part D Low-Income Subsidy enrollees (2010): 134,119

Number of Medicare Rx Drug Plans (2011): 30

05/05/2011Getting Started 2

Part D Rx Drug Coverage Gap Discounts as of August 5, 2011:

◦ 12,922 Minnesota beneficiaries with gap discount

◦ $522 = average gap discount amount per beneficiary

◦ $6,750,209 = total discount amount in MN

05/05/2011Getting Started 3

Covered by Medicare Part B Covered by Original Medicare, MA and other

plans Find problems early, when treatment works

best Coverage based on

◦ Age◦ Gender◦ Medical history

04/01/20114 7

Original Medicare◦ Pay nothing from provider who accepts

assignment May require coinsurance for office visit

◦ May pay more from provider who does not accept assignment

Medicare Advantage or other Medicare plans may require copayment

5 04/01/2011 7

Original Medicare – Part B deductible/copayment for these screenings eliminated (certain coverage criteria apply)

◦ Bone mass measurement◦ Cervical cancer screening, including Pap smear tests & pelvic exams◦ Cholesterol and other cardiovascular screenings◦ Colorectal cancer screening (except for barium enemas)◦ Diabetes screening◦ Flu shot, pneumonia shot, and the hepatitis B shot◦ HIV screening for people at increased risk or who ask for the test◦ Mammograms◦ Medical nutrition therapy to help people manage diabetes or kidney

disease◦ Prostate cancer screening (except digital rectal examinations)

6 04/01/2011

New in 2011 Available every 12 months– Blood pressure, height and weight measurements– Personalized prevention plan–Written screening schedule– Health advice – Referrals for health education and preventive

counseling

7 04/01/2011

Flu can lead to pneumonia–Dangerous for people 50 and over

Flu viruses are always changing– Shot updated annually for most current flu viruses

Flu shot covered for all people with Medicare

No copayment or deductible with Original Medicare

05/05/2011Getting Started 8

06/10/2010 9

You get Medicare-covered services through the plan◦ All Part A and Part B covered services◦ Some plans may provide additional benefits

Most plans include prescription drug coverage◦ Part D

You may have to go to network doctors or hospitals

MA may be different than Original Medicare◦ Benefits and cost-sharing

Medicare Advantage Plans and Other Medicare Plans

If you are accepted as a participant in an approved clinical research study◦ Your costs may be lower◦ Some costs may be covered by your plan

(Section 2101) MA Plans can’t charge more than Original

Medicare◦ For certain services, e.g., chemotherapy, dialysis,

and skilled nursing facility care (Section 3202) MA Plans must limit your out-of-pocket costs

◦ For Part A and part B covered services (Section 3202)

06/10/2010Medicare Advantage Plans and

Other Medicare Plans 10

Health Reform

Formerly called the Annual Election Period Changes in 2011

◦ October 15 – December 7◦ Coverage begins January 1, 2011

Joined/switched Medicare Advantage Plan Joined/switched Medicare Prescription Drug Plan

11

ACA

06/10/2010 12Medicare Advantage Plans and

Other Medicare Plans

When you can Join or Switch MA PlansNew in 2011Annual Disenrollment Period

Can leave an MA plan and switch to

Original Medicare Between January 1–February 14–Coverage begins the first of the month after you switch

If you make this change you also may join a Medicare Prescription Drug Plan to add drug coverage –Between January 1-February 14–Drug coverage begins the first of the month after the plan gets enrollment form

Health Refor

mSectio

n3204

Can enroll in 5-Star MA, MAPD or PDP plan Enroll at any point during the year

◦once per year New plan starts first of month after enrolled Effective December 8, 2011

13

5 Stars Excellent performance 4 Stars Above average performance 3 Stars Average performance 2 Stars Below average performance 1 Star Poor performance

06/10/2010Medicare Advantage Plans and

Other Medicare Plans 14

Secretary not required to accept any or every bid submitted by an MA organization

Secretary can deny a bid◦ Proposes significant increases in cost-sharing or ◦ Decreases benefits offered by the plan

Applies to bids from prescription PDP sponsors

Effective for contract years on/after January 1, 2011  ACA

Section

3209

16

Medicare Part D Drug plans approved by Medicare Run by private companies Available to everyone with Medicare Must be enrolled in a plan to get coverage Coverage provided through–Medicare Prescription Drug Plans (PDPs)–Medicare Advantage (MA-PDs) and other

Medicare plans with Rx coverage

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

17

ACA

Must occur at point-of-saleDiscounts can be provided at POS only if the entity adjudicating the electronic pharmacy claim has the information necessary to determine at that point in time:

◦ the drug is a discountable drug; ◦ the beneficiary is eligible for the discount; ◦ the claim is wholly or partially in the coverage gap;

and ◦ The amount of the discount, taking into

consideration plan supplemental benefits that pay first.

18

In addition to the 50 % manufacturer’s discount, beginning in 2013 plans will start providing an additional brand benefit◦ Increases incrementally over 7 years

Along with the manufacturer discount, this brand benefit looks to increase the total brand discount to 75% during the coverage gap by the year 2020

19

20

The coinsurance under basic prescription drug coverage will be reduced for generic covered Part D drugs purchased during the coverage plan gap phase

Coinsurance charged to beneficiary will be 93% of generic drug cost in 2011

21

22

http://www.kff.org/healthreform/upload/8059.pdf

23

24http://www.kff.org/healthreform/upload/8059.pdf

25http://www.kff.org/healthreform/upload/8059.pdf

Health insurance coverage for individuals under 65 with a pre-existing condition◦ May be a valuable option for family member or

spouse who is not yet 65 Eligibility criteria

◦ Uninsured for at least 6 months◦ Have a pre-existing condition◦ US citizen or legal resident

Visit www.pcip.gov for more information

05/05/2011Getting Started 26

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