Accountable Care Organizations: What Consumers Should Know Spring 2016

Medicare Rights Center  The Medicare Rights Center is a national, nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities through: Counseling and advocacy Educational programs Public policy initiatives Page 2 © 2016 Medicare Rights Center

National Council on Aging  This toolkit for State Health Insurance Assistance Programs (SHIPs), Area Agencies on Aging (AAAs), and Aging and Disability Resource Centers (ADRCs) was made possible by grant funding from the National Council on Aging Page 3 © 2016 Medicare Rights Center

This training will cover  Medicare basics  Accountable Care Organization (ACO) basics  Why do providers join ACOs?  Receiving care from an ACO Page 4 © 2016 Medicare Rights Center

Medicare basics © 2016 Medicare Rights Center Page 5

 Health insurance for people age 65+ and people who have received Social Security disability benefits for 24 months  People of all income levels are eligible  Run by the federal government but can be provided by private insurance companies that contract with the federal government What is Medicare? Page 6 © 2016 Medicare Rights Center

Medicare eligibility: Age  Who is eligible for Medicare? Those 65+ years who:  Collect or qualify to collect Social Security or Railroad Retirement benefits, or  Are a current U.S. resident, and either A U.S. citizen OR A permanent U.S. resident having lived in the U.S. for 5 continuous years before applying for Medicare  NOTE: The 5 years may be reduced if the individual qualifies for premium-free Medicare Part A Page 7 © 2016 Medicare Rights Center

Medicare eligibility: Disability  Who is eligible for Medicare? Those under 65 years who:  Have been receiving Social Security Disability Insurance (SSDI) for more than 24 months OR  Have been diagnosed with Amyotrophic Lateral Sclerosis (ALS) and have qualified for SSDI OR  Have been diagnosed with End-Stage Renal Disease (ESRD) AND Are getting dialysis treatments or have had a kidney transplant; Have applied for Medicare benefits; and Have been deemed eligible for SSDI, railroad retirement benefits, or are otherwise considered to be fully insured by Social Security Page 8 © 2016 Medicare Rights Center

Parts of Medicare  Medicare benefits are administered through three parts Part A – Hospital/Inpatient benefits Part B – Doctors/Outpatient benefits Part D – Prescription drug benefit  Added 2006  What happened to Part C? Private health plans (e.g., HMO, PPO)  Way to get Parts A, B, and D through one private plan  Known as Medicare Advantage  Not a separate benefit  May cover services not covered by Parts A and B (i.e. Original Medicare), such as vision and dental care © 2016 Medicare Rights Center Page 9

What Part A covers  Inpatient hospital care You are formally admitted into the hospital by a hospital doctor  Inpatient skilled nursing facility (SNF) care You must have spent 3 nights as a hospital inpatient  Home health care You must be considered homebound and need skilled care A doctor must approve and services must be received from a Medicare-certified home health agency  Hospice care You must be considered terminally ill © 2016 Medicare Rights Center Page 10

Part A costs Medicare Part A Costs for 2016 PremiumFree if you have10 years of Social Security work history $226/month if you worked 7.5 to 10 years $411/month if you worked less than 7.5 years Hospital deductible$1,288 in 2016 for each benefit period Hospital copay$322 per day for days 61-90, for each benefit period $644 per day for days (these are 60 non-renewable lifetime reserve days) Skilled nursing facility (SNF) copay $161 per day for days , for each benefit period © 2016 Medicare Rights Center Page 11

What Part B covers  Doctor services Medically necessary outpatient care Preventive care, such as mammograms and colonoscopies  Durable medical equipment (DME) Wheelchairs, walkers, oxygen tanks  Home health care  X-rays, lab tests, ambulance services  Therapy services (physical, occupational, speech)  Mental health/substance abuse treatment © 2016 Medicare Rights Center Page 12

Part B costs Exceptions: no coinsurance or deductible for certain preventive services; outpatient hospital copays cannot exceed the Part A deductible ($1,216) for the year. Note: coinsurance is sometimes called cost-sharing. Medicare Part B Costs for 2016 Annual deductible$166 Monthly premium*$ per month if you paid this amount out of your Social Security last year *Note: The premium is $ if you are new to Medicare in 2016 or if you are not collecting Social Security *People with high incomes pay more for the monthly premium CoinsuranceMedicare pays 80% of Medicare-approved amount for a doctor’s service; beneficiary pays 20% coinsurance © 2016 Medicare Rights Center Page 13

What Medicare does not cover © 2016 Medicare Rights Center Page 14  Most dental care  Most vision care  Routine hearing care  Most foot care  Most long-term care  Alternative medicine  Most care received outside the U.S.  Personal care or custodial care if a person does not also need skilled care  Most non-emergency transportation Note: Medicare Advantage Plans and/or Medicaid may cover some of these services.

ACO basics © 2016 Medicare Rights Center Page 15

What is an ACO?  A group of doctors, hospitals, and/or other health care providers that work together to provide you with coordinated care  ACOs aim to improve the quality of patient care while lowering the costs incurred by Medicare This is achieved by making providers financially accountable for patient health  ACOs receive incentives for giving you better care at a lower cost © 2016 Medicare Rights Center Page 16

Coordinated care  The key way that ACOs are expected to save money is by coordinating patient care  Providers share information and decide treatment plans with input from the patient All of your providers communicate with one another, discuss issues they’ve treated, and build consensus around next steps Medicare also shares your health information/records it has with providers (though patient can ask that Medicare not share such information) You should experience a reduction in repetitive care* © 2016 Medicare Rights Center Page 17

Who can receive care from an ACO?  Anyone with Original Medicare ACOs are not a different kind of health insurance plan (i.e. not a Medicare Advantage Plan, HMO, or Medigap) ACOs are networks of health care providers that work together with the aim of giving you better care at a lower cost  If you have a Medicare Advantage Plan, you cannot join an ACO  You can only be aligned with/assigned to one ACO  Even when in an ACO, you can receive care from providers that are not part of your ACO © 2016 Medicare Rights Center Page 18

ACO-eligible providers & organizations  ACOs may consist of: Individual providers* Group practices Networks of individual practices Hospitals Other Medicare providers and suppliers © 2016 Medicare Rights Center Page 19

Why do providers join ACOs? © 2016 Medicare Rights Center Page 20

Shared savings  Providers who join an ACO and are able to save money are able to share in those savings  The Centers for Medicare & Medicaid services (CMS) will set a benchmark cost for each ACO This benchmark predicts how much it should cost providers to care for their patient If a participating ACO’s costs fall below the benchmark (with positive health outcomes), they have created savings Savings are shared between CMS and providers, meaning that providers have a financial reason to reduce the overall cost of health care while continuing to deliver quality care © 2016 Medicare Rights Center Page 21

Shared losses  ACOs also have the option of sharing in the losses with CMS If total costs are above the benchmark, ACO is responsible for taking on a share of losses, rather than CMS paying them entirely  ACOs that elect to share in the losses are eligible for a greater portion of shared savings Taking on higher risks for greater rewards © 2016 Medicare Rights Center Page 22

Quality performance scoring  Before an ACO can share in any savings, it must demonstrate that it met the quality performance standard  ACOs are graded based on the quality of care you receive  Some of this information will be collected by CMS and some will come from surveys you fill out © 2016 Medicare Rights Center Page 23

Patient experience surveys  If you receive care at an ACO, you may get a survey afterwards asking you Whether you received timely care, appointments, and information How well your providers communicate To rate your provider Whether you had access to specialists If you received adequate health education during your stay About any shared decision-making About your health status following receipt of ACO care If your providers were able to put you in touch with other health care resources © 2016 Medicare Rights Center Page 24

Receiving care from an ACO Page 25 © 2016 Medicare Rights Center

Assignment to an ACO  Two ways to be assigned to/aligned with an ACO: If you receive most of your primary care services from primary care physicians within the ACO If you receive most of your primary care services from specialist physicians or certain non-physician practitioners* within the ACO  You can still choose your own doctors and hospitals ACO assignment is for determining shared savings/losses Assignment does not mean you can only use your ACO, though you cannot use more than one ACO  You can still see non-ACO providers, if you wish Page 26 © 2016 Medicare Rights Center

How are ACOs different?  ACOs avoid unnecessary duplication of care to reduce costs, meaning you may see some of these changes: Better communication among providers (e.g., shared records) Fewer repeated medical tests Fewer forms to complete  In addition, you may be asked to fill out surveys  You should be more involved in making care decisions Shared decision-making Individualized care plans © 2016 Medicare Rights Center Page 27

Shared decision-making  ACOs are required to involve you in the decision- making process  Shared decision-making means ACO professionals must take into account your: Unique needs Preferences Values Priorities  Each ACO may have a different process for shared decision-making Page 28 © 2016 Medicare Rights Center

Individualized care plans  You and your providers should develop individualized care plans that suit your particular needs Meant to improve health outcomes, especially for high-risk patients and those with multiple chronic conditions You should be at the center of the process  Each ACO must submit an individualized care program plan to Medicare This includes criteria for creating individualized care plans for patients Each ACO may have a different process for developing individualized care plans Page 29 © 2016 Medicare Rights Center

My doctor just joined an ACO  You will be notified if your doctor joins an ACO  Notification can be: A letter A conversation with your doctor Written information provided at the medical facility A notice posted within the medical facility  You can always ask your provider if you are unsure or call MEDICARE Page 30 © 2016 Medicare Rights Center

Your rights while using ACOs  Getting care at an ACO does not change your rights, including: Freedom to choose your Medicare provider Ability to seek a second opinion Filing complaints Appeal rights  You also have the right to opt out of the ACO Page 31 © 2016 Medicare Rights Center

Privacy rights  Your ACO providers share your medical information among themselves and receive additional information from Medicare This information is used to give you high-quality, coordinated care  You can request that Medicare not share your medical information with an ACO To do so, call MEDICARE If you ever received or are receiving treatment for drug or alcohol abuse, Medicare will not share your information without your written consent Page 32 © 2016 Medicare Rights Center

For more information and help  Local State Health Insurance Assistance Program (SHIP)  Social Security Administration  Medicare MEDICARE ( )  Medicare Rights Center  National Council on Aging © 2016 Medicare Rights Center Page 33

Medicare Interactive  Medicare Interactive  Web-based compendium developed by Medicare Rights for use as a look-up guide and counseling tool to help people with Medicare Easy to navigate Clear, simple language Answers to Medicare questions and questions about related topics, for example: “How do I choose between a Medicare private health plan (HMO, PPO or PFFS) and Original Medicare?” 2 million annual visits and growing © 2016 Medicare Rights Center Page 34

Medicare Interactive Pro (MI Pro)  Web-based curriculum that empowers professionals to better help clients, patients, employees, retirees, and others navigate Medicare Four levels with four to five courses each, organized by knowledge level Quizzes and downloadable course materials  Builds on 25 years of Medicare Rights Center counseling experience  For details, visit center/courses or contact Jay Johnson at or © 2016 Medicare Rights Center Page 35

 E-newsletter Released every two weeks  Clear answers to frequently asked Medicare questions Links to explore topics more deeply Additional resources and health tips Co-branding available  Sign up at mrc/newsletter-signup.phpwww.medicarerights.org/about- mrc/newsletter-signup.php © 2016 Medicare Rights Center Page 36