2. Overview of CMS

3. CMS Headquarters
The Centers for Medicare & Medicaid Services (CMS) is the federal agency that administers the Medicare, Medicaid and Children’s Health Insurance Program (CHIP). CMS headquarters is in Baltimore, Maryland.

4. DHHS Secretary Kathleen Sebelius
CMS is under the leadership of the Department of Health and Human Services (DHHS). DHHS is the United States government principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves.
Kathleen Sebelius was confirmed as the Secretary of the Department of Health and Human Services April 28, 2009.
Most recently, Kathleen Sebelius was the Governor of Kansas. She served on the National Governors Association’s Executive Committee and was co-chair of the National Governors Association’s initiative, Securing a Clean Energy Future. Sebelius is the immediate past chair of the Education Commission of the States and as past chair of the Democratic Governors Association, she currently serves on the DGA Executive Committee.
Married to husband, Gary, a federal magistrate judge, for 34 years, they have two sons: Ned and John. Sebelius is the first daughter of a Governor (John Gilligan, Ohio, ) in U.S. history to be elected to that same position.
Kathleen Sebelius

5. CMS Administrator Dr. Donald Berwick
Donald M. Berwick, M.D., M.P.P., is the Administrator for the Centers for Medicare and Medicaid Services (CMS). As Administrator, Dr. Berwick oversees the Medicare, Medicaid, and Children’s Health Insurance Program (CHIP). Together, these programs provide care to nearly one in three Americans.
Before assuming leadership of CMS, Dr. Berwick was President and Chief Executive Officer of the Institute for Healthcare Improvement, Clinical Professor of Pediatrics and Health Care Policy at the Harvard Medical School, and Professor of Health Policy and Management at the Harvard School of Public Health. He also is a pediatrician, adjunct staff in the Department of Medicine at Boston’s Children’s Hospital and a consultant in pediatrics at Massachusetts General Hospital.
Dr. Berwick has served as Chair of the National Advisory Council of the Agency for Healthcare Research and Quality, and as an elected member of the Institute of Medicine (IOM). He also served on the IOM’s governing Council from 2002 to In 1997 and 1998, he was appointed by President Clinton to serve on the Advisory Commission on Consumer Protection and Quality in the Healthcare Industry.
Dr. Berwick is the recipient of numerous awards and honors for his work, including the 1999 Ernest A. Codman Award, the 2001 Alfred I. DuPont Award for excellence in children’s health care from Nemours, the 2002 American Hospital Association’s Award of Honor, the 2006 John M. Eisenberg Patient Safety and Quality Award for Individual Achievement from the National Quality Forum and the Joint Commission on Accreditation of Healthcare Organizations, the 2007 William B. Graham Prize for Health Services Research, and the 2007 Heinz Award for Public Policy from the Heinz Family Foundation.
A summa cum laude graduate of Harvard College, Dr. Berwick holds a Master in Public Policy degree from the John F. Kennedy School of Government. He received his medical degree from Harvard Medical School, where he graduated cum laude.
Dr. Donald Berwick

6. Proposed Vision
CMS is a major force and a trustworthy partner for the continual improvement of health and health care for all Americans.

7. The “Three Part Aim” Better Health for the Population Better Care
Risk Factors
Vitality
Safe
Effective
Patient-Centered
Timely
Efficient
Equitable
Government
All Payers
Better Care
for Individuals
Lower Cost
through
Improvement

8. Medicare – The Beginning
Medicare and Medicaid enacted in 1965
Implemented in 1966
Over 19 million enrolled on July 1, 1966
President Johnson – Former President Truman and his wife received the 1st and 2nd Medicare cards
1965 Medicare and Medicaid were enacted in 1965 as Title XVIII and Title XIX of the Social Security Act, extending health coverage to almost all Americans aged 65 or older (e.g., those receiving retirement benefits from Social Security or the Railroad Retirement Board), and providing health care services to low-income children deprived of parental support, their caretaker relatives, the elderly, the blind, and individuals with disabilities. Seniors were the population group most likely to be living in poverty; about half had insurance coverage.
1966 Medicare was implemented and more than 19 million individuals enrolled on July 1.

9. What CMS Does Administer the Medicare program
Work with the states to administer
Medicaid
Children's Health Insurance Program (CHIP)
Administer Health Insurance Portability and Accountability Act of 1996 (HIPAA)
Maintain quality standards
Long-term care facilities (nursing homes)
Clinical laboratories
CMS:
Administers the Medicare program
Works with the states to administer Medicaid, and the Children's Health Insurance Program (CHIP),
Administers Health Insurance Portability and Accountability Act of 1996 (HIPAA),
Maintains quality standards in long-term care facilities (more commonly referred to as nursing homes) through its survey and certification process, and clinical laboratory quality standards under the Clinical Laboratory Improvement Amendments.
The CMS has over 4,500 Federal employees, but does most of its work through third parties. The CMS and its contractors process over one billion Medicare claims annually, monitor quality of care, provide the States with matching funds for Medicaid benefits, and develop policies and procedures designed to give the best possible service to beneficiaries. The CMS also assures the safety and quality of medical facilities, provide health insurance protection to workers changing jobs, and maintain the largest collection of health care data in the United States.

10. Medicare & Medicaid Statistics
Medicare enrollees
19.1 million in 1966
45.9 million in 2009
50.1 million Medicaid enrollees in 2009
Almost half, 24.9 million, are children
130% increase
Today, the Federal government spends almost $800B every year for Medicare and Medicaid/CHIP…that is 19% of the federal budget… making CMS over 5 times larger than the largest private payer in the United States…and the largest financer of healthcare among OECD countries…all with the oversight of fewer than 5,000 employees
In 2009, Medicare and Medicaid/CHIP combined had over 94 million individuals enrolled…46 million in Medicare and 57 million in Medicaid/CHIP…covering almost 1 in 3 Americans.
And, by 2019, Medicare and Medicaid/CHIP combined are expected to cover ~130 million Americans.
We’ll start by talking about some interesting statistics and information about health care expenditures in the United States.
The number of persons enrolled in Medicare has increased from
19.1 million in 1966 to
45.9 million in 2009
CMS also administers the Medicaid program, which is run by each state in accordance with Federal guidelines. On average, the number of Medicaid monthly enrollees in 2009 is estimated to be 50.1 million. Of these, 24.9 million (almost half) are children.

11. Drug Coverage Statistics
90% (40 million) have drug coverage
Medicare
Another source
26.6 million have Part D coverage
Growth of 1.5 million in one year
9.6 million get extra help
80% of those eligible
We also have current statistics on drug coverage. The numbers have changed in part due to better data on creditable coverage and eliminating duplication for those beneficiaries with multiple sources of coverage. However, it is important to note that 90% of Medicare beneficiaries have drug coverage from Medicare or another source.
There was a net increase of 1.5 million beneficiaries in Part D in January 2008 compared to January This includes 1.1 million beneficiaries who were new to Medicare in 2007 (about 41% of whom enrolled in Part D).
We also had growth in beneficiaries getting extra help where about 80% of those eligible or nearly 10 million people have coverage from Medicare or another source.

12. U.S. Health Care Expenditures
National health expenditures in 2007
$2.2 trillion
16.2% of gross domestic product
Per person health care expenditures
$211 in 1965
$7,421 in 2007
$13,101 expected in 2017
National health expenditures were $2.2 trillion, comprising 16.2% of the gross domestic product.
National health expenditures per person were
$211 in 1965
$7,421 in 2007
Expected projections are $13,101 in 2017.

13. CMS’ 10 Regional Offices

14. Consortium/Business Line Senior Management Official
Four Consortia
Consortium/Business Line
Consortium Administrator
(CA)
CA Location
Senior Management Official
Consortium for Medicare Health Plans Operations (CMHPO)
James T.  Kerr.
New York
Boston
Philadelphia
Consortium for Financial Management and Fee for Service Operations (CFMFFSO)
Nanette Foster Reilly
Kansas City
Kansas City
Denver
San Francisco
Consortium for Medicaid and Children's Health Operations (CMCHO)
Jackie Garner
Chicago
Seattle
Consortium for Quality Improvement and Survey & Certification Operations (CQISCO)
Randy Farris, M.D.
Dallas
Atlanta
The Four Consortia
Each consortium is led by a Consortia Administrator (CA) who serves as the Agency’s national focal point in the Field for their business line(s) and as such is responsible for consistent implementation of CMS programs, policy and guidance across all 10 regions for matters pertaining to their business line.
In addition to responsibility for a business line, each CA also serves as the Agency’s senior management official for two or three Regional Offices (Ros), representing the CMS Administrator in external affairs matters and overseeing administrative operations.
Moving from a geography based structure to a Consortia structure based on the agency’s key lines of business:
Medicare health plans;
Medicare financial management,
Medicare fee-for-service operations,
Medicaid & children’s health,
Survey and Certification and quality improvement
The intent of the new structure is to improve performance through uniform issue management, consistent communication and leadership focused on achieving the Agency’s strategic action plan.

15. Atlanta Regional Office
The Atlanta Regional Office serves eight states –
Alabama
Florida
Georgia
Kentucky
Mississippi
North Carolina
South Carolina
Tennessee

16. The Atlanta Regional Office
Provides health care security for over 18 million people
8.9 million Medicare beneficiaries
9 million Medicaid recipients (including 1.6 million dual eligibles)
725,000 CHIP kids

17. Program Basics
Medicare
Medicaid
Children’s Health Insurance Program

18. Medicare Medicare is the health insurance program for:
People age 65 and older
Certain people under age 65 with disabilities
People with all ages with End Stage Renal Disease (ESRD)
Medicare is a health insurance program for:
People age 65 and older
People under the age of 65 with disabilities who have been getting Social Security disability benefits for a set amount of time (24 months in most cases)
People of all ages with End Stage Renal Disease (ESRD) – people with permanent kidney failure and need dialysis or a kidney transplant
Medicare is the nation’s largest health insurance program, currently covering about 44 million Americans

19. Medicare Coverage Part A – Hospital Insurance
Part B – Medical Insurance
Part C – Medicare Advantage Plans
Part D – Medicare Prescription Drug Coverage

20. Medicare Part A Inpatient Hospital Stays Home Health Care
Skilled Nursing Care
Hospice
Blood

21. Medicare Part B Doctor’s services Outpatient Hospital Services
Home Health Services
Preventive Services
Durable Medical Equipment

22. Medicare Part C Live in plan’s service area
Entitled to Medicare Part A
Enrolled in Medicare Part B
Continue to pay Part B premiums
May also pay monthly premium to plan
Don’t have ESRD at enrollment
Some exceptions

23. Medicare Part C Usually get all Part A and B services through plan
May have to use providers in plan’s network
Generally must still pay Part B premium
May get extra benefits
Vision, hearing, dental
Prescription drug coverage
Still in Medicare program
Get all Part A and Part B services
Have Medicare rights and protections

24. Medicare Part D Medicare Prescription Drug Coverage
Began January 1, 2006
Provided through
Prescription drug plans
Medicare Advantage plans
Some employers and unions

25. Medicaid

26. Medicaid Federal and State program
For some with limited income and resources
If eligible, most health care costs covered
Each state decides
Who is eligible
How people apply
Office names vary
Social services
Public Assistance
Medicaid is a joint Federal and State program that helps pay medical costs for some people with limited income and resources. Medicaid is paid for in part by the Federal government and in part by the State government. The program is run by each state and CMS approves the state plan and any changes relating to it. Medicaid is for children, people who are aged, blind, or disabled, and some other groups, depending on how the state defines the benefit.
For people who have both Medicaid and Medicare, most of their health care costs are covered. People with Medicaid may get coverage for services that aren’t fully covered by Medicare, such as nursing home care.
Each state decides who is eligible for Medicaid, the income and resource requirements, how people will apply for Medicaid, and how much assistance they will receive. Individuals should contact State Medical Assistance (Medicaid) office. The office names are different in different states. For example, people in Hawaii would contact the Hawaii Department of Human Services. Folks in Hawaii can dial to get information about the program.

27. Children’s Health Insurance Program

28. Children’s Health Insurance Program
Families who earn too much to qualify for Medicaid and who cannot afford private insurance may be able to qualify for CHIP
For little or no cost, this insurance pays for: doctor’s visits; immunizations; hospitalizations, and emergency room visits
Insure Kids Now (877-KIDS-NOW) or
Families who earn too much to qualify for Medicaid and who cannot afford private health insurance may be able to qualify for CHIP – Children’s Health Insurance Program.
For little or no cost, this insurance pays for:
Doctor’s visits
Immunizations
Hospitalizations
Emergency room visits
For information about CHIP in your state, you can visit the website, “Insure Kids Now,” which will take you to your state’s webpage. You may also call KIDS-NOW.

29. PATIENT PROTECTION AND AFFORDABLE CARE ACT
CMS Highlights –
All information may be found on the cms.hhs.gov website

30. Patient Protection & Affordable Care Act (ACA)
Large number of changes
Many changes effective this year and next year
Only some of these are for CMS to implement

31. Medicare changes from ACA
Some provisions begin right away:
Begins to close the Medicare Part D “donut hole”– $250 checks in 2010
Makes preventative care free under Medicare – effective 1/1/11
Moves open season out of the Christmas holiday period – effective 2011 (Oct 15 – Dec. 7)
Reduction in number of MA plans for 2010 open season
BEGINS TO CLOSE THE MEDICARE PART D DONUT HOLE—Provides a $250 rebate to Medicare beneficiaries who hit the donut hole in 2010.  Effective for calendar year 2010. 
FREE PREVENTIVE CARE UNDER MEDICARE—Eliminates co‐payments for preventive services and exempts preventive services from deductibles under the Medicare program.  Effective beginning January 1, 2011.
Starting in 2011, beneficiaries will have the opportunity to change their benefits and their plans during the Annual Enrollment Period, October 15 through December 7. We tried hard to figure out a way to avoid impacting Thanksgiving, but the December holidays are now free and clear.
You’ll see in 2010 that the number of health plans dropped. And that was due to CMS’ conscious policy to work with the plan community for those plans that had indistinguishable differences from other plan offerings they were offered, or had consistent low enrollment, we said to the plans “Pull it back. [from about 3500 nationally in 2009 to about 2800 in 2010)

32. Medicare changes from ACA
Other changes are more subtle, requiring further regulations and/or phased implementation – some you may have heard of:
accountable care organizations
discounts on brand name drugs in Part D beginning 2011
reports on health resource utilization to individual physicians
incentives to reduce avoidable hospital re-admissions
tying MA plan payments to clinical outcomes
CMS will be proposing regulations later this fall to encourage group physician practices, possibly combined with hospitals to come into the program, as so-called ‘Accountable Care Organizations’.
Beginning in 2011, we will institute a 50% discount on prescription drugs in the donut hole; ACA plans to also completely close the donut hole by 2020.
CMS will be implementing, on a nation-wide basis, a system to provide confidential feedback reports to individual physicians about the relative resource use of their care, with the goal to ensure that physicians understand how they are providing care relative to their peers, because we know there is tremendous variation across the country, across regions, and across cities, in how care is provided to beneficiaries. We want physicians to make a much more conscious stake, and have much better knowledge about how they’re providing care, to ensure that care is efficient, care is high quality.
CMS will be providing clear financial incentives to hospitals that have higher rates of avoidable hospital re-admissions. We all know that some beneficiaries go into the hospital, leave the hospital, come back to the hospital within 30 days simply because care wasn’t followed, a physician didn’t follow up with the patient, and that patients should have been at home, rather than going back to the hospital.
Starting in 2012, a portion of a plan’s payments will be based upon its 5 star quality rating. We recognize that the current 5 star system was designed to help consumers choose a plan. But we also recognize that it’s largely based upon plans’ performance.

33. Other changes you may have read about
HHS has created a new office to work with the insurance industry called the Office of Consumer Information & Insurance Oversight, or OCIIO
You can see what they are working on at:
public information at

34. OCIIO tasks
Children with Pre-existing conditions- effective 6 months after enactment
Interim High Risk Pools – effective in 2010
Preventing Rescissions if someone gets sick - effective 6 months after enactment
Coverage for young people up to 26th birthday - effective 6 months after enactment
Early Retirees – effective 2010
Lifetime Limits - effective 6 months after enactment
Restrictive annual limits on coverage - effective 6 months after enactment

35. Pre-existing Condition Insurance Plan
Must be a US citizen or reside here legally;
Have been without health insurance for at least 6 months before applying
Have a pre-existing condition or denied coverage because of a health condition

36. Pre-existing Condition Insurance Plan
For more information, please visit:

37. Helpful Resources 1-800 medicare /1-800-633-4227 Medicare.gov Cms.gov
Medicare & You Handbook
GeorgiaCares – the State Health Insurance Assistance Program
Healthcare.gov
Pcip.gov
Our helpful resources are:
The medicare number – operates 24/7
Our website – offers comparison sites for quality and plan selections during the Annual Enrollment Period, publications and helpful contacts – phone numbers and websites
The Medicare & You 2010 handbooks are currently being mailed and also “going green”

38. Contact Information
Centers for Medicare and Medicaid Services Sam Nunn Federal Center 61 Forsyth Street, Suite 4-T-20 Atlanta, Georgia
I thank you for your time today. If you would be interested in partnering with us at CMS, please give us a call for more information.