1. Everything You Wanted to Know about the Medicare Improvement for Patients and Providers Act (MIPPA) …but Were Afraid to Ask!

2. About MIPPA The Medicare Improvement for Patients and Providers Act of 2008 (MIPPA) was enacted in July 2008 There are many changes included in MIPPA that will impact you and your clients, especially those with limited incomes.

3. MIPPA changes well cover Changes affecting your clients with limited incomes and resources –Medicare Part D Extra Help/Low-Income Subsidy (LIS) and Medicare Savings Programs (MSP) Changes to Medicare Advantage Medigap changes Other changes

4. LIS and MSP Asset eligibility alignment The Qualified Medicare Beneficiary (QMB), Specified Low- Income Beneficiary (SLMB) and Qualifying Individual (QI) programs will have the same asset (resource) level as full LIS, In 2009, these levels are $6,600 for a single individual and $9,910 for a married couple. These levels may be adjusted for 2010 –Some states have already raised MSP asset levels above the federal floor, or have eliminated an asset test Examples: AL, AZ, DC, DE, ME, MS, NY, VT, and CT (QI-only) Effective January 1, 2010

5. LIS and MSP Changes to the LIS application Cash surrender value of life insurance will no longer be counted as an asset for LIS eligibility –States may choose to continue counting the cash surrender value of life insurance as an asset in determining MSP eligibility

6. LIS and MSP Changes to the LIS application (continued) In-kind support and maintenance (ISM) will no longer be counted as income for LIS eligibility –A few states still count ISM in deciding about entitlement for MSPs

7. New question added (question 15) regarding the transmittal of data from SSA to state Medicaid agency to start an MSP application –Your clients should only check the box if they wish to OPT OUT of this process All changes effective January 1, 2010 LIS and MSP Changes to the LIS application (continued)

8. LIS and MSP Estate recovery for MSP States are prohibited from recovering Medicaid expenditures for Medicare premiums and cost- sharing paid under MSPs from the estates of deceased Medicaid/MSP recipients Effective January 1, 2010

9. LIS and MSP Part D Late Enrollment Penalties People with LIS are excused from paying Part D plan late enrollment penalty premiums –This provision put into the law current CMS policy Related notes: –QMB waives any otherwise applicable Medicare Parts A and B late enrollment penalty premiums –SLMB and QI waive any Part B late enrollment penalty premiums Already in effect

10. LIS and MSP: Transmission of LIS data from SSA to States LIS and MSP application provisions: –Social Security Administration will transmit the information on LIS applications to state Medicaid agencies, starting with LIS applications filed on January 2, 2010 –State Medicaid agencies must treat the data SSA transmits as the start of an MSP application Effective January 2, 2010

11. LIS and MSP New model MSP application CMS has been developing a new model MSP application –States are encouraged, but not required to use it –Will be available in 10 languages -- Arabic, Chinese, French, Haitian-Creole, Farsi, Korean, Spanish, Tagalog, Russian, and Vietnamese. Should be available online on CMS and SSA web sites in October

12. LIS and MSP: Other LIS/MSP application provisions SSA Field Offices must give LIS applicants information about how to get enrollment assistance from SHIPs. SSA personnel who take LIS applications will be trained on MSPs eligibility criteria and enrollment procedures as well as on the rules for LIS. –Because MSPs are Medicaid benefits, state Medicaid agencies must adjudicate MSP entitlement Effective January 1, 2010

13. LIS and MSP Extension of QI The QI program was extended, but only through the end of 2009 Already in effect NOTE: The American Recovery & Reinvestment Act (ARRA) extends QI even further – through December 31, 2010

14. Changes to Medicare Advantage Marketing Key marketing provisions: –Prohibits most cold marketing contacts –Prohibits cross-selling on non-health-related products, such as annuities or life insurance during an MA or Part D marketing encounter –Makes plan sponsors responsible for the actions of agents, brokers and other third parties –Plan type must be included in plan title Examples: –Favorite Plan (PFFS) –Even Better Plan (PPO) –Codifies many current CMS policies Already in effect

15. Changes to Medicare Advantage SNPs Special Needs Plans (SNP) provisions: –As of 2010, only those who have the explicit special needs the Medicare Advantage plan identifies are allowed to become Special Needs Plan (SNP) members No more spouses and friends who do not have the special needs the SNP focuses on allowed to join these plans –Each SNP must establish an evidence-based model of care and build its provider network to include an appropriate network of providers and specialists that can meet the special needs of its members Plans have their care models approved by CMS Plans do not have to make their model of care public –SNPs will be required to make an initial assessment of each new members needs, and use the assessment to create specific, individualized plans of care, in consultation with the member (to the extent feasible) Effective January 1, 2010

16. Changes to Medicare Advantage D-SNPs SNPs for people dually entitled to Medicare and Medicaid are called D-SNPs: –Background: D-SNPs may serve all duals, only full duals, or only partial duals. Around 75% of SNP enrollees are in D-SNPs –As of the 2010 Annual Enrollment Period, D-SNPs must provide people considering joining the plan with a written statement of Medicaid-covered benefits and what the D-SNP plan covers The statement must also describe the plan and Medicaid cost-sharing –D-SNPs are prohibited from charging members who have Medicaid any amounts in excess of the applicable cost-sharing allowed by Medicaid This information must be given to people before they enroll

17. Changes to Medicare Advantage D-SNPs (continued) As of 2010 plan year, D-SNPs must have a contract with the state Medicaid agency. The contract must detail how Medicaid benefits are provided to D-SNP members. The contract could be used to encourage coordination between Medicaid coverage and D-SNP coverage

18. Changes to Medicare Advantage I-SNPs SNPs for people who are in institutions such as Skilled Nursing Facilities or Nursing Facilities are called I-SNPs: –Background: Institutional SNPs serve people in residential facilities and may also choose to serve people living at home who meet level of care criteria for a residential care setting –As of 2010, SNPs serving people living at home must use a state assessment tool to determine the need for an institutional level of care of prospective members living in their own homes –The level of care assessment must be accomplished using an assessment tool used by the state in which a person lives –The assessment may not be performed by plan personnel It may be performed by the same entity that assesses level of care for the state Medicaid agency

19. Changes to Medicare Advantage C-SNPs SNPs for people who have one of 15 specified severe and disabling conditions such as cancer, HIV/AIDS or diabetes are called C-SNPS: –Background: limit membership to people with specified serious chronic conditions. In general, according to CMS, C-SNPs may only enroll people with one or more of these conditions who have one or more [co-morbid] and medically complex chronic conditions that are substantially disabling or life threatening, have a high risk of hospitalization or other significant adverse health outcomes, and require specialized delivery systems across domains of care –As of 2010, membership must be limited to people who have one or more of 15 specified conditions

20. Medigap changes Overview The Medigap standardized plans have been revised All states must ratify the Medigap changes in their laws and regulations by mid-2010 All Medigap policies sold or renewed after June 1, 2010 must comply with the new standard plan rules, as developed by the National Association of Insurance Commissioners (NAIC) and approved by CMS

21. Medigap changes Standardized plan revisions No more plans E, H, I, or J New plans M and N, with higher cost-sharing and (anticipated) lower premiums –More like Plans K and L –Plan M: Only 50% of Part A deductible covered, and no coverage for Part B deductible For Part B, coverage of 20% co-insurance replaced with $20 co-pay for office visits and $50 co-pay for ER visits –Plan N: Part A deductible fully covered, but Part B deductible not covered at all For Part B, coverage of 20% co-insurance replaced with $20 co-pay for office visits and $50 co-pay for ER visits

22. Medigap changes Other changes Preventive care and at home Medigap benefits have been eliminated for new or renewing Medigap plans as of July 2010, or earlier, depending upon State ratification date Hospice is covered as a basic Medigap benefit Any insurance company selling any Medigap plan must sell –A Plan A product, and –A Plan C or a Plan F product

23. Other MIPPA changes Welcome to Medicare Physical Changes to Part B psych services co-pays Rehabilitation therapies cost and coverage caps DMEPOS competitive bidding

24. Other changes Welcome to Medicare Physical Welcome to Medicare Physical –The time new Medicare beneficiaries have to get their Welcome to Medicare physical has been extended from 6 months to one year, as of January 1, 2009 –The physical includes body mass measurement, and an end-of-life planning consultation –Part B deductible is waived

25. Other changes Part B psych services co-pays Changes to Part B psych services co-pays –Currently, most out-patient psych services are subject to a 50% co-insurance, as opposed to the 20% co-insurance charged for most other Part B services Exception: brief office visits for medications management – 20 percent co-insurance currently charged (and not changing) –By 2014, psych services will become like other Part B services with only 20% co-insurance –This change is being phased in between 2010 and 2014 In 2010 and 2011, 45 percent co-insurance In 2012, 40 percent co-insurance In 2013, 35 percent co-insurance In 2014 and thereafter, 20 percent co-insurance

26. Other changes Rehab therapies cost and coverage caps Background: Medicare limits on outpatient coverage of rehabilitation therapies: –In 2009: $1,840 for Physical Therapy (PT) and Speech/Language Therapy (SLT) combined; $1,840 for Occupational Therapy (OT) –In 2010, $1,860 for Physical Therapy (PT) and Speech/Language Therapy (SLT) combined; $1,860 for Occupational Therapy (OT) –Exceptions to therapy caps if therapist documents medical necessity - The exceptions to the therapy caps remain in effect, but only until the end of 2009

27. Other changes DMEPOS DMEPOS competitive bidding is coming Look for more info this summer as we approach the effective date for the change in how people with Medicare in the affected areas obtain their durable medical equipment and medical supplies

28. Resources CMS: Limited Income and Resources http:///www.cms.hhs.gov/limitedincomeandresources http:///www.cms.hhs.gov/limitedincomeandresources Model MSP applications http://www.ssa.gov/prescriptionhelp/cms_pubs.htm http://www.ssa.gov/prescriptionhelp/cms_pubs.htm CMS: Patient Brochure on Therapy Caps http://www.medicare.gov/publications/pubs/pdf/10988.pdf http://www.medicare.gov/publications/pubs/pdf/10988.pdf Additional information on Medicare Part D marketing changes (including a webinar on this topic) http://www.mymedicarecommunity.org/showthread.php?t=3538 http://www.mymedicarecommunity.org/showthread.php?t=3538 SSA Fact Sheet on MIPPA Changes (English) http://www.socialsecurity.gov/pubs/10040.html http://www.socialsecurity.gov/pubs/10040.html SSA Fact Sheet on MIPPA Changes (Spanish) http://www.socialsecurity.gov/espanol/10934.html http://www.socialsecurity.gov/espanol/10934.html

29. Contact us Feel free to contact me directly: hilary.dalin@ncoa.org Visit us on the Web at www.CenterforBenefits.org www.CenterforBenefits.org If you would like to be added to our email list to be notified about future trainings and other resources, please email us at centerforbenefits@ncoa.org centerforbenefits@ncoa.org