How does the Patient Protection and Affordable Care Act impact Medicare?

The Michigan Chronicle met with Karen Wintringham, the Vice President of Medicare Programs with Health Alliance Plan (HAP), to gain insights regarding how the Patient Protection and Affordable Care Act impacts Medicare.

According to Wintringham, the existing Medicare coverage will not be reduced or taken away under the Affordable Care Act (ACA). In fact, the ACA adds a number of benefits and protections to Medicare coverage, including:

Improved coverage in the donut hole: If a consumer has Medicare Part D coverage, the ACA helps them save money on drugs. For 2014, if they’re in the prescription drug “donut hole,” they will get a discount of 52.5 percent when they buy Part D-covered brand name prescription drugs. They will save on generic drugs, too. By 2020, all but 25 percent of a beneficiary’s costs – both brand-name and generic – will be covered. This compares to the beneficiaries having to pay 100 percent of both generic and brand-name drugs prior to the passage of the Affordable Care Act.

Additional preventive benefits: Medicare now has a list of approved preventive benefits covered at no cost to the beneficiary, including:

• A yearly wellness visit: This is different from a physical, which is a more extensive exam. Consumers may choose to have a physical at another visit with their doctor, but generally Medicare will not pay for the physical.

• Routine screening exams, such as mammograms, colorectal cancer screenings, Pap smears, prostate exams, bone density measures and other preventive screenings.

Extra resources to fight fraud and inefficiency: The ACA provides extra resources to fight fraud and abuse in Medicare and puts in place more tools to catch those who fraudulently bill Medicare.

Financial incentives for Medicare Advantage Plans and Prescription Drug Plans (pdp): The ACA provides financial incentives for Medicare Advantage plans and Prescription Drug Plans that provide high quality care and high levels of customer satisfaction. Plans that rate at least four out of five stars by Medicare will receive bonus payments. In addition, plans must now limit how much they spend each year on administrative costs.

Income-related Medicare premiums: Some Medicare beneficiaries will pay an extra amount for Part D because of their yearly income. The extra amount is paid directly to Social Security (not the Medicare plan). The income level that drives the additional premium starts at $85,000 for a single person or $170,000 for married couples filing joint tax returns. These income levels will stay the same until 2020.

Inclusion of Individuals with ALS: Individuals with Amyotrophic lateral sclerosis (ALS), also referred to as “Lou Gehrig ’s Disease,” can now qualify for Medicare coverage.

When is Open Enrollment for Medicare? In 2013, open enrollment for Medicare runs from October 15 until midnight on December 7. Medicare beneficiaries whose plan is ending on December 31 have a special election period. They can enroll in a Medicare plan up until December 31 for coverage effective on January 1, 2014.

Medicare Expert Karen Wintringham answers Medicare questions:

Q. What changes are happening in 2014 to the prescription drug coverage?

A. Medicare prescription drugs are becoming more affordable under the health care reform law. As a result of the Affordable Care Act, Medicare beneficiaries will continue to have better coverage for both brand name and generic drugs than in prior years, so they’ll pay less in out-of-pocket prescription costs over time. This filling of the Donut Hole is scheduled to continue each year through 2020, at which time all but 25 percent of a beneficiaries’ costs will be covered. In other words, Part D will cover 75% of both generic and brand-name drugs in the Donut Hole.

For 2014 members of approved Medicare Prescription Drug Plans will receive a 28% discount on generic drugs and 52.5% on brand-name drugs. Prior to the passage of the Affordable Care Act, members had to pay 100% of the costs for both generic and brand-name drugs.

In addition, some of the payment amounts under Part D (outpatient prescription drug benefits) will change annually as they do under Part A and Part B. For 2014:

a) The Initial Coverage Limit (the amount a member pays for prescriptions plus what the member’s plan pays before entering the Donut Hole) decreases from $2,970 to $2,850.

b) The amount the member must pay out of his or her own pocket (the True Out-Of-Pocket costs or TrooP) decreases from $4,750 to $4,550. This is the amount for deductibles, copays, and coinsurance (not premiums) the member pays for Part D services before being able to exit the Donut Hole.

c) The copays a member might pay after entering the Part D catastrophic coverage period benefit decrease from $2.65 for generics to $2.55 and from $6.60 for all other drugs to $6.35. Members at this coverage level pay either the copay or 5%, whichever is greater. One other change happing to prescription drugs includes access to barbiturates.

In 2013 Medicare Part D added coverage for benzodiazepines and for barbiturates when used to treat epilepsy, cancer, or a chronic mental health disorder. For 2014 the restricted use for barbiturates is removed, and may be covered under Part D for medically accepted indications.

Q. What Hints Do You Have for Consumers When Comparing Medicare Plans

A. As you begin reviewing the new plan benefits and premiums for 2014, be sure to look at more than just the premiums and whether there is a deductible or not. How much would you pay out of your own pocket if you were hospitalized, or if you needed skilled nursing care? If the plan offers care outside the network, how much would you pay? What you would pay if you have an ambulatory surgery procedure or service in a hospital outpatient setting? Are there restrictions on how much care you can receive? What are the new coverage rules for emergencies when you travel outside the country? Depending on your personal needs, these could be areas with significant financial impact.

Q Why Preventive Services Are Covered?

A. On January 1, 2013 Medicare began covering many – but not all – preventive services with no cost to the Medicare beneficiary. Preventive services coverage will continue in 2014. Here are a few examples of covered services: Mammograms, cancer screenings, and vaccinations for influenza, pneumonia, and Hepatitis B (for at risk individuals). A complete list of preventive is available in the Medicare and You handbook sent to every Medicare beneficiary. Medicare Advantage plans fully cover preventive services and annual well visits (with no copay, no coinsurance).

Editor’s Note: Karen Wintringham leads HAP’s Medicare programs and provides legislative and regulatory policy expertise on program administration and compliance. Since joining HAP in 2007, Karen has expanded HAP’s portfolio of affordable health care solutions for Medicare beneficiaries. She previously held leadership positions at Excellus Blue Cross Blue Shield and Aetna and has participated in national policy committees and quality initiatives. She received a bachelor’s degree with honors from Colby College and a master’s degree with honors in Health Policy and Health Administration from Washington University School of Medicine. She serves on the board of directors of

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