Medicare Improvement for Patients and Providers Act of 2008

Preliminary Summary of Beneficiary and Plan Provisions July 14 th , 2008

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Beneficiary Improvements

   Initial Preventive Exam – Eligibility extended from 6 months to one year after entry to Medicare – Not subject to the deductible – “End of Life” / Advance Directives planning added Mental Health Co-Pays Equalized Benzodiazepines and barbiturates covered by Part D 2

Medicare Low Income Programs

        QI eligibility extended through 2009 LIS/MSP assets equalized for January, 2010 SSA funded to eliminate processing and application barriers; transmit data to states; states process as MSP application No Part D late penalties for LIS eligibles No estate recovery for Medicare Savings Program In-kind income excluded Life Insurance not considered an asset State Health Insurance (SHIPs), AAAs and ADRC’s Programs funded for outreach 3

Special Needs Plans Provisions

     SNP authority extended one more year – through plan year 2010; expires1/1/2011 – moratorium lifted; dual plans have new criteria CMS prohibited from “designating” a plan as a SNP; all plans must apply.

100% of new enrollees must be in the targeted enrollment category. The plan may not impose higher cost sharing on the duals than permitted under Medicaid Provisions effective in 2010 4

SNP Provisions: Quality

  Care Management – Evidenced based model of care – Appropriate network of providers and specialists – Initial and annual assessment of physical, psychosocial and functional needs – Individual plan of care identifying goals, objectives, measureable outcomes and specific benefits – Care management included in CMS periodic audit Quality Reporting – Plans must provide data to “measure health outcomes and other measures of quality“ – All data shall be at the plan level – May be based on claims data 5

SNP Provisions: Dual SNPs

  Plan provides prospective enrollees a written statement describing – Benefits and cost sharing protections under Medicaid – Which Medicaid and cost sharing protections are covered by the plan Plan has a contract with the state to provide benefits or arrange for Medicaid benefits to be provided.

– Dual SNPs without a contract may operate, but cannot expand during 2010.

– CMS must designate “staff and resources” to assist state coordination with SNPs – States are not required to contract with SNPs 6

SNP Provisions: Institutional SNPs

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I-SNP members in the community must be assessed as needing an institutional level of care

– Assessed by an entity other than the organization – Using the assessment tool of the state of residence 7

Chronic SNPs

  “Chronic and disabling” definition amended – co-morbid and medically complex condition(s) – substantially disabling or life threatening – high risk of hospitalization or significant adverse outcome – require care across domains of care HHS to convene a panel to determine which conditions meet this definition; AHRQ must serve on the panel.

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Marketing Restrictions

   Effective January,1 2009 Contains all provisions of CMS’ proposed rules re: cold calling, cross selling, limitations on meals, gifts and incentives

( ACAP still reviewing

) Strengthens State Oversight – Agents and brokers must be licensed – Plans must cooperate with state information requests. 9

MedPAC Studies

   Chronic Care Demonstration – Feasibility of a standing Chronic Care Practice Network – Report due June 15, 2009 .

Quality Measurement – Recommend how comparable measures of performance and patient experience can be collected and reported by 2011 that compare quality across plans AND compare FFS to MA plans – Report Due March 31, 2010 on findings and recommended legislation and administrative actions Medicare Advantage payments – Costs plans incur as reflected in their bids – Ways to improve the estimates of county level per capita spending including use of VA services by Medicare beneficiaries – Alternate payment approaches administrative actions

The “Pay-For” Provisions

CBO Estimates Savings for All Provisions as $12.5b for 2009-2013; $47.5b for the 2009-2018; overall MA enrollment down 2.3 m from 2013 projections

  Small changes in FFS; delay home oxygen volume purchase Phase-out of indirect medical education (IME) – Plan year 2010 MA rates reduced by .06

– Reduced an additional .06 each subsequent year till phased out – PACE programs excluded  Adjustment to the Medicare Advantage stabilization fund.

– Removes all but one dollar from the fund  PFFS Required to Have Networks – Areas with less than 2 network plans exempted – Network requirements assumed to reduce enrollment 11