Medicare 2020 What are the changes Medicare Update

Medicare 2020 – What are the changes ? Medicare Update 2020

Disclaimer William Malm ND nor Health Revenue Integrity Services Inc. is an insurance broker We are only providing high level education and not providing insurance selection assistance For specific questions regarding your particular insurance requirements we urge you to contact your insurance broker, agent or insurance company or the Federal Exchange (Marketplace) Material enclosed SHOULD NOT be used for making independent insurance decisions – these should be determined between you and a professional 2 Copyright HRIS 2019

Objective To increase the knowledge of these plans To assist in understanding some of the obstacles and pitfalls with each plan Understand the types of Medicare Plans 3 Copyright HRIS 2019

Parts A, B, C and D 4 Copyright HRIS 2019 Medicare 2020

Copyright HRIS 2019 Overview

Ways to Find Out More Medicare: https: //www. medicare. gov/plan-compare/ https: //www. medicare. gov/ Understanding Part D https: //www. medicare. gov/drug-coverage-part-d Difference between Medicare & Medicare Advantage https: //www. bcbsm. com/medicare/help/faqs/works/difference- original-medicare-advantage. html 6 Copyright HRIS 2019

Enrolment Deadline DECEMBER 7 2019 7 Copyright HRIS 2019

2020 Deductible / Copays https: //www. cms. gov/newsroom/fact-sheets/2020 -medicare-parts- b-premiums-and-deductibles For 2020, the Medicare Part B monthly premiums and the annual deductible are higher than the 2019 amounts. The standard monthly premium for Medicare Part B enrollees will be $144. 60 for 2020, an increase of $9. 10 from $135. 50 in 2019. The annual deductible for all Medicare Part B beneficiaries is $198 in 2020, an increase of $13 from the annual deductible of $185 in 2019. The increase in the Part B premiums and deductible is largely due to rising spending on physician-administered drugs. These higher costs have a ripple effect and result in higher Part B premiums and deductible. 8 Copyright HRIS 2019

Overview of Medicare Single Payer system Began in 1966 30 -50% of commercial payers contract with Medicare Insures citizen 65 years or older Insures younger people with disability https: //en. wikipedia. org/wiki/Medicare_(United_States) End Stage Renal Disease (ESRD) 9 Copyright HRIS 2019

Medicare Parts Part A Inpatient Hospital Hospice Some medically necessary Skilled Nursing / Rehab stays Part B Medical Insurance Part C Medicare Advantage Part D Prescription Drugs 10 Copyright HRIS 2019

Medicare Beneficiary Documents https: //www. cms. gov/Outreach-and-Education/Medicare- Learning-Network-MLN/MLNProducts/downloads/Bene. Pub. FS -ICN 905183. pdf https: //www. medicare. gov/medicare-and-you/medicare-and- you. html https: //www. medicare. gov/pubs/pdf/10050 -Medicare-and- You. pdf 11 Copyright HRIS 2019

Medicare and You Homepage – Two key items for success with Medicare 12 Copyright HRIS 2019

The Importance of Medical Necessity is not just because your provider recommends a service Medical Necessity is dictated through the Social Security Act Additional Guidance through: 42 Code of Federal Regulations National Coverage Determinations by HHS Local Coverage Determinations by the Medicare Administrative Contractor (MAC) 13 Copyright HRIS 2019

The Importance of Medical Necessity Sec. 1862. [42 U. S. C. 1395 y] (a) Notwithstanding any other provision of this title, no payment may be made under part A or part B for any expenses incurred for items or services— (1)(A) which, except for items and services described in a succeeding subparagraph, are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, (B) in the case of items and services described in section 1861(s)(10), which are not reasonable and necessary for the prevention of illness, 14 Copyright HRIS 2019

Who Determines the Medical Necessity for Medicare The Medicare Administrative Contractor (MAC) using guidelines by Medicare A MAC is a �private health care insurers that processes claims for Medicare beneficiaries Each jurisdiction has a MAC assigned to it In Ohio the MAC is CGS https: //cgsmedicare. com/parta/index. html https: //cgsmedicare. com/partb/index. html 15 Copyright HRIS 2019

Observation Still A Problem In order to be a Medicare Inpatient under Part A you must pass two midnights in the hospital and meet medical necessity requirements Observation is an occurrence whereby you are physically in the hospital but remain an outpatient Copay and deductibles are per EACH service rendered and can frequently be financially prohibitive Observation does not count toward 3 night stay for Skilled Nursing Care Will give you the MOON document so you can understand 16 Copyright HRIS 2019

17 Copyright HRIS 2019 Medicare Vs. Medicare Advantage Plans

Comparison Table (Ehealth Medicare) 18 Copyright HRIS 2019

Comparison Table 19 Copyright HRIS 2019

Medicare Vs. Medicare Advantage https: //www. ehealthmedicare. com/medicare-advantage- articles/what-are-the-pros-and-cons-of-medicare-advantagevs-original-medicare/ https: //www. bcbsm. com/medicare/help/faqs/works/differen ce-original-medicare-advantage. html 20 Copyright HRIS 2019

Denials Are They A Concern ? Medicare Advantage Plans are known for high denial rates that could leave you on the hook for many out of pocket dollars Providers will use any means possible to collect if the insurance does not pay NY Times Article: https: //www. nytimes. com/2018/10/13/us/politics/medicare- claims-private-plans. html 21 Copyright HRIS 2019

NY Times Article Quoted directly for Educational Purposes 22 Copyright HRIS 2019

Cleveland Magazine has a complete listing by county or plan of all Medicare Advantage Plans Provides a side – by – side comparison of the plans https: //www. cleveland. com/business/2019/10/compare-ne- ohio-medicare-advantage-plans-ratings-for-2020 -searchablechart. html 23 Copyright HRIS 2019

MA Plans in Cuyahoga https: //www. cleveland. com/business/2019/10/compare-ne-ohio-medicare-advantage-plans-ratings-for-2020 searchable-chart. html 24 Copyright HRIS 2019

Copyright HRIS 2019 Medi. Gap Vs. Medicare Advantage

Medi. Gap Vs. Medicare Advantage https: //www. investopedia. com/articles/personal-finance/071014/medigap-vs-medicare-advantage-which-better. asp 26 Copyright HRIS 2019

Medicare Advantage Vs. Medi. Gap Medigap is the supplement between traditional Medicare that covers things Medicare does not cover. https: //www. investopedia. com/articles/personal- finance/071014/medigap-vs-medicare-advantage-which-better. asp What happened in 2020 ? As of 2020, Medicare Supplement plans (AKA Medigap) will no longer sell Plan F or Plan C to newly eligible Medicare members. Congress has issued the MACRA law stating that new Medigap plans will no longer be allowed to cover the Part B deductible after January 1, 2020. https: //www. gomedigap. com/medicare-answers/medicaresupplement-plans/medicare-2020 -changes/ 27 Copyright HRIS 2019

Medi. Gap Changes 2020 Starting January 1, 2020, Medigap plans sold to new people with Medicare won’t be allowed to cover the Part B deductible. Because of this, Plans C and F will no longer be available to people new to Medicare starting on January 1, 2020. If you already have either of these 2 plans (or the high deductible version of Plan F) or are covered by one of these plans before January 1, 2020, you’ll be able to keep your plan. If you were eligible for Medicare before January 1, 2020, but not yet enrolled, you may be able to buy one of these plans. https: //www. medicare. gov/supplements-other-insurance/how- to-compare-medigap-policies 28 Copyright HRIS 2019

29 Copyright HRIS 2019

Questions ? 30 Copyright HRIS 2019

Copyright HRIS 2019 Appendix: Additional Information

32 Copyright HRIS 2019 Part A - Hospital

Part A - Hospital Paid for through employer / employee taxes 1. 45 % from employer and 1. 45% from employee Covers inpatient hospital care Outpatient care billed through Part A but paid through Part B If you did not have employer / employee taxes then your premium is $413 / month (2017 rate) 33 Copyright HRIS 2019

What Part A Covers In general, Part A covers: • Hospital care • Skilled nursing facility care • Nursing home care (as long as custodial care isn't the only care you need) • Hospice • Home health services 34 Copyright HRIS 2019

Part A – Hospital - 2017 https: //www. medicare. gov/Pubs/pdf/11579 -Medicare-Costs. pdf 35 Copyright HRIS 2019

Key Concept: Inpatient (Part A) or Outpatient (Part B) As a Medicare beneficiary it is essential you understand whether you are an inpatient status or outpatient status There is the “ 2 Midnight Rule” which states a Medicare beneficiary, with few exclusions, is only considered an “inpatient” when “medically necessary services pass the second midnight” This has been a HUGE issue with patients as they are in a bed receiving services but don’t understand that they may have significant financial implications 36 Copyright HRIS 2019

Are You Inpatient or Outpatient ? Resources Provided by Medicare These are key resources that if you receive Medicare as an insurance you are “deemed responsible” for knowing. https: //www. medicare. gov/what-medicare-covers/part- a/inpatient-or-outpatient. html https: //www. medicare. gov/Pubs/pdf/11435. pdf 37 Copyright HRIS 2019

Medicare Provides Beneficiary Guidance 38 Copyright HRIS 2019

Your Status Determines Your Cost ! 39 Copyright HRIS 2019

What would I pay as an Inpatient 40 Copyright HRIS 2019

Generally known as “Outpatient Services” 41 Copyright HRIS 2019 Part B Services

What is Included in Part B Medicare covers services (like lab tests, surgeries, and doctor visits) and supplies (like wheelchairs and walkers) considered medically necessary to treat a disease or condition. Coverage is always determined through “benefit” status Coverage is given through the Social Security Act For more information: https: //www. medicare. gov/what-medicare-covers/part-b/what- medicare-part-b-covers. html 42 Copyright HRIS 2019

What is Included in Part B Medicare Part B covers 2 types of services • Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice. • Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best. You pay nothing for most preventive services if you get the services from a health care provider who accepts assignment. 43 Copyright HRIS 2019

What Part B Covers 44 Copyright HRIS 2019

Find Out if Your Service is Covered https: //www. medicare. gov/coverage/your-medicare-coverage. html 45 Copyright HRIS 2019

When an Outpatient Looks Like an Inpatient Observation care is a well-defined set of specific, clinically appropriate services, which include: Ongoing short term treatment, Assessment, Reassessment These are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. You are in a bed within the hospital so many patients think they are inpatients but they really are outpatients for Medicare 46 Copyright HRIS 2019

What is Observation “Observation services are hospital outpatient services given to help the doctor decide if the patient needs to be admitted as an inpatient or can be discharged. Observation services may be given in the emergency department or another area of the hospital. ” Observation status is OUTPATIENT not inpatient Will need to pay copayment and deductibles as if you were an outpatient which can be in excess of what it would have been if you were an inpatient 47 Copyright HRIS 2019

What Do I Pay As Outpatient ? 48 Copyright HRIS 2019

What is a MOON ? The MOON is a standardized notice to inform Medicare beneficiaries (including health plan enrollees) that they are outpatients receiving observation services and are not inpatients of a hospital or critical access hospital (CAH). The MOON is mandated by the Federal Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act), passed on August 6, 2015. The NOTICE Act requires all hospitals and CAHs to provide written and oral notification under specified guidelines. Take Away – Make sure you understand what you are signing !!!! 49 Copyright HRIS 2019

What Does A MOON Look Like 50 Copyright HRIS 2019

What About Outpatient Drugs ? Medicare only covers certain types of drugs under Part B These drugs cannot be of a type that is deemed “self- administered” Self Administered Medications will be billed DIRECTLY to you the beneficiary at the hospital chargemaster defined charge The same medications may have been covered as an inpatient may not be covered as an outpatient so very important that you know if you are an inpatient or outpatient 51 Copyright HRIS 2019

Self Administered Drug 52 Copyright HRIS 2019

Self Administered Drug The Medicare program covers medications in different fashions based on the plan part Part A – covered Part B – only those medications that are not integral to a procedure and are not determined to be SAD Cover medications such as eyedrops before cataract surgery Part D – based on the plan, formulary and fee schedules 53 Copyright HRIS 2019

Pills, Tabs, Capsules, Suppositories, Creams, Lotions, Inhalation = SAD=$$$ 54 Copyright HRIS 2019

Example – Chest Pain A 65 year old male is placed in the Intensive Care Unit for chest pain. Since he hasn’t been “formally admitted as an inpatient” and undergoing observation services he is an OUTPATIENT Higher copayment Self Administered Medications are also out of pocket Copayment is placed on each test or service rendered until discharge or admission to hospital $$$$$$ 55 Copyright HRIS 2019

What If A Skilled Nursing Is Required? A 3 day qualifying stay is necessary as an INPATIENT During the time a patient is in observation you are considered and OUTPATIENT and does not count towards the 3 day requirement for Medicare Coverage Days spent as an outpatient are not counted as inpatient days. Inpatient stay begins on the day of formal admission or your first inpatient day Date of discharge DOES NOT COUNT as a day Therefore you must physically be in inpatient status for 3 calendar days plus a discharge day (4 days total) 56 Copyright HRIS 2019

Example of SNF Coverage https: //www. medicare. gov/coverage/skilled-nursing-facility-care. html 57 Copyright HRIS 2019

Priscription Drug Plan 58 Copyright HRIS 2019 Medicare Part D

Medicare Part D Basics This is premium based drug plan offered by Medicare or an associated approved company If you chose to not enroll when first eligible you will need to pay a late enrollment premium which is more May affect other plans that you might have TRICARE Veterans Affairs 59 Copyright HRIS 2019

Medicare Part D Each Medicare drug plan has its own list of covered drugs (called a formulary). Many Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less than a drug in a higher tier. If your prescriber thinks you need a drug that's on a higher tier, you or your prescriber can ask your plan for an exception to get a lower copayment. 60 Copyright HRIS 2019

Part D Coverage “Medicare drug plans may have these coverage rules: Prior authorization: You and/or your prescriber must contact the drug plan before you can fill certain prescriptions. Your prescriber may need to show that the drug is medically necessary for the plan to cover it. Quantity limits: Limits on how much medication you can get at a time. Step therapy: You must try one or more similar, lower cost drugs before the plan will cover the prescribed drug. ” To learn more: https: //www. medicare. gov/part- d/coverage/rules/drug-plan-coverage-rules. html 61 Copyright HRIS 2019

Part D Take Away: Make sure you look at all your prescriptions before picking a plan to make sure they are in the formulary ! Some higher tier drugs are available off patent at a lower tier – consider getting your provider to look into alternatives 62 Copyright HRIS 2019

The Doughnut Hole ? 63 Copyright HRIS 2019

What is a Doughnut Hole It is a coverage gap in Part D benefits The gap is between the initial coverage limit and the catastrophic coverage threshold The gap is reached when a shared insurer payment and consumer payment for all covered prescriptions reaches the yearly set amount by Medicare. Once the beneficiary enters the “gap” the prescription payments are re-set to zero and will continue until the maximum amount is reached. 64 Copyright HRIS 2019

Phases of the Doughnut Hole https: //medicare. healthreformquotes. com/part-d-rx-prescriptions/donut-hole-graphic/ 65 Copyright HRIS 2019

Information on the “Gap” The coverage gap is quite difficult to understand. The following are good explanations to assist with the concern. We also recommend speaking with your pharmacy professional and/or Medicare both of which are quite well versed in the topic https: //en. wikipedia. org/wiki/Medicare_Part_D_coverage_gap https: //www. medicare. gov/part-d/how-part-d-works-with-other -insurance/part-d-and-other-insurance. html https: //www. medicare. gov/part-d/costs/coverage-gap/part-dcoverage-gap. html 66 Copyright HRIS 2019

Parts A – B and D Copyright HRIS 2019 Medicare Part C

What is Medicare Part C https: //www. medicare. gov/sign-up-change-plans/medicare- health-plans/medicare-advantage-plans/how-medicareadvantage-plans-work. html Medicare Advantage Plans, sometimes called "Part C" or "MA Plans, " are offered by private companies approved by Medicare. Your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage from the Medicare Advantage Plan and not Original Medicare. Note: some plans offer Part D as part of the plan 68 Copyright HRIS 2019

Medicare Advantage = Part C Medicare Advantage Plans must cover all of the services that Original Medicare covers. Original Medicare will still cover the cost for hospice care, some new Medicare benefits, and some costs for clinical research studies. In all types of Medicare Advantage Plans there is coverage for emergency and urgently needed care. 69 Copyright HRIS 2019

Medicare Advantage = Part C Medicare C may also cover: Vision (not covered under traditional Medicare) Hearing (not covered under traditional Medicare) Dental (not covered under traditional Medicare) Part D – Drug Benefit plan Medicare Advantage Plans differ by needs of the beneficiary and have different offerings We recommend you seek professional guidance when reviewing your particular needs and plans available 70 Copyright HRIS 2019

Type of Medicare Advantage Plans 71 Copyright HRIS 2019