(February 3, 2012) Each year Medicare coverages are revised and as a result, beneficiaries often require assistance in understanding how these changes affect their care and services. To assist patients in understanding and to be able to answer their questions, it is important that caregivers and providers understand the changes that affect their service lines and know what resources are available to answer the patient and/or family questions regarding overall Medicare revisions.
 The improved preventive services coverage, including wellness visits and select screenings, continue in 2012, along with a discount (50 percent) on brand name prescriptions once beneficiaries are in the coverage gap. There are now different time frames for the beneficiary to review current selected Medicare health and drug plans and to make any enrollment changes in the coverage plans selected. Time frames for disenrollment in Medicare Advantages plans have also been revised and are termed the Annual Enrollment Period (AEP). Prior to the AEP, beneficiaries are sent updated information on coverage changes for the next calendar year. This is termed an Annual Notices of Change (ANOC) and along with this document, the beneficiary is also provided Evidence of Coverage (EOC) documents for plans including Medicare Part D. It’s now necessary for beneficiaries to show a new Medicare Part D Plan (PDP) coverage card to pharmacy providers. This means that prior to using the Part D prescription drug coverage in 2012, the new card must be shown at the pharmacy dispensing the medications. Unfortunately, not all beneficiaries will be able to physically show their new Medicare Part D card at the pharmacy, resulting in questions about the process. Home care and hospice staff may need to assist in explaining this requirement as well as getting this new card to the pharmacy.
The Medicare Advantage (MA) open enrollment period also changed this year and was shortened to a 45-day period on Jan. 1. For beneficiaries that might be considering dropping the Medicare Advantage Plan and returning to the original Medicare, this decision must be made promptly along with the selection of a Part D prescription plan to complement the original Medicare coverages.
For specific plans with a five star rating, there are some exceptions to the enrollment periods. CMS will allow Medicare beneficiaries a Special Election Period (SEP) to enroll in MA or PDP plans with an overall quality rating of five stars at any time during the year (CMS). This is intended as an added incentive for plans to promote provider quality. Quality is taking on an incentivized focus, as CMS has also introduced quality bonus payments to Medicare Advantage plans that earn three star ratings and higher. Stars are focused on performance in the areas of preventive care, chronic condition care management, care and responsiveness, complaints and appeals activities and customer service.
Other changes that began at the beginning of the year for Medicare Advantage plans include:
- Prohibiting higher cost sharing requirements for key medical services such as chemotherapy, renal dialysis, skilled nursing care and other services.
- Providing a low annual payment adjustment.
- Limiting administrative expenses and profit levels beginning in 2014.
One cautionary thought on how these changes may affect beneficiaries directly is that premiums could increase, beneficiary cost sharing could increase and extra benefits could be reduced. There could also be more limitations of providers within the plan’s network (The Henry J Kaiser Family Foundation, May 2010, p.3).
Part D benefits are being revised for both traditional and Medicare Advantage Part D plans. Within Medicare Advantage Part D plans, discounts will be given for both brand name (50 percent) and generic (14 percent), once the beneficiary is in the Part D coverage gap. Some standard / traditional plans could see an increase in the initial coverage limits and an increase in the out-of-pocket maximums prior to catastrophic coverage beginning. These revisions mean that beneficiaries should compare their current standard/traditional plan’s coverage to the Medicare Advantage Part D coverages.
Resources available to beneficiaries and health care staff include the following:
- Centers for Medicare and Medicaid Services (federal government)
www.medicare.gov
Phone: l-800-MEDICARE (1-800-633-4227)
- Medicare Rights Center (national, nonprofit consumer service organization)
www.medicarerights.org
Phone:1-800-333-4114
- Administration on Aging (federal agency)
www.aoa.gov
Resources:
Centers for Medicare and Medicaid Services. Medicare and You 2012. Retrieved here on Jan. 10, 2012
Medicare Changes 2012: Five Things You Need to Know. Retrieved here on Jan. 10, 2012
The Henry J. Kaiser Family Foundation. Explaining health care reform: Key changes in the Medicare Advantage program. Focus on Health Reform. May 2010.
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