Medicare Beneficiaries and the ACA - Marcelo Espiritu presentation at Townhall, ICC Milpitas

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Townhall meeting about the implications of ACA/Obamacare
How the Affordable Care Act Affects You
- Moderator: Aditya Ullal, Veterans Affairs Palo Alto Health Care System
- Panelist: Marcelo Espiritu, HICAP Product Analyst,
Sourcewise previously Council on Aging Silicon Valley

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  • All of these parts have some type of cost sharing.
    For example,
  • To find out if Medicare covers a service you need, visit www.medicare.gov and select “Find Out What Medicare Covers,” or call 1-800-MEDICARE (1‑800‑633‑4227). TTY users should call 1‑877‑486‑2048
  • COBRA insurance is not considered coverage due to active employment. Some remain in COBRA past their 8 month SEP and later incur a Part B penalty.
  • ACO are rewarded based on:
    •Patient/Caregiver Experience of Care•Care Coordination•Patient Safety•Preventive Health•At Risk Population/Frail Elderly Health
  • New Maximum Out of Pocket Limits
  • New Maximum Out of Pocket Limits
  • Penalty is added on to any adjustment and collected by Social Security.
    ACA implemented means testing for Medicare Part D.
  • “Closing the Part D donut hole” means that enrollee gap responsibility will be limited to 25% or less of the total drug price.
  • ACA implemented quality star rating for both Medicare Advantage Plans and Medicare Prescription Drug Plans.
    Plans that achieve a 5 star rating receive more money. Furthermore, prospective members are allowed to enroll at anytime under a new 5-Star Special Enrollment Period.
  • The ACA freezes these income ranges
  • Medicare Beneficiaries and the ACA - Marcelo Espiritu presentation at Townhall, ICC Milpitas

    1. 1. 1
    2. 2. Helping Seniors Age Well at Home Sourcewise provides expertise, education, and quality support services to Santa Clara County seniors, their families and caregivers. 2
    3. 3. Medicare Beneficiaries and the ACA Marcelo Espiritu, Product Analyst Health Insurance Counseling & Advocacy Program Connie Corrales, Director Health Insurance Counseling & Advocacy Program 3
    4. 4. Background: Medicare Coverage “ “Medicare Advantage”  Inpatient hospital care  Skilled nursing care managed care capitation Original Medicare fee-for-service” Part A  Home health care  Hospice care A  Doctor’s services and outpatient care  Annual Wellness Visit   Home health care Diagnostic tests  Some therapies  Part D Preventive services  Part B Part C Durable medical equipment  Outpatient prescription drugs B Part D 4
    5. 5. Not Covered by Medicare Part A or B  Long-term care  Routine dental care  Dentures  Vision  Cosmetic Surgery  Acupuncture  Hearing aids and exams for fitting hearing aids  Other- check on www.medicare.gov 5
    6. 6. Enrollment: Delaying Part B  Some people may delay enrolling in Part B with no penalty  Must be covered under employer or union group health plan . . . AND  coverage must be based on active employment  Individual’s or spouse’s Special Enrollment Period (SEP) Anytime while working and up to eight months after active employment or employer coverage ends, whichever happens first. 6
    7. 7. Late Enrollment in Part D  People who wait to enroll may pay a penalty  Additional 1% of national base premium ($32.42 in 2014)  Must pay the penalty as long as enrolled in a Medicare drug plan  No penalty if one has “Creditable Coverage” 7
    8. 8. ACA Effects on Part A and B  Eliminates co-pay for preventive services  Accountable Care Organizations  Links payment to quality outcomes  Hospital readmissions are being watched 8
    9. 9. ACA Effects on Part C  New Maximum Out of Pocket Limit  Annual Election Period starts earlier  Plans will have quality ratings  Special enrollment periods  Decreases capitation to Medicare Advantage Organizations (overpaid by 14% per person)  Pegs MA capitation to Quality metrics 9
    10. 10. ACA Effects on Part D  Means test for Part D premium  The Coverage Gap or “Donut Hole” is closing 10
    11. 11. 2013 Part D Premium Adjustment If your Modified Adjusted Gross Income in 2011 was: You pay Social Security an extra (Individual Tax Return) (Joint Tax Return) $85,000 or less $170,000 or less $0 $85,001-$107,000 $170,00-$214,000 $11.60 $107,001-$160,000 $214,001-$320,000 $29.90 $160,001-$214,000 $320,001-$428,000 $48.30 Above $214,000 Above $428,000 $66.60 11
    12. 12. Part D Coverage Gap Shrinking 2014 “Donut Hole”  What: Discount and subsidy apply to Part D- covered drugs in plan’s formulary or granted an exception by plan.  Brand name drugs- 52.5% discount (same as 2013)  Generic drugs- 28% discount (change of 7%)  Where: Point-of-Sale (e.g. at the pharmacy) 12
    13. 13. Comparing Part D Plans Use the Medicare.gov Plan Finder Tool  Based on your own  Zip code  Prescription drug list  Pharmacy . . .  Sorts plans by the lowest estimated annual drug cost (calculates donut hole costs as well)  Check the new quality star rating 13
    14. 14. Prevent Fraud and Abuse  Medicare Card  SS#  Just Say NO!!!  Contact HICAP at (408) 350-3200 option 2 14
    15. 15. Health Insurance Counseling & Advocacy Program  HICAP counselors are available at Sourcewise and at senior centers throughout Santa Clara County  Call HICAP at (408) 350-3200 Option 2 to make an appointment 15
    16. 16. Thank You 16
    17. 17. 17
    18. 18. 2013 Part B Premium If your Modified Adjusted Gross Income in 2011 was: You pay Social Security Individual Tax Return Joint Tax Return $85,000 or less $170,000 or less $104.90 $85,001-$107,000 $170,00-$214,000 $146.90 $107,001-$160,000 $214,001-$320,000 $209.80 $160,001-$214,000 $320,001-$428,000 $272.70 Above $214,000 Above $428,000 $335.70 18

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