The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) brought important improvements to the Medicare system. MIPPA is a complicated piece of legislation, running over 275 pages. Not all provisions are discussed here; rather, this brief overview aims to discuss pertinent areas that are of particular importance to states and low-income beneficiaries. Topics included are:
- Changes Affecting Beneficiaries with Limited Incomes and Resources
- Medicare Advantage Changes
- Medigap Changes
- Changes to Therapy and Psychiatric Costs and Coverage Caps
Alignment of Asset Level for Medicare Savings Plans and Low Income Subsidy
Effective January 1, 2010, MIPPA mandated that the basic minimum federal eligibility rules for all Medicare Savings Plans (MSP) will have the same asset (resource) level as full Low Income Subsidy (LIS).In 2010, these levels are $6,600 for a single individual and $9,910 for a married couple. In addition to allowing more seniors and people with disabilities to qualify for their state’s Medicare Savings Plans, this change should simplify the relationship between Medicare Savings Plans and the Part D low-income subsidy.
Calculating Beneficiaries Income & Assets for LIS
Effective January 1, 2010, cash surrender value of life insurance is no longer being counted as an asset for LIS eligibility. Notwithstanding this, states may choose to continue counting the cash surrender value of life insurance as an asset in determining MSP eligibility. Also, in-kind support and maintenance, non-cash help in the form of food, clothing, or shelter, will no longer be counted as income for LIS eligibility. However, a few states continue to count in-kind support and maintenance in calculating income for MSPs.
Part D Late Enrollment Penalties Eliminated
Starting January 1, 2009, MIPPA mandated that people with LIS be excused from paying Part D plan late enrollment penalty premiums. In conjunction, enrollment in Qualified Medicare Beneficiary Program (QMB) waives any otherwise applicable Medicare Parts A and B late enrollment penalty premiums, and enrollment in Specified Low Income Medicare Beneficiary program (SLMB) or Qualified Individual program (QI) waive any Part B late enrollment penalty premiums.
Estate recovery for Medicare Savings Plan Eliminated
Effective January 1, 2010, states were prohibited from recovering Medicaid expenditures for Medicare premiums and cost-sharing paid under MSPs from the estates of deceased Medicaid/MSP recipients. This change should encourage more eligible people to apply for these programs.
Better Coordinated Outreach with Social Security -- Transmittal of LIS Data for MSP Application
Before January 2010, low-income beneficiaries who enrolled in the Part D LIS through the Social Security Administration (SSA) were not screened for eligibility for MSPs. As a result, there were many low-income beneficiaries receiving the LIS who were eligible for, but not enrolled in, a MSP. Starting January 1, 2010, when a person consented to the transmittal of their LIS data, the Social Security Administration (SSA) transmitted the information on the beneficiary’s LIS application to state Medicaid agencies. Upon receipt of the data, state Medicaid agencies are obligated to treat the data SSA transmits as the start of an MSP application. In addition, SSA Field Offices must give LIS applicants information about how to get enrollment assistance from State Health Insurance Assistance Program (SHIP), and SSA personnel who take LIS applications must be trained on MSPs eligibility criteria and enrollment procedures as well as on the rules for LIS. This process will help to ensure that low-income seniors who apply for the LIS will have an opportunity to receive MSP benefits as well. The process also presents an outstanding opportunity to enroll eligible seniors for other programs including Supplemental Nutrition Assistance Program (SNAP). Issue Brief discussing how LIS, MSPs, and SNAP can be integrated to allow for a greater opportunity for eligible people to enroll in the programs
Model MSP Application & LIS/MSP Application Provisions
CMS has developed a model MSP application. While states are encouraged to use this model, they are not required to do so. The MSP model applications are available in eleven languages including Arabic, Chinese, English, French, Haitian-Creole, Farsi, Korean, Spanish, Tagalog, Russian, and Vietnamese. Model Applications for MSPs
Also, beginning January 1, 2010, SSA Field Offices must give LIS applicants information about how to get enrollment assistance from State Health Insurance Assistance Programs (SHIPs). SHIPs can answer questions dealing with Medigap policies, long-term care insurance, Medicare health plan choices, Medicare rights and protections, and help with filing an appeal. In addition, SSA personnel who take LIS applications will be trained on MSPs eligibility criteria and enrollment procedures as well as on the rules for LIS. Notwithstanding this, because MSPs are Medicaid benefits, state Medicaid agencies must adjudicate MSP entitlement. Contact Details for State Health Insurance Assistance Programs (SHIPs)
Effective January 1, 2009, MIPPA prohibited most “cold” marketing contacts and the cross-selling on non-health-related products, such as annuities or life insurance during a Medicare Advantage or Part D marketing encounter. Also, MIPAA required that the plan type, i.e., PPO, PFFS, etc., be plainly included in the title of the plan. In addition, MIPPA mandated that the plan sponsors be responsible for the actions of agents, brokers and other third parties marketing and selling their products.
Members of Special Needs Plans
As of January 1, 2010, only those who have the explicit special needs identified by the Medicare Advantage plan may be members of the particular Special Needs Plan (SNP); this means spouses and friends are no longer allowed to join such plans. Also, each SNP must establish an evidence-based model of care, approved by CMS, and build its provider network to include an appropriate network of providers and specialists that can meet the special needs of its members. In addition, each SNP provider must make an initial assessment of each new member’s needs, and use the assessment to create specific, individualized plans of care, in consultation with the member to the extent feasible.
SNP for Beneficiaries that are Dually Entitled to Medicare and Medicaid (D-SNPs)
As of the 2010 Annual Enrollment Period, D-SNPs must provide people considering joining the plan with a written statement of Medicaid-covered benefits and what the D-SNP plan covers; this statement must also describe the plan and Medicaid cost-sharing, and most importantly, D-SNPs are prohibited from charging members who have Medicaid in any amount in excess of the applicable cost-sharing allowed by Medicaid. In an effort to encourage coordination between Medicaid coverage and D-SNP coverage, most D-SNPs must have a contract with the state Medicaid agency; this contract must detail how Medicaid benefits are provided to D-SNP members.
SNPs for People Residing in Institutions (I-SNPs)
Institutional SNPs serve those who reside or are expected to reside for 90 days or longer in a long term care facility (defined as either: skilled nursing facility (SNF) nursing facility (NF), intermediate care facility (ICF) or inpatient psychiatric facility), or it may also choose to serve people living in the community but requiring an equivalent level of care to those residing in a long term care facility. As of 2010, SNPs serving people living at home must use a state assessment tool to determine the need for an institutional level of care of prospective members living in their own homes. The level of care assessment must be accomplished using an assessment tool used by the state in which a person lives. The assessment may not be performed by plan personnel, but it may be performed by the same entity that assesses level of care for the state Medicaid agency.
SNPs for People who have Severe or Disabling Conditions (C-SNPS)
As of 2010, membership to C-SNPs is limited to people who have one or more of the 15 specified conditions identified by a panel of clinical advisers as meeting the MIPPA-clarified definition of "severe or disabling." CMS List of Fifteen Specified Conditions
A Medigap policy (Medicare Supplemental Insurance) is health insurance sold by private insurance companies to fill the “gaps” in Original Medicare Plan coverage (Part A & Part B). Medigap policies help pay some of the health care costs that the Original Medicare Plan doesn’t cover. If you are in the Original Medicare Plan and have a Medigap policy, then Medicare and your Medigap policy will pay both their shares of covered health care costs.
Revised Medigap Standardized Plans
Standard Coverage for Medigap
Standard coverage for Medigap has changed so that preventive care and at home Medigap benefits have been eliminated for new or renewing Medigap plans as of July 2010, or earlier, depending upon state ratification date. Hospice coinsurance will be included as a basic core benefit in Medigap A and all other Medigap policies. In addition, MIPAA eliminated Medigap preventive benefit because Medicare Part B is covering more preventive, wellness and screening services, the Medigap coverage seemed less useful than it used to be in the past.
New Medigap Plans
Medigap policies M and N are new standardized policies that can be offered. These plans have higher cost-sharing for the Medicare Part A deductible and limited or no coverage for the annual Part B deductible ($135 in 2009). These new policies substitute set co-payments for coverage of the usual Part B 20 percent cost-sharing. Plan M covers half of the Part A hospital deductible, has no coverage for the Part B annual deductible, and provides copayments of $20.00 for office visits and $50 for hospital Emergency Room visits. Plan N covers the Part A hospital deductible, but has no coverage for the Part B annual deductible. Plan N also imposes Part B copayments of $20.00 for office visits and $50 for hospital Emergency Room visits.
Beginning January 1, 2009, MIPPA enabled people new to Medicare have one full year after enrolling in Medicare Part B to get their one Medicare-covered physical, "Welcome to Medicare Exam," and the Part B deductible is waived for purposes of getting the Welcome to Medicare physical. The physical includes body mass measurement and an end-of-life planning consultation.
Changes to Part B Psychiatric Services Co-Pays
As of 2009, most out-patient psychiatric services were subject to a 50% co-insurance, as opposed to the 20% co-insurance charged for most other Part B services. The only exception to this rule is psychiatric diagnostic and brief medications management services, which has always been at the 20 percent coinsurance level. By 2014, psychiatric services will become like other Part B services with only 20% co-insurance. This change is being phased in between 2010 and 2014: 2010 and 2011, 45 percent co-insurance; 2012, 40 percent co-insurance; 2013, 35 percent co-insurance; 2014 and thereafter, 20 percent co-insurance
Rehabilitation Therapies Cost and Coverage Caps
In 2010, coverage caps for Physical Therapy (PT) and Speech/Language Therapy (SLT) and Occupational Therapy (OT) will increase slightly, and the exceptions to the therapy caps ceased at the end of 2009. CMS Patient Brochure on Therapy Caps
Durable Medical Equipment, Prosthetics, Orthotics and Supplies Competitive Bidding
As of October 1, 2009, suppliers of durable medical equipment, like wheelchairs and hospital beds, supplies, and prosthetic devices, such as artificial limbs, had to be accredited and bonded. In addition, starting in 2011, competitive bidding will return to ten large metropolitan areas.
Information for People with Limited Income and Resources
Congress created Medicare Savings Programs (MSPs) and the Low-Income Subsidy (LIS) to help ensure low-income seniors and people with disabilities have the necessary support to receive Medicare coverage and access to affordable drug prescriptions.
The MSPs are a family of four programs that provide assistance directly to low-income seniors and people with disabilities who rely on Medicare:
- Qualified Medicare Beneficiaries (QMB) Beneficiaries in the QMB program receive help with their Medicare Part A and B premiums, deductibles, coinsurance and co-payments.
- Specified Low-Income Medicare Beneficiaries (SLMB) Beneficiaries in the SLMB program receive help with their Medicare Part B premium.
- Qualified Individuals (QI) Beneficiaries in the QI program receive help with their Medicare Part B premium.
- Qualified Disabled and Working Individuals (QDWI) Beneficiaries in the QDWI program receive help with their Medicare Part A premium.
LIS (or "Extra Help") is a vital program for ensuring that needy seniors and people with disabilities have affordable prescription drug coverage. LIS is funded by the federal government and pays for part of the costs associated with Medicare Part D, which includes a monthly premium, yearly deductible, prescription coinsurance and co-payments and no gap in coverage. Some people are automatically eligible for LIS, including those who are:
- Full benefit dual eligibles (individuals eligible for both Medicare and Medicaid)
- Supplemental Security Income (SSI) recipients with Medicare
- MSP beneficiaries