Medicare Watch

New York Releases Proposal to Integrate Benefits and Financing for Dual Eligibles

State proposals to integrate coverage for dually eligible individuals, or people with both Medicare and Medicaid, under the Centers for Medicare and Medicaid Services’ (CMS') new demonstrations and financing models continue to be made public for comments by stakeholders. Last week, the New York State Department of Health posted its demonstration proposal, under which, beginning in 2014, dual eligibles will be automatically enrolled into private insurance plans that provide both Medicare and Medicaid benefits, including pharmacy and long-term care benefits.

The proposal describes New York’s plan in general terms: the state will pursue an integrated financing pathway, under which it will enter into a three-way contract with CMS and private insurance companies that receive capped payments to administer both Medicare and Medicaid benefits. According to the proposal, although beneficiaries subject to the demonstration will be passively enrolled into plans, they will have the ability to disenroll or opt out of the model. The proposal also states that New York will engage independent enrollment brokers to help affected individuals navigate plan choices and enroll into plans. In addition, New York hopes to establish an integrated appeals process for both Medicare and Medicaid benefits, though the state did not provide specifics about the new appeals structure. Implementation of the demonstration will occur in eight designated counties throughout the state, including the five counties that comprise New York City. 

Beginning July of this year, New York plans to enroll dual eligibles requiring long-term care under Medicaid into managed long-term care plans. The demonstration proposal released last week largely builds on this existing framework, which sees the conversion of the Medicaid long-term care benefit from a fee-for-service model into a private managed care model.

Many details about New York’s dual eligible integration demonstration remain unclear, requiring further clarification from the state. The public can comment on New York’s proposal until April 20, 2012.

New York was one of several states that released proposals last week. The National Senior Citizens Law Center (NSCLC) has developed a new website that provides information on state demonstration proposals as they become available. NSCLC’s website also features additional resources designed to help advocates engage in stakeholder processes and provide meaningful input on state plans.

Read the New York State Department of Health’s proposal to integrate care for dually eligible individuals.

Visit NSCLC’s new website, “Dual Eligible Integrated Care Demonstrations: Resources for Advocates.”

House Passes Budget Converting Medicare into a Voucher Program

Today the U.S. House of Representatives voted 228 to 191 along party lines to approve the Fiscal Year 2013 budget that would end the Medicare program as it currently exists. The House budget would replace Medicare, beginning in 2023, with a capped voucher that individuals could use to buy private insurance or Original Medicare. According to initial analysis, the plan would shift significant costs to older adults and people with disabilities. The Center on Budget and Policy Priorities (CBPP) reports that the House budget would limit Medicare spending to a rate that will not keep pace with the growth of health care costs. As a result, the value of the voucher would decrease over time, requiring people to pay more in out-of-pocket expenses for health care coverage. CBPP’s analysis also questions whether Original Medicare would remain a workable option: private plans would likely attract healthier beneficiaries, while those in poorer health would choose Original Medicare. Consequently, if Original Medicare were to cover high numbers of beneficiaries in need of more expensive care, the budget could render the program less financially viable.

In addition, the House budget raises the Medicare eligibility age over time, to age 67 in 2034. Because the budget also repeals the Affordable Care Act (ACA), individuals aged 65 to 67 would not have access to Medicare, coverage through health insurance exchanges or subsidies to help them pay for individual insurance. An additional implication of the repeal of the ACA would be the re-opening of the Medicare prescription drug coverage gap: if the House budget were to take effect, individuals who reach the coverage gap would be required to pay the total cost of their drugs out-of-pocket during this period. The ACA gradually closes the coverage gap by the end of the decade. This year, beneficiaries who reach the coverage gap receive a 50 percent discount on brand-name drugs and a 14 percent discount on generics. Furthermore, the House budget would reintroduce cost-sharing for preventive services that are currently provided at no charge to Medicare beneficiaries under the ACA.

The House proposal also cuts over $800 billion in Medicaid funding, converting it into a block grant program. Unless states are able to offset the cuts in federal funding under the budget, they would likely reduce Medicaid provider payments, further restrict eligibility for the program or cut benefits, including coverage of long-term supports and services that enable people with Medicare who rely on Medicaid for long-term care to remain in their homes and communities.

The budget passed today by the House of Representatives will be sent to the Senate, but it is unlikely to pass in the Senate to become law.

Read Medicare Rights Center President Joe Baker’s statement on the passage of the Fiscal Year 2013 House budget.

Read CBPP’s report, “Medicare in the Ryan Budget.”

Read CBPP’s report, “Ryan Medicaid Block Grant Would Cut Medicaid by One-Third by 2022 and More After That.”

Medicare Reminder

The prescription drug coverage gap, or doughnut hole, starts when your total drug costs—including what you and your plan have paid—reach $2,930 in 2012. In the past, most people had to pay the full cost of their drugs in the coverage gap. However, because of the Affordable Care Act (ACA), the government now helps you pay for your drugs in the coverage gap: in 2012, you will receive a 50 percent discount on brand-name drugs and a 14 percent discount on generics. These discounts will increase each year until 2020, when the coverage gap will close, and you will pay no more than 25 percent of the cost of your drugs at any point during the year.

You get out of the coverage gap in 2012 when you have paid $4,700 in out-of-pocket costs for covered drugs since the start of the year. Your Medicare prescription drug plan should keep track of how much money you have spent out-of-pocket on your medications. This information should be printed on your monthly statements. To make sure this information is correct, you should keep your receipts from the pharmacy.

If you have Extra Help, the federal program that helps people with limited incomes pay the costs of Medicare prescription drug coverage, you will not have a coverage gap. In 2012, individuals with monthly incomes up to $1,396 ($1,891 for couples) and assets up to $13,070 ($26,120 for couples) may be eligible for Extra Help. Contact the Social Security Administration at 1-800-772-1213 for more information.

Learn more about the prescription drug doughnut hole and how you get out of it at www.medicareinteractive.org

Spotlight

How have you been keeping up with the Supreme Court case on the Affordable Care Act (ACA)? On March 26, the court began hearing three days of arguments challenging and defending the constitutionality of the law. The ACA closes the prescription drug coverage gap and provides new preventive services at no cost-sharing for beneficiaries. These improvements to the Medicare program hang in the balance of the Supreme Court’s decision.

Watch live coverage of the Supreme Court case on C-SPAN.

Read Medicare Rights Center President Joe Baker’s statement on the Supreme Court proceedings.

Read Families USA’s guide to the case.