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Medicare and the Affordable Care Act

Adapted from a presentation at the Myositis Support Group at Hospital for Special Surgery

Like most Americans, people on Medicare have questions about the Affordable Care Act (ACA). This legislation has resulted in a few changes to Medicare and Medicaid, and offers a new option for purchasing healthcare insurance to those not covered by Medicare, Medicaid, or other forms of private insurance. (The ACA is sometimes referred to as Obamacare.)

At a recent presentation at Hospital for Special Surgery, Alison Cook, MPH, from the Medicare Rights Center, a patient advocacy group, reviewed some of the key points about the ACA that are of particular significance to those on Medicare.

This summary provides information on:

  • Changes in Medicare resulting from the Affordable Care Act
  • A general overview of Medicare, Parts A, B, and D
  • A comparison of Medicare Private Health Plans, otherwise known as Medicare Advantage (MA) with original Medicare which is administered directly by the government.

The Affordable Care Act and Medicare Coverage (Parts A, B, and D)

Medicare provides health insurance that covers hospitalization, doctors’ visits, and prescription drugs.

  • For the most part, services provided during hospitalization or on an in-patient basis are covered by Part A.
  • Visits to the doctor’s office are covered by Part B.
  • Part D is the portion of Medicare that covers your prescription drugs.
    • For many years, patients whose prescription expenses exceeded a certain dollar amount found themselves in the “doughnut hole”, a gap in drug coverage that continued until their expenses reached another predetermined level, at which point drug coverage was again provided by Medicare.
    • Prior to healthcare reform, people in this gap were responsible for the total cost of their drugs during the time they were in the “doughnut hole”.
    • This gap began closing in 2010, and will be phased out by 2020 in the following way:
      • 2014: There is a 52.5% discount on brand name drugs and a 28% discount on generic drugs during the doughnut hole.
      • 2015 - 2020: Greater drug discounts each year for people in the doughnut hole.

Medicare and the Marketplace (Insurance Exchange of the ACA)

During this presentation, Ms. Cook emphasized that people who are eligible for Medicare should not purchase a plan through the ACA Insurance Exchange, which is designed to help non-eligible Americans purchase health care insurance. In addition:

  • If you purchased a plan through the exchange when you were under 65, you should enroll in Medicare as soon as you are eligible.
  • Medigap (supplemental policies), stand-alone Part D plans, and Medicare Advantage plans will not be sold through the exchange.

Preventive Care and the ACA

  • Going forward, people with Medicare will have little or no costs for many preventive services.
  • There are no deductibles or coinsurance payments for such services as:
    • Annual wellness visits - which are not the same as your annual physical. During this visit your doctor will develop a wellness plan based on your individual needs. This will include an update of your medical history; a list of your doctors and medications; a record of height, weight, blood pressure, and body mass index (BMI); and a screening for cognitive issues.
    • Mammograms
    • Colonoscopies
    • Diabetes screenings
    • Bone density tests
  • Medicare Advantage Plans must cover the same services and will be reimbursed at the same cost as long as plan rules are followed.

ACA helps Consumers Pick Better Plans

Medicare uses a Star Rating System to measure how well the Medicare Advantage and prescription drug plans (Part D) are performing; this system has been strengthened by the ACA. There are many factors to consider when choosing the plan that is best for you, but the star rating is one piece of information that may be helpful. The system works in the following way:

  • Ratings range from a low of one star to a high of five stars
  • New star ratings come out each Fall.
  • To learn more about the Star Ratings, you can go to: https://www.medicare.gov/ or call: 1.800.MEDICARE

Enrollment Periods under the Affordable Care Act

The ACA has affected some enrollment periods, which allow you to switch your Medicare coverage. Please note that Medicare Advantage and Part D plans change from year to year and they should be reviewed thoroughly.

  • The following is a list of the changes affecting Enrollment Periods:
    • Fall Open Enrollment Period: October 15 - December 7; this is when you can switch Medicare coverage; changes that you make go into effect January 1 of the following year.
    • Medicare Advantage Disenrollment Period: (MADP) January 1 - February 14 of each year. This is when you can switch from a Medicare Advantage Plan to original Medicare.
    • Five Star Special Enrollment Period: Created so that, once per year, you can switch to a Medicare Advantage or Part D plan that has a five star rating.
    • Consistently Low Star Plan Special Enrollment Period; Allows you, once per year, to switch out of your Part D plan if it has received fewer than three stars for three years in a row.

Affordable Care Act (ACA): Additional Benefits

Improvement in Quality of Care: The ACA is designed to improve the quality of care provided to people with Medicare in the following ways.

  • ACA increases payments to doctors who report their information to Medicare
  • ACA lowers payments to hospitals with high readmission rates as a way to provide incentives to hospitals to improve quality of care.

Reducing Fraud: One goal of the ACA and Medicare is to reduce fraud. This is being accomplished  by:

  • Imposing stricter penalties on those found guilty of fraud.
  • Creating groups to help those receiving Medicare better able to prevent and detect fraud.

Payment Reform

  • Current Medicare Advantage (MA) plans are paid 9 to 13% more by the Centers for Medicare and Medicaid Services (CMS) than original Medicare to provide the same care.
  • ACA seeks to bring the MA payments more in line with those of original Medicare.
  • Under the reform, 85% of payments received must go toward the benefits of enrollees rather than other business expenses.

Changes for Dual Eligibles (People with both Medicare and Medicaid)

Under the ACA, people who have both Medicaid and Medicare, will continue to receive this coverage. However:

  • There will be changes in how some dually eligible individuals in New York receive their Medicaid and/or Medicare benefits in 2014.
  • Private plans may be managing some of the services.
  • People with dual eligibility can also expect changes in their managed long term care (MLTC) coverage.

Where to Get More Information and Help

Changes resulting from the ACA can be very confusing, but there IS free help out there! Resources include:

  • Medicare: 800.MEDICARE (800.633.4227) www.medicare.gov
  • Medicare Rights Center. Founded in 1989. this national, non-profit organization that helps people with Medicare obtain high quality and affordable health care. It is the largest independent source of Medicare information and assistance in the United States. MRC provides information in the following ways:
    • The MRC helpline: 800-333-4114. This is a free national helpline, where qualified people will answer your questions about Medicare and help with Medicare issues.
    • Medicare Interactive is a free online Medicare encyclopedia. Easy-to-understand information about Medicare is provided and is easy to navigate. Find them online through www.medicareinteractive.org
    • Dear Marci e-newsletter: This e-newsletter provides up-to-date and answers to Medicare questions in easy to understand language. Additional resources and health tips are provided. Dear Marci is released every two weeks. Sign up online.
    • Local State Health Insurance Assistance Program (SHIP): National resource center www.shiptacenter.org

Learn more about the HSS Myositis Support Group, a free support and education group, held monthly for people with myositis and their family and friends.

Summary completed by: Suzan Fischbein, LCSW, 
Coordinator, Myositis Support Group at HSS
Edited by Nancy Novick


Ms. Allison Cook, MPH
Medicare Rights Center
New York, New York


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