The mandate to buy health insurance is the one thing everyone seems to know about Obamacare. Without the mandate, insurance companies cannot afford to offer coverage to everyone irrespective of their heath condition.  If the mandate is deemed unconstitutional by the Supreme Court, they will then need to decide if everything that comes under the Affordable Care Act must also be canceled.

Here are some of the Medicare-related parts of the Affordable Care Act that would go down with Obamacare. The list is provided by  Patients Aware.org.

IN GENERAL, through a long list of programs and policies, the Affordable Care Act saves Medicare about $450 billion in the first decade, mostly through agreed upon reductions in payment rates for inpatient hospitals, long-term care hospitals, home health services, skilled nursing facilities, and other providers, as well as reduced subsidies to private Medicare Advantage plans.

PART D
• Closes the donut hole in the Part D prescription drug program.
• Provides a 50 percent discount for brand name drugs beginning in 2011 for seniors in the donut hole, regardless of income.

MEDICARE
• Eliminates cost-sharing for proven preventive services.
• Provides a comprehensive annual wellness visit and personalized prevention plan.
• Improves seniors’ access to primary care by providing bonus payments to primary care providers.
• Establishes initiatives to encourage the development of a more efficient health care delivery, especially for seniors with multiple chronic conditions.
• Provides transition services to high-risk Medicare beneficiaries when they are discharged from the hospital.
• Helps seniors living in rural areas by making sure their physicians are adequately paid.

MEDICARE ADVANTAGE
• Phases down subsidies for Medicare Advantage plans over time so that, on average, plans will ultimately receive payments comparable to what it would cost traditional Medicare to cover the same seniors.
• Requires all Medicare Advantage plans to spend at least 85 percent of revenue on senior care rather than profits or overhead, beginning in 2014.

MEDICARE FRAUD
• Includes new resources and tools to protect taxpayer dollars by preventing fraud in Medicare and Medicaid.
• Allows the Department of Health and Human Services to share IRS data to help screen and identify fraudulent providers.
• Strengthens oversight of Durable Medical Equipment providers.
• Increases overall funding for the Health Care Fraud & Abuse Control Fund to $700 million over the next decade.

I’m in Connecticut visiting friends and family and enjoying the cool rain. A friend who is on Medicare was bemoaning her high drug costs and going into the donut hole, so I did a little research to see if she could qualify for help from the state of Connecticut. I was shocked by what I found.

While most states use standard income levels (up to 135% of the federal poverty level) to determine if a person should get help with their Medicare costs, Connecticut will help people who have nearly twice the standard limit.

Income of $1,246 per month for an individual and $1,675 for a couple is generally the cut-off for getting your state to pay your Part B premium ($96 – $115.40 per month). The income limit in Connecticut is $2,091 for an individual and $2,816 for a couple. And Connecticut does not consider assets a person has such as bank accounts, investments, or retirement accounts. They only look at  a person’s income, so people who live on their Social Security check would likely qualify for help from the state of Connecticut.

If my friend qualifies for help from the state of Connecticut, the state will inform Social Security that she also qualifies for help with her Part D costs.  When this goes into her Medicare record, she will pay $6.30 for her brand drugs and $2.50 for generics, which is the help she really needs.  And she will have no donut hole in her Part D coverage, saving her thousands of dollars each year.

Now, before you decide to move to Connecticut, I must warn you that my home state is an expensive place to live.  My friend had mail from a Medicare supplement company and I was shocked to see that the cost of a Medigap Plan F  is $220 per month for a person turning 65 in Connecticut. That is $100 more than the cost in Arizona for the same coverage with the same company.

Medicare Advantage plans are also more expensive in Connecticut. My friend is enrolled in an Advantage plan for which she pays $110 per month – though it offers much better coverage than $0 premium plans in Arizona.  And we won’t even talk about property taxes, which are three to five times higher than in Arizona.

Maybe, when I’m 65, I’ll buy a Medicare supplement in Arizona and spend my summers in Connecticut – though I can probably only afford a single-wide trailer at Connecticut prices.

For more info on getting help with Medicare and Part D costs, check out a previous post: Help with Medicare Costs

Folks in Connecticut should contact an Agency on Aging for more info and an application.  Here is a link to a web site that provides phone numbers for offices across the state.  http://www.ctagenciesonaging.org/pages/home.php

I came across a website for Connecticut elder services and found an application there – but the application was four pages and asked for lots of info. Turns out that is an old, out-of-date application.  The new application is just two pages.  I used the link above and talked to a very nice lady in Norwich who sent my friend the correct application for the Medicare Savings Program.

Six months ago I was predicting big changes for Arizona Medicare Advantage plans in 2011.  I was wrong.  There will be very few changes to most of the Arizona Medicare Advantage plans in 2011. Most HMO plans still have $0 premium.  Co-pays for doctor visits and hospital stays have not changed much. Plans are still offering free gym memberships.  Some Advantage plans are being canceled and this will require about 2000 people in southern Arizona to find a new plan.  Plan cancellations are more about the “business model” of the canceled plans than changes brought about by health care reform.

POSITIVE CHANGES

Every Medicare Advantage plan must cap enrollees’ out-of-pocket expenses. This means all the co-pays for doctor visits, hospital stays, chemo and radiation treatment, and other services (when added up during the year) are capped at a certain limit for that year.  The highest allowable maximum-out-of-pocket (MOOP) is $6,700, but most plans have set their MOOP at $5,000 or less. $3,400 is the lowest MOOP being offered by two companies.

Relief in the Part D Donut Hole: In 2011, if a person reaches the donut hole, he will get a 50% discount on the price of his brand drugs and a 7% discount on generics.  A person reaches the donut hole when what the enrollee and the Part D plan have spent (added together) totals $2,840.  If a person has total monthly drug costs of $400 (even if his co-pays are just $100), he would hit the donut hole after 7 months ($400 x 7 = $2,800). Starting in August he would be responsible for 100% of his drug costs ($400), but he will get a 50% discount if these are brand drugs.  Thus he would pay only $200 for his brand name prescriptions each month from August to December.

A new Medicare Advantage plan in Pima County: SCAN (Senior Care Action Network) is a California-based not-for-profit which began operating in Maricopa County two years ago. They say they will have a good doctor network in Pima County, though that could take some time to accomplish.  Their Part D drug plan could make it worthwhile to look into SCAN as it will cover generics through the gap. I’ve met some people with expensive generics that put them in the donut hole.

NEGATIVE CHANGES

The Annual Election Period (November 15 – December 31) will be the only time to change your Medicare Advantage plan or Part D plan.  In previous years seniors had another chance to switch Advantage plans during the Open Enroll Period from January 1 – March 31. The Open Enrollment Period has been eliminated.  If a person decides in January that she doesn’t like her Advantage plan….too bad.  She cannot change to another Advantage plan – but she can dis-enroll from her plan and go back to Original Medicare (between January 1 and February 14).  She would probably want to purchase a stand-alone Part D plan as well as a Medicare Supplement, both of which have monthly premiums. As of February 15th she is “locked into” her advantage plan unless she qualifies for a special enrollment period due to certain chronic illnesses, limited income subsidy, or moving out of her plan’s service area.

A number of plans are being canceled for 2011 and people enrolled in them will have to shop for a new Advantage plan – or go back to Original Medicare, get a stand-alone Part D plan and a Medicare Supplement.  See my recent post about “guaranteed issue” for Medicare Supplements if your Advantage plan is canceled: http://tucsoncitizen.com/medicare/2010/09/27/medicare-advantage-cancellation-your-options/

Health Net’s Amber plan is changing to a “Dual Eligible” Advantage plan.  The Amber plan has always been a plan for people who get their co-pays covered by AHCCCS (Arizona Health Care Cost Containment System, aka Medicaid).  But the Amber plan has also covered people who had incomes less than $1,240 (single) or $1,660 (couple) if they applied for Medicare Cost Sharing help.  These seniors on limited incomes (but not low enough to qualify for Medicaid) have been helped by the low co-pays that came with the Amber plan.  As of January 1, 2011, the Amber plan will have 20% co-pays (which will be paid by AHCCCS for “full duals”). That means that people who do not get their co-pays paid by AHCCCS will need to shop for another Medicare Advantage plan. Unfortunately,  most Advantage plans have co-pays that are double the Amber co-pays.  Seniors who have to move off the Amber plan will face sticker shock as their co-pays double for doctor visits and hospital stays. They will still get help with their prescription costs. There is one plan in Tucson with co-pays similar to the Amber plan, but it has a limited doctor network.  People leaving the Amber plan will have to choose between plans with a bigger network of doctors and hospitals or a plan with low co-pays and a limited network.

FOR MORE INFORMATION GO TO MEDICARE CHOICES OF ARIZONA .