Extensive MIPPA Provisions Become Effective January 2010

Extensive MIPPA Provisions Become Effective January 2010

Many provisions in the Medicare Improvement for Patients and Providers Act (MIPPA) of 2008, which was signed into law July 2008, become effective as of January 2010. A significant portion of these new improvements will affect beneficiaries with low-incomes. This article highlights these provisions below.

2010 MIPPA Provisions

Mental Health Parity

Starting January 1, 2010, Medicare will pay 55% of the approved costs for psychiatric services and beneficiaries will pay 45%. Over the next 5 years, Medicare’s cost-sharing will gradually increase; by 2014, Medicare will pay 80% of the approved costs and beneficiaries 20%. This pay structure will reflect what’s used for other Part B outpatient services where beneficiaries have a 20% coinsurance. Currently Medicare only pays 50% of the approved costs for psychiatric services, leaving beneficiaries to pay the other 50%.
Here’s a table showing Medicare’s increased mental health coverage over the next 5 years.

Year Medicare Pays Beneficiary Pays
2010 55% 45%
2011 55% 45%
2012 60% 40%
2013 65% 35%
2014+ 80% 20%

Medicare Advantage (MA) Plan Provisions

Special Needs Plans

  • Extends authority for plan sponsors to offer SNPs through 2010.
  • Extends moratorium on offering new SNPs.
  • All SNPs must meet new coordination of care requirements, such as: 1) using an evidence-based model of care with an appropriate network of providers; 2) developing a plan of care in consultation with the enrollee that identifies the goals, objectives, specific services and benefits to be provided; 3) conducting an initial and annual assessment of each enrollee’s needs; and 4) having an interdisciplinary team manage each enrollee’s care.
  • All SNPs (including SNPs for dual-eligible, institutionalized and chronic condition beneficiaries) may enroll only individuals who meet the special need requirement of the plan.
  • Institutional SNPs (I-SNPs) must use a state assessment tool to determine the need for institutional level care in the community. The assessment must be done by an entity other than the SNP.
  • Dual SNPs (also known as D-SNPs — plans explicitly for beneficiaries with Medicare and Medicaid) must have contracts with State Medicaid agencies to provide appropriate Medicaid benefits for enrollees. (Note: this is true for new SNPs and SNPs that are expanding; existing SNPs don’t have to contract with the state Medicaid agency (Medi-Cal in California) if they’re not expanding.) States are not required to enter into contracts with SNPs.
  • D-SNPs must give each prospective enrollee a written notice describing the benefits and cost-sharing under the state Medicaid program, and explicitly state which of these benefits and cost-sharing are also covered by the plan.
  • D-SNPs are prohibited from charging enrollees any costs that exceed the amounts permitted under Medicaid for duals not enrolled in a D-SNP.
  • Chronic Condition SNPs (C-SNPs) must abide by a new definition of people eligible for C-SNPs. The definition states that a person must have “one or more co-morbid and medically complex chronic conditions that are substantially disabling or life-threatening, [have] a high risk of hospitalization or other significant adverse health outcomes, and [require] specialized delivery systems across domains of care.”

All MA Plans

  • All plans must inform Medicare and Medicaid providers of rules relating to cost-sharing for dual-eligible beneficiaries. Two such rules are that: 1) plans may not impose cost-sharing that exceeds what the dual would be required to pay through Medicaid; and 2) contracts with providers must state that providers will accept the plan’s payment as payment in full or bill the appropriate state source. Providers cannot balance bill their Medicare patients.
  • All plans must include the type of plan in their plan names and use standard abbreviations created by the Centers for Medicare and Medicaid Services (CMS).

Medicare Part D Prescription Drug Coverage Provisions

  • Part D prescription drug plans (PDPs) are required to provide prompt payment to pharmacies. PDP and Medicare Advantage prescription drug plans (MA-PDs) must pay clean claims to retail pharmacies within14 days if submitted electronically, or within 30 days otherwise.

Low-Income Subsidy (LIS) and Medicare Savings Programs (MSP) Provisions

MSPs

  • Increases asset levels for MSP eligibility to the more generous asset level amounts used for the full Part D LIS eligibility (not partial). From 2010 on, MSP asset levels will also be indexed each year. Current MSP and LIS asset levels for 2009 are: MSP- $4,000 for individuals, $6,000 for couples; LIS – $8,100 for individuals, $12,910 for couples. (Note: these resource limits include $1,500 per person for burial expenses.)

LIS Eligibility

  • Excludes in-kind support and maintenance as countable income.
  • Excludes the cash surrender value of life insurance policies from the countable assets limit.
  • The new application form will no longer ask about these excluded items. 2010 application form will be available late December at your local Social Security office, or by January 2, 2010 online at the Social Security website.
  • In early 2010, Social Security will contact all individuals who have been found ineligible for the LIS with information about the new rules and will be invited to reapply.

Note: Social Security has some helpful video and webinar resources explaining these upcoming changes.

Elimination of LIS & MSP Enrollment Barriers

  • Social Security must provide information on both the MSPs and LIS to LIS applicants, including those identified as potentially eligible. They must also provide information on people’s local State Health Insurance Assistance Program (SHIP).
  • Social Security will send all LIS applicants’ information to the state Medicaid agency (Medi-Cal in California) to be screened for the MSPs unless an applicant opts out. LIS applicants can check a box on the form to agree to have their application forwarded. The state Medicaid office will then treat the forwarded data as an application for both Medi-Cal and the MSPs. The date of the LIS application is the protected filing date for all programs.
  • MSP applications will be to be translated into at least 10 of the most common non-English languages spoken by Medicare beneficiaries.

2011 MIPPA Provisions

Medicare Advantage Private-Fee-for-Service (PFFS) Plans

  • All non-employer sponsored PFFS plans in counties with at least 2 HMOs and/or local PPOs must have a network of contracted providers for their enrollees to use. (Note: regional PPOs don’t count.) Based on the 2010 plan market, this new rule would apply to 28 out of 58 counties in the state.
  • All employer-sponsored PFFS plans must have a network of contracted providers for their enrollees in each county of operation, regardless of the number of HMOs or PPOs in a given county.

In addition to these provisions, MIPPA has several provisions already in effect and several still to come. See our past MIPPA articles for more information:

Our blogger Karen J. Fletcher is CHA's publications consultant. She provides technical expertise, writing and research on Medicare, health disparities and other health care issues. With a Masters in Public Health from UC Berkeley, she serves in health advocacy as a trainer and consultant. See her current articles.