The Affordable Care Act—What Health Care Reform Means for

The Affordable Care Act—
What Health Care Reform
Means for Seniors
Brenda L. Marrero, Esq.
Community Legal Services,
Community Legal Services, Inc.
We are a non-profit public interest legal agency
providing free legal services to low income
We have 2 offices: Center City (15th &
Chestnut) and Broad and Erie
Aging and Disability Unit: @ Broad and Erie.
We represent low income seniors in areas like
Medicare, Medicaid, long term care, nursing
home law, and Social Security/SSI matters
Debunking myths
The Affordable Care Act (ACA) does
NOT cut Medicare benefits
Medicare’s guaranteed benefits remain
Changes to Medicare
Open Enrollment Period is eliminated—
starting in 2011 an individual who enrolls
in a Medicare Advantage (MA) Plan may
return to original Medicare
(red/white/blue card) and a Part D Plan
during the first 45 days of the year
Annual Enrollment Period is now
October 15 thru December 7—this took
effect January 2011
Medicare Cost Sharing improved
Starting in January 2011 there will be no
coinsurance or deductibles for traditional
Medicare preventive services
Medicare will cover free annual
comprehensive wellness visit, and
personalized prevention plan
Smoking cessation and counseling
services are free
Medicare Advantage PlansChanges and Improvements
Starting January 2011 MA Plans cannot
impose cost-sharing for chemotherapy,
renal dialysis services or skilled nursing
care services that exceed the costsharing for those services under original
Medicare—so whether you are in MA
Plan or Traditional Medicare, your cost
share will be the same
MA Plans Con’t
Starting in 2014, 85% of MA Plan
revenues must go towards benefits, NOT
profits, or plans may and will be subject
to sanctions
Goal: to improve quality of care and to
avoid MA Plans from being paid more for
the same services as offered under
Traditional Medicare
Elimination of Exclusion of Coverage
of Certain Part D Drugs
Starting in 2014 Medicaid can no longer
exclude smoking cessation drugs,
barbiturates and benzodiazepines.
Because Part D covered drugs are
defined generally as those drugs
covered under Medicaid, this ACA
provision results in a small expansion of
Part D coverage of barbiturates.
Con’t: Part D Drugs
Starting in 2013 Part D will cover
benzodiazepines and will cover
barbiturates used in the treatment of
epilepsy, cancer of a chronic mental
Part D and Closing the Donut
The ACA creates a multi-part process for
closing the Part D coverage gap, or
“donut hole”
Starting in 2011 the coverage gap will
decrease each year until 2020 when it
will be eliminated and then beneficiaries
will pay 25% co-insurance for
How the donut hole will be
Starting in 2011:
Gradually phasing down the amount beneficiaries pay
for generic drugs
Drug manufacturers must offer a 50% discount on
brand name drugs filled when you are in the donut
Phasing down cost-sharing for brand name
drugs starts in 2013
Reducing the out of pocket amount needed to
reach “catastrophic coverage” from 2014-2019
Improvements to Medicare
For exceptions and appeals filed on or
after January 1, 2010, Rx drug plan
sponsors have to use a single, uniform
exceptions and appeals process and
provide access to that process through a
toll-free telephone number and an
Internet website
Improvements to Medicare
complaint system
Required to develop an easy to use
complaint system that will allow for
collection and maintenance of
complaints received through and by
Prescription Drug Plan (PDPs) and
Medicare Advantage-Prescription Drug
(MA-PD) Plans
Low-Income Medicare
There are ACA Provisions related to low
income Medicare beneficiaries that will
help with cost sharing
LIS & Special Rule for Widows
and Widowers
Effective January 1, 2011 an individual
whose spouse dies in the middle of a
low-income subsidy eligibility period is
granted continued eligibility for a full year
beyond the date when his/her eligibility
would normally cease to be effective
Eliminate Cost Share for Certain
Effective no earlier than January 1,
2012, the ACA eliminates cost sharing
for Part D drugs for all full benefit dual
eligibles (MA and Medicare) who are
receiving home and community based
• This creates equity b/w those receiving care
in an institution (i.e. nursing home) and those
receiving the same care in the community
Funding Outreach/Assistance
Extends and increases the amount of
additional funding (that was included in MIPPA
law in 2008) for State Health Insurance
Counseling Programs (SHIPs), Area Agencies
on Aging (AAA) and Aging and Disability
Resource Centers (ADRCs)
ACA increases funding to $15 million for SHIPs and
AAAs, and $10 million for ADRC’s for FY 2010-FY
Medicaid Provisions
The ACA gives states the option as of January
2010 to expand coverage to childless adults,
except for those with Medicare Part A and/or
Part B, with incomes up to 133% of FPL
Beginning in January 2014 states will be
required to cover these individuals
This is helpful for those who have to wait 2
years after their social security disability
benefits begin before being entitled to
Medicare coverage
ACA Long Term Care Provisions:
Some Highlights
Community First Choice Option
Money Follows The Person
Spousal Impoverishment Protections for
HCBS Recipients
Community First Choice (CFC)
This is a provision of the ACA that
provides the States with a financial
incentive to make a new Medicaid
benefit available to individuals who have
a need for personal attendant services
CFC Benefits
Help with ADLs, IADLs, and health related
Services must be provided per care plan with
significant consumer participation in a home or
community setting
Optional: Transition services (NH to
community). Funding can be used to pay for
rent and utility deposits, 1st month’s rent and
utilities, bedding, basic kitchen supplies and
other necessities
Eligibility for CFC Option
Income limit up to 150% of FPL (or 300%
of SSI limit, which would be PA and that
limit is $2022 per/mo)
Must be “nursing facility clinically
eligible” (NFCE)
Spouse’s income can be deemed
available! This is different from typical
HCBS waiver
Money Follows The Person
Grants to states to fund HCBS for
Medicaid recipients transitioning out of
nursing homes (the Medicaid $ follows
the person out of the facility)
Under the ACA the amount of time a
person had to have been in a nursing
home is reduced to 90 days (v. 180)
Spousal Impoverishment
Spousal Impoverishment: income and resource
counting rules which protect recipient’s spouse
from being impoverished by spouse’s long
term care costs
Currently these rules only apply to nursing
facility residents
ACA provision would requires States to extend
this protection to spouses of recipients of
HCBS services
Health Care Reform and PA
Unclear what if any implementation may
occur under Corbett
Secretary of DPW Gary Alexander may
consider a Medicaid block grant—bad
idea for low income seniors—see
Budget challenges present risk to
implementation of Medicaid expansion
Medicaid cuts in PA—how they
affect seniors
Current budget cut proposals include:
• Eliminating coverage for dentures for
Medicaid recipients—Medicare already does
not cover this
Limiting prescriptions to 6 per month
Eliminating funding for Human Services
Development Fund entirely—will affect senior
centers and Meals on Wheels
How you can get involved
Write to your state senators and
representatives! Voice your opposition to
the state Medicaid funding cuts that will
harm seniors’ health
Write to your senators and
representatives voicing your support for
the ACA and its improvements to
Medicare and long term care
Community Legal Services, Aging &
Disability Unit: 215-227-2400
National Senior Citizens Law Center,
Kaiser Family Foundation,
Center for Medicare Advocacy, Inc.,
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