Medicare Changes for 2012

Medicare Advantage

Starting in 2012, Medicare Advantage (MA) plans (Medicare HMOs) will not be able to charge enrollees for preventive care services that are free for people with Original Medicare. However, they typically do (and still can) charge if MA members go “out of network” for these services. For more information, see Medicare-Covered Preventive Services .

Donut Hole

Just as in 2011, there will be a 50 percent discount for brand-name drugs during the coverage gap (also known as the donut hole). The discount for generics during the donut hole will increase to 14 percent.

In 2012 the coverage gap begins when beneficiaries reach $2,930 in total drug costs, which includes both what the beneficiary and plan pays, for drugs covered by their plan. The coverage gap ends when total drugs costs reach $6,657.50. The amount the beneficiary pays for all drugs and the amount covered by the 50 percent discount on brand-name drugs count toward the total drug costs needed to get out of the donut hole and into catastrophic coverage. The amount covered by the 14 percent discount on generic drugs does not count toward getting out of the donut hole. After reaching $6,657.50 in total drug costs, beneficiaries pay no more than 5 percent of the cost of the drugs covered by their plan.

• More information: Donut Hole Fact Sheet

Physician and Hospital Payments

2012 will see changes in reimbursement rates as well. One change reduces payments to hospitals with high rates of preventable hospital readmissions in order to promote higher-quality outcomes. Another change establishes a “value-based” purchasing system for hospitals. Medicare would link payments to hospitals to their performance on quality measures. Similar plans are in the works for value-based purchasing programs in other areas, including home health agencies and skilled nursing facilities. The purpose is to create a more efficient system that will reduce costs while also providing patients with higher-quality care and better health outcomes.

Tips

• A growing trend is for Part D plans to differentiate between “preferred” and “non-preferred” pharmacies within their network. You pay the least when you use preferred pharmacies. Make sure the pharmacies you use are “preferred.”
• Again in 2012, people with higher incomes will pay higher Part B and Part D premiums. Individuals with incomes over $85,000 ($170,000 for couples) will pay the higher premiums. Note: The premiums listed on the online Plan Finder are the basic premiums. They do not reflect the additional amount you must pay if you have high income, even if you enter personalized information.

-From Fall Open Enrollment: A Resource for Journalists, Medicare Rights Center, http://www.medicarerights.org/pdf/Fall-Open-Enrollment-Resource-for-Journalists.pdf?utm_source=Medicare-Watch-email&utm_medium=e-mail&utm_term=mcw&utm_content=mcw&utm_campaign=9.08.11, retrieved 9/9/11.

 

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