helping medicare beneficiaries stay healthy€¦ · hiv screening new 2/6/15 lung cancer screening...

1Improving the lives of 10 million older adults by 2020 © 2015 National Council on Aging

February 2015

Helping Medicare Beneficiaries Stay

Healthy

Audio Portion: 1-866-740-1260

Web Portion: www.ReadyTalk.com

Code: 4796976


What we’ll cover

Medicare Preventive Services

• What’s covered

• Who’s eligible

• Costs

NCOA’s Healthy Aging National Chronic Disease Self-

Management Education (CDSME) Resource Center

State CDSME collaborative efforts

Nevada – Ken Napier

Maryland – Sarah Bush

Washington – Melody Coleman


Paying for Preventive Services in 2015

In Original Medicare pay nothing for preventive

services if provider accepts assignment

ACA waived coinsurance and deductible for A and B rated

services for the US Preventive Services Task Force (USPSTF)

May pay more if provider doesn’t accept assignment

May have copayment

If doctor performs other services not part of covered preventive

benefits, or

For certain preventive services rated less than A or B by USPSTF,

or

If you are in a Medicare Advantage or other Medicare health plan

Source: MLN Matters News Flash updated 12/5/14

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7012.pdf


What is Covered?

Welcome To Medicare Preventive visit

Yearly “Wellness” visit

Abdominal aortic aneurysm screening

Alcohol misuse screening and counseling

Bone mass measurement

Breast cancer screening (mammogram)

Cardiovascular disease (CVD) Risk

Reduction Visit

Cardiovascular disease screenings

Cervical and vaginal cancer screening

Colorectal cancer screenings

• Screening fecal occult blood test

• Screening flexible sigmoidoscopy

• Screening colonoscopy

• Screening barium enema

Depression screening

Diabetes screenings

Diabetes self-management training

Flu shots (Vaccine)

Glaucoma tests

Hepatitis B shots (Vaccine)

HIV screening

New 2/6/15 Lung Cancer Screening

Medical nutrition therapy services

Obesity screening and counseling

Pneumococcal shot (Vaccine)

Prostate cancer screening

Sexually transmitted infections screening

and counseling

Tobacco use cessation counseling

More information: Full CMS Preventive Services PPT

http://www.cms.gov/Outreach-and-Education/Training/CMSNationalTrainingProgram/Training-Library-Items/CMS026513.html?DLPage=2&DLSort=0&DLSortDir=ascending


“Welcome to Medicare” Preventive Visit

Once within first 12 months of getting Part B

Provider will

• Review medical and social history

• Measure height, weight and body mass index

• Perform a simple vision test

• Review risk factors for depression and level of safety

• Educate and counsel you to help you stay well

• Refer you for additional screenings if needed

Pay nothing if doctor accepts assignment

• Clinical lab tests are not included

Covered by Part B with coinsurance and deductible for labs


Annual (Yearly) Wellness Visit (AWV)

Can’t be within 12 months of your Welcome to

Medicare Preventive Visit

Available once every 12 months

Focus is on “wellness”

• not a routine physical check up

• MLN article

Pay nothing if doctor accepts assignment

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/mm7079.pdf


AWV Includes

Review of medical and family history

Update medical providers, suppliers, and medications lists

Measure height, weight, body mass index, blood pressure, pulse, and

temperature

Detection of cognitive impairments

Depression screening

Assess functional capacity and level of safety at home

Referrals for health education and preventive counseling

Health risk assessment (in-person or may complete prior to visit) asks

about

Personalized Prevention Plan Services (PPPS) a screening schedule

for 5 to 10 years


Why are there charges for the AWV?

Call the provider to verify the charges

Most likely received services outside the scope of

the AWV

• Provider identifies an acute condition that requires

investigation, diagnosis or treatment

• Services are separate and distinct from the AWV even

though they occur during the same visit and require 20%

coinsurance and deductible


VaccinesVaccine Type Medicare

Coverage

Coverage Rules & Frequency Cost in Original

Medicare

Influenza Part B Medicare pays for (and recommends) one shot

every flu season. Additional flu vaccines may be

covered if considered medically necessary

$0

Shingles All Part D

plans must

cover

One shot paid for (and recommended) after age

60. Patient must check with plan to find out

specific rules for administration and payment

Vary by plan

Pneumococcal

(pneumonia)

Part B Medicare pays for one shot, recommended for all

adults aged 65+ and younger adults with chronic

health conditions

$0

Hepatitis B Part B Series of three shots, paid for by Medicare for

high- or medium-risk individuals, including those

with hemophilia, end stage renal disease,

diabetes, and other chronic conditions that lower

resistance to infection

$0

Source: NCOA Tip Sheet Vaccines: What Medicare Pays For

http://www.ncoa.org/assets/files/pdf/center-for-benefits/medicare-vaccines.pdf


Cancer Screenings

Type of cancer

screened

Medicare

Coverage

Coverage Rules & Frequency Cost in Original

Medicare

Breast Part B Screening mammograms every 12 months

for women age 40 and over. Medicare

covers one baseline mammogram for

women between ages 35 and 39.

$0

Cervical and

Vaginal

Part B Pelvic and pap tests every 2 years or every

12 months for women at high risk (including

child-bearing age, and cancer or abnormal

tests in last 3 years)

$0 but may be

charges for other

care delivered during

the visit

Prostate Part B PSA blood test and digital rectal exam are

covered every 12 months for men age 50

and over.

PSA test = $0

Rectal exam =

coinsurance and

deductible apply (not

A or B rated by

USPSTF)

NEW Lung Part B Annual low-dose computed tomography (CT)

scan for those at high risk (see next slide for

high-risk definition)

$0


NEW Lung Cancer Screening

CMS Decision Memo effective 2/5/15

Dec. 2013 USPSTF awarded a “B” grade to the CT screening

Coverage for individuals• Age 55 to 77,

• Smoked the equivalent of one pack of cigarettes per day for 30 years,

• Current smoker or quit within last 15 years, and

• Asymptomatic (no signs or symptoms of lung cancer)

American Lung Association Fact Sheet

http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=274&bc=AAAAAAAAAAEAAA%3d%3d&

http://www.lung.org/assets/documents/lung-disease/lung-cancer/medicare-proposed-decision.pdf


Cancer Screenings - Colorectal

Screening Test If Normal Risk Covered

Once Every

If High Risk Covered

Once Every

You Pay

Screening Fecal

Occult Blood Test

Age 50 or older

12 months 12 months No deductible or

copayment

for this test.

Screening Flexible

Sigmoidoscopy

Age 50 or older

4 years or 10 years after

a previous screening

colonoscopy

Every 4 years No deductible or

copayment

for this test.

Screening

Colonoscopy

No minimum age

10 years (generally) or 4

years after a previous

flexible sigmoidoscopy

Every 24 months

(unless a screening flexible

sigmoidoscopy is

performed, then only every

4 years)

No deductible or

copayment

for this test.

Screening Barium

Enema

Age 50 or older

4 years when used

instead of a

sigmoidoscopy or

colonoscopy

Every 24 months (as an

alternative to a covered

screening colonoscopy).

There is no deductible for

this test. You pay 20% of

the Medicare-approved

amount for the doctor’s

services. In a hospital

outpatient setting, you pay

a copayment.


Screening vs. Diagnostic Services

Screening Diagnostic

Costs $0 20% coinsurance and

deductible apply

Purpose Helps prevent or find disease early Diagnosis disease when

exhibiting symptoms or

manage chronic conditions

Example:

Mammogram

Beneficiary has no symptoms or prior

history of breast cancer and goes for

annual check up

Test ordered based on pain

or an identified lump, as

medically necessary

Example:

Colonoscopy

Test ordered based on age, if a polyp is

removed the removal is preventive.

However, the lab testing of the polyp is

diagnostic and requires coinsurance

(deductible waived).

Test ordered based on

symptoms like irregularity or

bleeding, as medically

necessary

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7012.pdf


Preventive Services Usage – 2013 State data

Source: CMS Beneficiaries Using Free Preventive Services 2013

http://downloads.cms.gov/files/Beneficiaries-Utilizing-Free-Preventive-Services-by-State-YTD2013.pdf


Medicare-Medicaid State Profiles

Source: MMCO State Data Center Medicare-Medicaid State Profiles

http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/StateProfiles.html


Resources

NCOA Fact Sheets

• Original Medicare: Preventive Benefits Overview

• Quick-Reference Chart: Medicare’s Preventive Benefits

• A Closer Look: Medicare’s Annual Wellness Visit (AWV)

• Medicare Health Risk Assessment and AWV

• Vaccines: What Medicare Pays For

• Welcome to Medicare Exam

Personalized help

• Area Agency on Aging or Aging Disability Resource Centers

o Eldercare.gov

• Senior Health Insurance and Assistance Programs (SHIP)

o http://www.shiptacenter.org/

http://www.ncoa.org/assets/files/pdf/center-for-benefits/medicare-preventive-benefits.pdf

http://www.ncoa.org/assets/files/pdf/center-for-benefits/medicare-preventive-benefits-chart.pdf

http://www.ncoa.org/assets/files/pdf/center-for-benefits/medicare-annual-wellness-visit.pdf

http://www.ncoa.org/assets/files/pdf/center-for-benefits/medicare-health-risk-assessment.pdf

http://www.ncoa.org/assets/files/pdf/center-for-benefits/medicare-vaccines.pdf

http://www.ncoa.org/assets/files/pdf/center-for-benefits/medicare-welcome-to-medicare-exam.pdf

http://eldercare.gov/Eldercare.NET/Public/Index.aspx

http://www.shiptacenter.org/


Resources

CMS

• Your Guide to Preventive Services Booklet

• Preventive Services Checklist

• Medicare.gov Preventive & Screening Services

• NTP Medicare Preventive Services PowerPoint and workbook

• Staying Healthy: Medicare’s Preventive Services

• Hospital Discharge Checklist

• Welcome to Medicare Preventive Visit Q & A

• Questions to Ask about Medicare Preventive Services

• MyMedicare.gov Card

• Medicare helps cover Diabetes supplies and services (2 pg)

• Medicare & You Handbook (pgs 41-61 apple next to Prev. Svcs)

http://www.medicare.gov/Publications/Pubs/pdf/10110.pdf

http://www.medicare.gov/Pubs/pdf/11420.pdf

http://medicare.gov/coverage/preventive-and-screening-services.html

http://www.cms.gov/Outreach-and-Education/Training/CMSNationalTrainingProgram/Training-Library.html







http://www.medicare.gov/medicare-and-you/medicare-and-you.html


Resources

CMS Product Ordering website (partners only) Order multiple copies at http://productordering.cms.hhs.govYou must register your organization.

CMS Medicare Learning Network

The Medicare Learning Network® (MLN) Preventive Services page provides

educational products for health care professionals. These products contain

coverage, coding, billing, reimbursement, and claim filing information.

• ABCs of Providing the Welcome to Medicare Preventive Visit/

Initial Preventive Physical Examination (IPPE)

• ABCs of Providing the Annual Wellness Visit (AWV)

• Preventive Services

http://productordering.cms.hhs.gov/

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/PreventiveServices.html

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/AWV_Chart_ICN905706.pdf

http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS_QuickReferenceChart_1.pdf


Chronic Disease Self-Management Education

Can Increase the Quality and Years of Life

Cora Plass, MSW

Senior Director, National CDSME Resource Center

February 26, 2015

Helping Medicare Beneficiaries Stay Healthy


NCOA Social Impact Goal: Older Adults

Older adults will have:

Greater economic security through increased

access to benefits, financial resources, and job

opportunities

Improved health and reduced disability through

greater access to proven programs

Enhanced capacity to live independently in

communities


NCOA Social Impact Goal: Organizations & Programs

Community organizations serving older adults will

achieve:

Greater social impact, capacity, and sustainability

Public programs will:

More effectively meet the needs of older adults,

especially those who are struggling


Overarching goal: To help older adults live longer and

healthier lives

Supports expansion and sustainability of evidence-based

health promotion and disease prevention programs

Collaborates with federal, state, and community partners to

achieve its goals

2 National Resource Centers funded by ACL/AoA:

Chronic Disease Self-Management Education (CDSME)

Falls Prevention

Other topics include physical activity, behavioral health, and

oral health

Center for Healthy Aging


Funded by ACL, AoA for more than a decade

Develops and disseminates information and resources to

support expansion and sustainability of CDSME programs

Provides communication channels for networking and

sharing best practices

Manages and maintains national database for CDSME:

16,000 workshops offered in 46 states, DC, and Puerto Rico

Offered in 52% of counties in the US

Nearly 180,000 participants served

Average age 66, mostly female

More than half have MCC

Who We Are – National CDSME Resource Center


80% of older adults have at least one chronic disease

Nearly 2 of every 3 have multiple chronic conditions

U.S. health care is most costly in the world

95% of health care costs for older Americans are for

chronic diseases

Spending escalating with the increase in chronic

diseases and the aging population

Fragmented care; patient lost in health care maze

Primary focus has been on “sick care” rather than

prevention

Health Care Challenges: Why Our Work Is Important


Goals for Transforming Health Care


Self-management helps participants take control of their

health and make lifestyle changes that lead to better health

outcomes and a better quality of life

An array of programs developed by Dr. Kate Lorig at

Stanford, including:

Chronic Disease Self-Management (CDSMP)

In English and Spanish

Diabetes Self-Management (DSMP)

In English and Spanish

Chronic Pain Self-Management (CPSMP)

Cancer Thriving and Surviving

CDSME Programs


6 workshop sessions held once a week

Each session 2 ½ hours, highly interactive

Co-facilitated by 2 trained leaders, one of

whom has an ongoing health condition

Detailed script provided for leaders

Core content similar across programs:

Symptom management/social role function

Builds self-efficacy

Participants set personal goals and action

plans

Problem solving to overcome challenges

Program Overview


Action

Planning

Managing

Pain and

Fatigue

Fitness/

Exercise

Getting a Good

Night’s Sleep

Problem-

solving

Dealing with

Difficult

Emotions

Healthy

Eating/Weight

Management

Working with

Health

Professionals

Decision

Making

Better

Breathing

Communication Medication

Usage

CDSMP Program Overview


Self-Efficacy or ConfidencePeople who believed there was nothing they could

do to help themselves didn’t improve.

BUT those with confidence in their ability to make changes improved.

Participants are taught to set goals and action plans and to use problem solving to

overcome barriers to making lifestyle changes.

Why It Works


Improved self-rated health

Increased self-efficacy

Less reported disability

Increased energy/less fatigue

Increased healthy behaviors

Reduced health distress and depression

Less pain

Reduced health care utilization (ER visits and

hospitalizations) = Cost savings

Research Findings


National Study Results

CDSMP Helps Achieve Triple Aims Goal

Better Care:

Communication with health care team

Medication compliance

Health literacy

Better Health:

Self-assessed health,

Depression,

Quality of life,

Unhealthy physical/mental days improved

Lower Costs:

Lower ER visits

Fewer hospitalizations


$364 cost savings per person after considering

cost of the program

Reaching 10% of Americans with one or more

chronic conditions could save $4.2 billon

Based on one national study.

More research needed to substantiate findings.

Estimated Cost Savings

ER Visits and Hospitalizations


Lack understanding of what preventive health/health promotion

programs and services are available and what the benefits are

Lack awareness of how to access programs/services

Mistrust of the social welfare and health care system

Low self-confidence in ability to effect change in health or financial

situation

Difficulty accessing programs, especially in rural areas due to:

Social isolation

Lack of transportation

Programs not uniformly available - limited human and financial

resources

Fragmented approaches to service provision

Challenges for Older Adults


You Can Make a Difference

Find out who the CDSME program providers are in your

community

Arrange a meeting to determine how you can work

together to help older adults access programs and

services

Ask for a schedule of local workshops

Maintain ongoing relationships with CDSME staff

Provide information to older adults about the benefits

of CDSME and help them to enroll in local workshops

Communicate, Coordinate, Collaborate


Get Connected through NCOA’s CHA Website

www.ncoa.org/cha

Email:

[email protected]

http://www.ncoa.org/improve-health/center-for-healthy-aging/


Find a Healthy Aging Program

CDSME Program Locator

http://www.ncoa.org/improve-health/center-for-healthy-aging/chronic-disease-1.html


For More Information about Stanford Programs

http://patienteducation.stanford.edu/

http://patienteducation.stanford.edu/


Nevada

Ken Napier• Medicare Benefits Counselor

• Medicare "Extra Help" Outreach Program Coordinator

• State of Nevada, Aging & Disability Services Division

• State Health Insurance Assistance Program (SHIP)

1820 E. Sahara Ave., Suite 205

Las Vegas, NV 89104

Phone: 702-486-3478 and 702- 486-4581

[email protected]


Maryland

Sarah Bush

• Older Americans Act Program Manager

125 Virginia Ave

Cumberland, MD 21502

301-784-1710

[email protected]

mailto:[email protected]


Washington

Melody Coleman• ADR/FCSP Supervisor

Northwest Regional Council

600 Lakeway Drive, Suite 100

Bellingham, WA 98225

(360) 676-6749

[email protected]



Contact Us

Presenters:

Melissa Simpson

[email protected]

Cora Plass

[email protected]

www.ncoa.org

www.ncoa.org/centerforbenefits

Social media: @NCOAging



http://www.ncoa.org/

http://www.ncoa.org/centerforbenefits

helping medicare beneficiaries stay healthy€¦ · hiv screening new 2/6/15 lung cancer screening...

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