www.insurance.arkansas.gov

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www.insurance.arkansas.gov
Arkansas Insurance Department
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Arkansas Insurance Department

• The primary mission is consumer protection
  through insurer solvency and market conduct
  regulation, and fraud prosecution and
  deterrence. 

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Insurance Department Divisions

• Health Insurance Premium Rate Review
• Liquidation
• Life and Health
• Property and Casualty
• Public Employee Claims
• Risk Management
• Senior Health Insurance Information Program

• Administration
• Accounting
• Consumer Services
• Consumer Assistance Program
• Criminal Investigations
• Finance
• Human Resources
• Legal
• License
• Health Benefits Exchange

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Consumer Services Division Stats

• Toll-free Phone [phone]
• Assisted Arkansans in collecting 14,006,232
• Received 2,864 consumer complaints
• Closed 3,164 consumer complaint files
• Responded to 19,207 telephone inquiries and
  assisted 299 walk-in consumers
• Participated in 130 dislocated worker workshops
  and 28 expos and health fairs

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SHIIP Stats

• Assist Arkansans with all things MEDICARE
• Assisted more than 14,500 Medicare recipients or
  caregivers
• 6,642 Part D comparisons of which 2,648 assisted
  with enrollment
• 2,132 Medigap comparison and eligibility
• 2,008 Medicare Advantage comparisons

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Complaints

• Contact Insurance Plan/Carrier first and ask for
  clarification
• Insurance Department Complaints
• Claims payment concerns
• Agent misconduct
• Medicare Supplement Policy
• Medicare Complaints via SHIIP
• Claims Payment Issues Plan False or Misleading
  Sales Marketing Practices

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Patient Protection and Affordable Care Act (PPACA)
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Affordable Care Act Changes

• Take Care Arkansas
• Temporary (until 2014) high-risk pool for those
  with pre-existing conditions
• Administered by Blue Cross Blue Shield
• 1-800-285-6477
• WWW.TAKECAREARKANSAS.ORG
• Early Retirees (before age 65)
• Temporary program to offset cost of retiree
  coverage paid to employers (not retirees)

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Affordable Care Act Medicare

• Annual Election Period
• EARLIER starts Oct 15 and ends Dec 7
• Medicare Claims
• Maximum period for submission of Medicare claims
  reduced time period
• Not more than 12 months
• Preventive Services
• No longer pay Part B deductible and coinsurance
  for most preventative services

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Affordable Care Act- Medicare

• Therapy caps extended
• Physical Speech pathology combined 1,860 per
  year
• Occupational therapy 1,860 per year

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Affordable Care Act- Medicare

• Power-driven wheelchairs effective Jan 2011
• Medicare no longer purchase with lump-sum
• Paid over 13-month period
• Increased ground ambulance rates retroactive to
  Jan 2010 3 rural, 2 urban
• Hospice Reform effective Nov 2011
• Face-to-face encounter is required with hospice
  physician or nurse practitioner

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Affordable Care Act MA Plans

• MA Plans can not charge more than Original
  Medicare
• Services chemotherapy, skilled nursing facility,
  dialysis, etc.
• Payments to MA frozen in 2011
• MA Disenrollment Period Jan 1-Feb 14
• Leave MA and go to Original Medicare with stand
  alone Part D

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Affordable Care Act- Part D

• Donut Hole in 2012
• 50 discount on brand name drugs
• 14 discount on generic drugs
• Higher income people pay higher Part D premium
• Effective Jan 2011
• Same thresholds as Part B premium
• Modified Adjusted Gross Income
• Income reported on IRS tax return 2 years ago

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Medicare Preventive Services
Centers for Disease Control and Prevention
reports less than 10 of Medicare beneficiaries
receive all recommended screenings and
immunizations.

• SESSION TOPICS
• What is covered
• Why preventive services are important
• Who is eligible
• How much you pay

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Medicare Preventive Services

• Medicare coverage based on
• Age
• Gender
• Medical history
• Covered by
• Part B of Original Medicare
• Medicare Advantage and other Medicare plans

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Covered Screening and Preventive Services

• One time Welcome to Medicare physical exam
• Physical Exam (yearly Wellness Exam)
• Abdominal aortic aneurysm screening
• Bone mass measurement
• Cardiovascular disease screenings
• Colorectal cancer screenings
• Diabetes screenings

• EKG Screening
• Flu shots
• Glaucoma tests
• Hepatitis B shots
• HIV Screening
• Mammograms (screening)
• Pap test/pelvic exam/clinical breast exam
• Prostate cancer screening
• Pneumococcal shots
• Smoking cessation

Health Reform Section4103
When referred during Welcome to Medicare
physical exam
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Elimination of Part B Deductible and Coinsurance
Requirements in 2011
Health Reform Section 4104

• Starting January 1, 2011
• You pay nothing for most preventive services
• If you get them from a doctor or other health
  care provider who accepts assignment
• Services affected must have an A or B rating
• By the United States Preventive Services Task
  Force
• http//www.uspreventiveservicestaskforce.org/uspst
  f/uspsabrecs.htm

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One Time Welcome to Medicare Physical Exam

• Covered within first 12 months of having Part B
• Height, weight and body mass index
• Blood pressure and end of life planning
• Education, counseling, and referrals (e.g., EKG)
• In Original Medicare pay
• No deductible or copayment starting
• January 1, 2011

Changes in 2011
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Abdominal Aortic Aneurysm Screening

• Abdominal aortic aneurysms (weak area bulges)
• Risk factors include
• A family history of abdominal aortic aneurysms
• Men age 65 to 75 who have smoked at least 100
  cigarettes in their lifetime
• Ultrasound screening covered by Medicare
• Referral from the Welcome to Medicare physical
  exam
• Pay 20 of the Medicare-approved amount with no
  Part B deductible
• No deductible or copayment starting
• January 1, 2011

Changes in 2011
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New Annual Wellness Visit
Health Reform Section 4103

• Effective January 1, 2011
• Annual Wellness Visit
• Comprehensive health risk assessment
• Personalized prevention plan
• Health advice and referral to education and
  preventive counseling
• No copayment or deductible
• Available every 12 months (after first 12 months
  of initial Part B coverage)
• But not within 12 months of receiving either a
  Welcome to Medicare physical exam or another
  Annual Wellness visit

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Bone Mass Measurement

• Covered if at risk for osteoporosis
• Every 2 years (more often if medically necessary)
• Risk factors include but arent limited to
• Age 50 or older
• Female
• Family or personal history of broken bones
• White or Asian
• In Original Medicare pay
• No deductible or copayment starting
• January 1, 2011

Changes in 2011
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Cardiovascular Disease Screening

• Blood test for early detection
• Heart disease
• Stroke
• Tests for levels of
• Cholesterol
• Triglycerides
• Lipids
• Covered every 5 years
• In Original Medicare you pay nothing

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Cardiac Rehabilitation

• Medicare covers cardiac programs that include
• Exercise
• Education
• Counseling certain patients with a doctors
  referral
• Intensive cardiac rehabilitation programs
• In Original Medicare, pay 20 of the
  Medicare-approved amount
• If you get the services in a doctors office
• No change in 2011, is not rated A or B
• Pay a copayment in a hospital outpatient setting

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Colorectal Cancer Screening

• Helps find precancerous growths
• Helps prevent or find cancer early
• One or more of the following tests may be covered
• Fecal Occult Blood Test
• Flexible Sigmoidoscopy
• Colonoscopy
• Barium Enema

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Diabetes Risk Factors

• Diabetes is a chronic condition
• Body does not produce or properly use insulin
• Risk Factors
• High blood pressure
• High cholesterol
• Obesity
• History of high blood sugar
• At least two of the following
• Age 65 or older,
• Overweight,
• Family history of diabetes, or
• Past gestational diabetes or having a baby over 9
  pounds

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Diabetes Management

• May be able to avoid or delay complications
• Manage diabetes
• Test blood sugar regularly
• Eat a proper diet
• Exercise regularly
• Take medication as prescribed

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Diabetes Screening

• Testing for people at risk
• Includes fasting blood glucose test
• Talk with your doctor about frequency
• Got pre-diabetes, then screening up to twice in a
  12-month period
• Not diagnosed or pre-diabetic, then screening
  once in 12-month period
• In Original Medicare pay
• No deductible or coinsurance

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Covered Diabetes Services

• Screening for all at risk
• For people with diabetes (need prescription)
• Self-management training
• Medical nutrition therapy
• Blood sugar testing supplies
• Lancets, monitors, testing strips Part B
• Insulin, syringes, needles, alcohol swabs, gauze
  Part D
• Special eye exams
• Hemoglobin A1c tests

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Covered Diabetes Services

• People with diabetes who need them
• Insulin pumps
• Special foot care
• Therapeutic shoes
• In Original Medicare pay
• 20 after Part B deductible
• No change in 2011
• Medicare Coverage of Diabetes Supplies
  Services (CMS Pub. 11022)

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Glaucoma Examination

• Glaucoma is caused by increased eye pressure
• May gradually lose sight without symptoms
• Protect yourself with screening eye exam
• Covered if high risk once every 12 months
• High-risk Family history, African American and
  age 50 or old, or Hispanic and age 65 or older
• In Original Medicare pay
• 20 of the Medicare-approved amount
• Part B deductible applies for the doctor services
• A copayment in a hospital outpatient setting
• No change in 2011

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HIV Screening

• Medicare covers HIV screening for people
• Who are pregnant or at increased risk for the
  infection
• Includes anyone who asks for the test
• Covered once every 12 months
• Up to 3 times during a pregnancy
• In Original Medicare pay
• Generally pay 20 of the Medicare-approved amount
  for the doctors visit
• No deductible or copayment for the test
• No change in 2011

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Pap Test and Pelvic Exam with Clinical Breast
Exam

• Risk factors for some cancers in woman include
• Had an Abnormal Pap test
• Infected with Human papilloma virus (HPV)
• Began sexuality activity before age 16
• Had many sexual partners
• Medicare covers
• Pap test to help find cervical and vaginal cancer
• Screening pelvic exam to help find
  fibroids/ovarian cancers
• Clinical breast exam (another way to look for
  breast cancer)

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Pap Test and Pelvic Exam with Clinical Breast
Exam

• Covered for all women with Medicare
• Once every 24 months for most women
• Once every 12 months if
• At high risk for cervical or vaginal cancer
• Childbearing age and abnormal Pap test in the
  past 36 months

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Pap Test and Pelvic Exam with Clinical Breast
Exam

• In Original Medicare pay nothing
• Nothing for Pap lab test
• No Part B deductible
• No copayment starting January 1, 2011

Health Reform Section 4104
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Prostate Cancer Risks

• Risk increases with age
• Age 45 1 in 2,500
• Age 50 1 in 476
• Age 55 1 in 120
• Age 60 1 in 43
• Age 65 1 in 21
• Age 70 1 in 13
• Age 75 1 in 9
• Ethnicity risk AA, White, Hispanic at highest
  risk
• Hereditary risk

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Prostate Cancer Screening

• Covered
• For all men with Medicare
• Beginning the day after 50th birthday
• Tests include
• Digital rectal exam
• PSA blood test
• Prostate-specific antigen
• In Original Medicare pay
• Nothing for the PSA blood (lab) test
• 20 after Part B deductible for digital rectal
  exam
• No change in 2011

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Breast Cancer and Mammography

• Breast cancer in women in U.S.
• Most commonly diagnosed non-skin cancer
• Second leading cause of cancer death
• Risk increases with age
• Successfully treated when found early
• Mammogram
• Checks for abnormal breast tissue
• Coverage includes digital technology

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Screening Mammogram
Health Reform Section 4104

• Covered for all women with Medicare
• One baseline mammogram age 35 to 39
• Once a year starting at age 40
• In Original Medicare pay nothing
• No Part B deductible
• No deductible or copayment starting
• January 1, 2011

Changes in 2011
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Diagnostic Mammogram

• Used when there are clinical findings
• On physical exam
• Abnormal screening mammogram
• Medicare covers as many as needed
• Also covered for men
• Different payment rates if diagnostic mammograms
• Usually pay 20 of Medicare approved amount and
  Part B deductible applies

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Smoking Cessation

• Quitting gives significant health benefits
• Even older adults who smoked for years
• When services are covered
• If you have an illness caused or complicated by
  tobacco use
• Includes smokers with heart or lung disease,
  stroke, multiple cancers, weak bones, blood
  clots, or cataracts
• If you take medication affected by tobacco use
• Such as insulin, medication for high blood
  pressure, blood clots, and depression

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Smoking Cessation Services

• Cessation counseling
• Up to 8 sessions per year
• Inpatient or outpatient
• Intermediate or intensive
• In Original Medicare pay
• 20 after Part B deductible
• No change in 2011
• Medicare Part D prescription drug coverage
• Can help pay for drug therapy
• Nicotine patches, for example

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Influenza (Flu) Shot

• Flu can lead to pneumonia
• Can be dangerous for people 50 and over
• Flu viruses are always changing
• Shot updated for most current flu viruses
• Recommended in fall or winter (Oct or Nov)
• Flu shot covered for all people with Medicare
• Once each flu season protects for about a year
• In Original Medicare pay
• No deductible or copayment

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H1N1 Flu Vaccine

• H1N1 flu is caused by a new strain of influenza
  virus
• Risk factors not as high for those over 65
• Higher risk for those with certain disabilities
• Medicare covers administration of the H1N1 flu
  shot
• You cant be charged for the vaccine (providers
  get it free)
• You pay nothing if provider accepts assignment
• Part B deductible and coinsurance dont apply
• To the vaccine or its administration
• You should still get the seasonal flu shot

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Pneumococcal Pneumonia Shot

• Pneumonia is inflammation in the lungs
• Caused by bacteria (streptococcus pneumoniae)
• One shot could be all you ever need
• All people with Medicare are eligible
• In Original Medicare pay nothing
• No deductible or copayment

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Hepatitis B Shots
Health Reform Section 4104

• Serious disease (virus attacks the liver)
• Can cause lifelong infection, cirrhosis
  (scarring) of the liver, liver cancer, liver
  failure, or death
• Covered for medium to high risk
• End-stage renal disease and hemophilia
• Condition that lowers resistance to infection
• In Original Medicare pay nothing
• No deductible or copayment starting
• January 1, 2011

Changes in 2011
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Medicare Education Benefit

• People with Stage IV chronic kidney disease
• Have advanced kidney damage and
• Will likely need dialysis or a kidney transplant
  soon
• Medicare Part B covers
• Up to six sessions of kidney disease education
  services if have stage IV and doctor refers for
  the service
• Provided to help prevent or delay the need for
  dialysis
• Pay 20 of the Medicare-approved amount, and the
  Part B deductible applies
• No change in 2011

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Protecting the Medicare Trust Funds

• Centers for Medicare Medicaid Services (CMS)
  has to balance how to
• Pay claims on time vs. conduct reviews
• Prevent/detect fraud vs. limit burden on
  providers
• CMS must protect the Trust Funds
• Medicare Hospital Insurance Trust Fund (Part A)
• Supplementary Medical Insurance Trust Fund (Part
  B)

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Medicare Overview
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Medicare Dictionary
Abuse
Fraud
When someone intentionally falsifies information
or deceives Medicare.
When health care providers or suppliers dont
follow good medical practices, resulting in
unnecessary costs to Medicare, improper payment,
or services that arent medically necessary.
Fraud and Abuse Costs 60-90 billion
annually or 1.6-2.6 million per day
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Examples of Fraud

• Medicare/Medicaid is billed for
• Services never delivered
• Equipment never delivered or returned
• Unauthorized use of Medicare/Medicaid card
• A company uses false information
• To mislead a beneficiary into joining a Medicare
  plan

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Fighting Fraud

• Medicare Summary Notices
• www.MyMedicare.gov
• 1-800-MEDICARE
• Senior Medicare Patrol
• www.stopmedicarefraud.gov
• Protecting Personal Information/ID Theft
• Tips
• Part C and D Plan Marketing Fraud

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Medicare Summary Notice (MSN)

• Part A and Part B MSNs
• Shows all your services or supplies
• Billed to Medicare in 3-month period
• What Medicare paid
• What beneficiary owes
• Read it carefully
• Keep receipts and bills
• Keep note of appointments/services dates
• Compare them to MSN

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MyMedicare.gov

• Secure site to manage personal information
• Review eligibility, entitlement and plan
  information
• Track preventive services
• Keep a prescription drug list
• Complete Authorization Form
• Review claims
• Dont have to wait for MSN

Click the Blue Button to download your data to
a text file
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Medicare Part C D Plans Marketing Rules

• Examples
• Plans cant send unwanted emails
• Agents cant come to uninvited to home
• Cant call beneficiaries unless already a member
• Offer cash to join their plan
• Give free meals while trying to sell a plan

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Telemarketing Fraud

• Durable Medical Equipment Telemarketing Rules
• DME suppliers cannot make unsolicited sales calls
  
• Potential scams
• Calls or visits from people saying they represent
  Medicare
• Telephone or door-to-door selling techniques
• Equipment or service is offered free and then ask
  for Medicare number for record keeping
  purposes
• Told that Medicare will pay for the item or
  service if provide a Medicare number

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Arkansas Silver Alert System

• Modeled after Amber Alert
• sign up for instant email messages
• https//www.ark.org/asp/alerts/mnaa/silver.php
• Do not have to be missing 24 hours
• Statewide alerts for missing seniors and/or other
  adults with Alzheimers or other cognitive
  disorders
• AR State Police
• AR Sherriffs Association
• AR Police Association