What the health reform law does for Medicare

We hear a lot of back and forth these days about the Affordable Care Act (ACA) — aka the federal health reform law — but not much about how it affects people with Medicare.

When you sort through all the rhetoric, one thing is clear: the two-year-old reform law contains some real benefits for those who get their coverage through Medicare. Take the so-called “donut hole” in the Medicare prescription drug program, Part D.

The donut hole is a gap where you don’t have coverage even though you’re still paying premiums. After you have paid a certain amount out of pocket, your coverage resumes. Congress intended the hole to hold down costs in the drug program, the biggest expansion of Medicare benefits in many years.

Under the Affordable Care Act, the hole is gradually being closed until it completely disappears in 2020. This year, the law gives people with Medicare a 50 percent discount on covered brand-name drugs in the donut hole, and a 14 percent discount on covered generics.

In 2011, more than 319,000 Medicare beneficiaries in California saved a total of $171 million in the donut hole. That’s an average savings of $538 per person.

The ACA also helps people with Medicare by eliminating coinsurance and deductibles on vital preventive health services. Such services can help keep people healthy and detect disease in its earliest, most treatable stages. As a result, Medicare now offers a long list of preventive health services with no out-of-pocket costs, including screenings for cancer, diabetes, cardiovascular disease, osteoporosis, and shots for flu, and pneumonia. The health reform law also adds new preventive screenings and counseling for obesity, alcohol abuse and depression.

More than 2 million Californians with Medicare received at least one Medicare-covered preventive health benefit in 2011.

The health reform law also creates another important benefit for people with Medicare: annual wellness visits. If you’ve had Medicare Part B for longer than 12 months, you can get a yearly wellness visit with your doctor to develop or update a personalized plan to prevent illness based on your current health and risk factors. The annual wellness visit is in addition to the one-time “Welcome to Medicare” preventive visit when you first enroll. More than 165,000 Californians with Medicare took advantage of a wellness visit last year.

Because of financial incentives in the ACA, seniors also can expect to see better quality in their Medicare Advantage health plans. Such plans are operated by private insurers and generally require you to stay within a network of physicians and other providers or face higher out-of-pocket expenses. Medicare Advantage plans that receive quality ratings of three stars or more under Medicare’s five-star rating system will get bonus payments. The bonuses are intended to motivate one- and two-star plans to improve their quality as well.

Medicare Advantage plans that receive five stars – the highest rating – will be able to market to and enroll seniors year-round, not just during the open enrollment period in the fall. That means seniors can switch to the best plans at any time. (To check your plan’s rating, go to

Last, the ACA provides a variety of new tools to crack down on Medicare fraud. The law not only toughens federal sentencing guidelines for fraud (meaning crooks will spend more time in prison), it also allows Medicare to suspend payments to providers suspected of trying to rip off the program.

In addition, sophisticated predictive analytics software is now being used to identify patterns of fraud and target crooks. This is the same type of software credit card companies use to stop fraud.

David Sayen is Medicare’s regional administrator for California, Arizona, Nevada, Hawaii, and the Pacific Trust Territories. You can get answers to your Medicare questions by calling 1-800-633-4227
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