Change can be scary . . . but change is not always a bad thing. Changes have been made to Medicare coverage for 2013. However, for the most part, the changes included added preventive care services, more assistance in the “donut hole”, and the addition of a Special Enrollment Period (also known as “SEP”) for enrollment in a “Five Star Plan.”

The new preventive services covered in 2013 must be provided in a primary care setting and you will pay nothing for these services if your medical provider accepts assignment. Assignment means that your doctor, provider, or supplier agrees (or is required by law) to accept the Medicare-approved amount as full payment for covered services. The new preventative services that will be covered in 2013 by Medicare include the following:

Alcohol misuse counseling

In 2013, and thereafter if appropriately defined, Medicare will cover one alcohol misuse screening per year for adults with Medicare (including pregnant women) who use alcohol, but don’t meet the medical criteria for alcohol dependency. If your primary care provider determines you’re misusing alcohol, you can get up to four brief face-to-face counseling sessions per year (if you’re competent and alert during counseling).

Cardiovascular disease (behavioral therapy)

In 2013, and thereafter as appropriately defined, Medicare will cover one visit per year with your primary care provider to help lower your risk for cardiovascular disease. During this visit, your medical provider may discuss aspirin use (if appropriate), check your blood pressure, and give you tips to make sure you’re eating well.

Depression screening

In 2013, and thereafter if appropriately defined, Medicare covers one depression screening per year. The medical provider must be able to provide follow-up treatment and referrals.

Obesity screening and counseling

If you have a body mass index (BMI) of 30 or more, Medicare covers intensive counseling to help you lose weight. The provider must coordinate the counseling with personalized prevention plan. Talk to your primary care provider to find out more.

Sexually transmitted infections screening and counseling

In 2013, and thereafter as properly defined, Medicare will cover sexually transmitted infection (STI) screenings for chlamydia, gonorrhea, syphilis and/or Hepatitis B. These screenings are covered for people with Medicare who are pregnant and/or for certain people who are at increased risk for an STI when the tests are ordered by a primary care provider. Medicare covers these tests once every 12 months or at certain times during pregnancy. Medicare also covers up to 2 individual 20 to 30 minute,face-to-face, high-intensity behavioral counseling sessionseach year for sexually-active adults at increased risk for STIs. Counseling conducted in an inpatient setting, like a skilled nursing facility, won’t be covered as a preventive service.

New 2013 Special Enrollment Period (SEP) to leave a consistently low rated medical drug or health plan

In 2013, the Centers for Medicare and Medicaid Services (also known as “CMS”) will notify plan members if their Medicare Part D drug plan or Medicare Advantage health plan has failed for three straight years to achieve at least a three-star quality rating and offer a Special Enrollment Period (also known as “SEP”). The Special Enrollment Period will allow the member to move to a higher quality plan, if desired.

What is the Star Plan? It is a system that rates insurance plans offered by private insurance companies, such as Medicare Part D (also known as “PDP”) and Medicare Advantage plans (also known as “MA” or “MAPD” plans), on a scale of 1 – 5. A Five Star Plan has demonstrated the highest quality of service. The Star Rating System is based on two different methods and the methodology is based upon what the plan offers. First, a plan is rated based on its quality of service for medical services. This would include the Medical Advantage (also known as “MA”) plans which offer medical coverage only. The plan is scored based on its overall quality of services for thirty-six different topics in five categories. With regard to Medicare Advantage Plans with a built in Prescription Drug Plan (also known as “MAPD”), the plan is scored based on overall quality of services for seventeen different topics in four categories.

Changes to the Part D 2013 Standard Benefit Model Plan Details

The standard “Standard Benefit Plan” is the minimum allowable plan to be offered.  Please remember, each Medicare Part D plan can have different cost-sharing.  However, the must be at least as good as Medicare’s “Standard Benefit Plan”. Changes to the “Standard Benefit Plan” for 2013 are as follows:

Initial Deductible will be increased by $5 to $325 in 2013.

Initial Coverage Limit will increase from $2,930 in 2011 to $2,970 in 2013.

Out-of-Pocket Threshold will increase from $4,700 to $4,750 in 2013.

More Assistance in the Coverage Gap (donut hole).

The Coverage Gap, (also known as the “donut hole”)begins once you reach your Medicare Part D plan’s initial coverage limit ($2,970 in 2013) and ends when you spend a total of $4,750 in 2013.In 2013, Part D enrollees will continue receive a 52.5% discount on the total cost of their brand-name drugs while in the donut hole. The full retail cost of the drugs will still apply to getting out of the donut hole even though 52.5% was paid for by others. Enrollees will pay a maximum of 79% co-pay on generic drugs while in the coverage gap.

Minimum Cost-sharing in the Catastrophic Coverage Portion of the Benefit will increase to greater of 5% or $2.65 for generic or preferred drug that is a multi-source drug and the greater of 5% or $6.60 for all other drugs in 2013.

Maximum Co-payments below the Out-of-Pocket Threshold for certain Low Income Full Subsidy Eligible Enrollees will increase to $2.65 for generic or preferred drug that is a multi-source drug and $6.50 for all other drugs in 2013.

In 2013, you will receive a 52.5% discount on Brand-name drugs and a 21% discount on Generic drugs.

Please note, that the Doughnut Hole discount is not available to anyone receiving financial Extra Help (the Low-Income Subsidy). Also the discount is only for Medicare Part D drugs included on your Medicare Part D prescription drug plan formulary.


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