The Affordable Care Act and Older Americans
The Affordable Care Act is providing affordability, access and quality for older Americans. The law’s new protections include strengthening Medicare, offering a range of preventive services at no cost, and giving discounts on drugs when in the coverage gap (also called the “donut hole”) in prescription drug coverage. Learn how the health care law affects all people with Medicare.
Medicare Preventive Services
Because of the Affordable Care Act, if you have Original Medicare, you may qualify for a yearly wellness visit and many preventive services for free.
If you’re new to Medicare, your “Welcome to Medicare” preventive visit is now covered during your first 12 months of Part B coverage. This one-time visit includes a review of your health as well as education and counseling about preventive services and other care. If you’ve had Part B for longer than 12 months, you can get a yearly wellness visit to develop or update a personalized prevention plan based on your current health and risk factors. Your first yearly wellness visit must be at least 12 months after your “Welcome to Medicare” preventive visit if you received one.
Several Medicare preventive services that are covered without cost-sharing are listed below. For these preventive services, you’ll generally pay nothing. However, you may have to pay the Part B deductible and/or coinsurance (your share of the cost) for the office visit or if you get these services in the same visit as other services. If you’re in a Medicare Advantage Plan (like an HMO or PPO), your costs may be different. Check with your plan to find out about these costs.
- Screenings and Other Services: You don’t have to pay the Medicare Part B deductible or copayment for these screenings if certain coverage criteria are met:
- Bone mass measurement
- Cervical cancer screening, including Pap tests and pelvic exams
- Cholesterol and other cardiovascular screenings
- Colorectal cancer screening (except for barium enemas)
- Diabetes screening
- Flu, pneumonia, and hepatitis B vaccinations
- HIV screening
- Medical nutrition therapy to help people manage diabetes or kidney disease
- Prostate cancer screening (except digital rectal examinations)
- See the full list of covered preventive services at Medicare.gov
- Tobacco Use Cessation Counseling: This benefit is considered a covered preventive service if you have not been diagnosed with an illness caused or complicated by tobacco use. If you have already been diagnosed with a tobacco related illness, the Part B deductible and/or coinsurance may apply.
Medicare Drug Discounts
The Affordable Care Act has made Medicare drug coverage more affordable with the gradual closing of the coverage gap (known as the “donut hole”). If you reach the “donut hole” in 2015, you will get a 55 percent discount on covered brand name drugs and a 35 percent discount on generic drugs. Nationally, 9.4 million people with Medicare have saved over $15 billion on prescription drugs since the law’s enactment, for an average savings of $1,598 per person.
And thanks to the health care law, coverage for both brand name and generic drugs will continue to increase over time until the coverage gap is closed in 2020.
See the schedule below for information on what you’ll pay for drugs while you’re in the coverage gap:
- 2015: 45% for brand-names and 65% for generics
- 2016: 45% for brand-names and 58% for generics
- 2017: 40% for brand-names and 51% for generics
- 2018: 35% for brand-names and 44% for generics
- 2019: 30% for brand-names and 37% for generics
- 2020: 25% for brand-names and 25% for generics
You don’t need to do anything to get the discount. If you reach the coverage gap and you don’t get a discount when you pay for your brand-name prescription, you should review your next Explanation of Benefits (EOB) notice. You can work with your drug plan to make sure that your drug records are correct.
For more information, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
Here are some other ways we’re improving how Medicare works:
- Fighting Medicare Fraud
We’re taking strong action to reduce payment errors, waste, fraud, and abuse in Medicare. The health care law helps stop fraud with tougher screening procedures, stronger penalties, and new technology.
Since the program began in 1997, fraud enforcement efforts have recovered $27.8 billion from fraudsters. For every dollar spent on health care-related fraud and abuse investigations in the last three years, the administration recovered $7.70. This is about $2 higher than the average return on investment in the HCFAC program. Learn more about fraud enforcement efforts.
- Higher Quality Care
The coordination of care between doctors and the overall quality of care will improve so you’re less likely to experience readmission to the hospital and other preventable harms. Hospitals have new, strong incentives to improve your quality of care. With new initiatives to support care coordination, your doctor may get additional resources to make sure that your care best meets your needs.
- Medicare Advantage Plans
The health care law offers additional protections for Medicare Advantage Plan members and Prescription Drug Plan members by taking strong steps that limit the amount these plans spend on administrative costs, insurance company profits, and things other than health care.
Medicare is stronger today thanks to the Affordable Care Act. In 2014, the Medicare Trustees projected that the Medicare Trust fund financing Medicare’s hospital insurance coverage will remain solvent until 2030, four years beyond what was projected in the 2013 report. Just a few years ago, the Medicare Trust fund was projected to run out of money by 2017.
If you have specific questions about your coverage or want to learn more, visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.