Akamai Advantage Annual Provider Training. October 12, 2016

Transcription

1 Akamai Advantage Annual Provider Training October 12, 2016

2 Agenda Akamai Advantage Plans for 2017 Akamai Advantage Drug Plans for 2017 Medicare Plan Enrollment Periods Akamai Advantage Dual Care Plan Akamai Advantage Model of Care DSNP Care for Older Adults Provider Practice 11/15/2016 6

3 Akamai Advantage plans for 2017 HMSA Akamai Advantage has options available on every island All options include Part D drug coverage Oahu plans Neighbor Island plans Complete (706) Standard (708) Complete Plus (707) Standard Plus (709) 11/15/2016 7

4 Why choose Akamai Advantage? Large statewide provider network Comprehensive benefits all Original Medicare benefits, and more Financial protection Maximum Out-of-Pocket limit Predictable costs 11/15/2016 8

5 Complete Plans - Oahu In-Network Complete (706) Complete Plus (707) Premium $70 $158 In-network MOOP $6,700 $3,400 Combined MOOP $10,000 $5,100 PCP Visit $35 $15 Specialist Visit $50 $30 Inpatient Hospital Care Days 1-6: $300/day Days 7-60: $44/day Days 61-90: $0/day Annual Wellness Visit $0 $0 Outpatient services/surgery $150 deductible, then 20% Days 1-7: $280/day Days 8-90: $0/day $0 for additional days No deductible 20% Ambulance $200 $200 Routine Eye Exams $35 1 per year $15 1 per year 11/15/2016 9

6 Standard Plans Neighbor Islands In-Network Standard (708) Standard Plus (709) Premium $153 $202 In-network MOOP $6,700 $3,400 Combined MOOP $10,000 $5,100 PCP Visit $35 $15 Specialist Visit $50 $40 Inpatient Hospital Care Days 1-6: $300/day Days 7-60: $44/day Days 61-90: $0/day Days 1-7: $300/day Days 8-90: $0/day $0 for additional days Annual Wellness Visit $0 $0 Outpatient services/surgery $150 deductible, then 20% No deductible 20% Ambulance $200 $200 Routine Eye Exams $35 1 per year $15 1 per year 11/15/

7 Stage Deductible- $0/$380/$400 Part D Drug Benefits All Plans Complete Standard T1: $0 T2-T5: $380 (Complete) T2-T5: $400 (Standard) Complete Plus Standard Plus No Deductible Initial Coverage Stage Until total drug costs reach $3,700 Coverage Gap 40% for brand drugs 51% for generic drugs Additional coverage for T1 drugs 40% for brand drugs 51% for generic drugs Catastrophic Stage Coverage After yearly out-of-pocket costs reach $4,950 11/15/

8 CY 2017 Akamai Advantage Drug Plans Tier 1 Preferred Generic Tier 2 Generic Tier 3 Preferred Brand Tier 4 Non-Preferred Drug Tier 5 Specialty Complete H Complete Plus H Standard H Standard Plus H $4.50 $4.00 $5.00 $4.00 $12.00 $11.00 $20.00 $11.00 $47.00 $45.00 $47.00 $45.00 $ $95.00 $ $ % 33% 25% 33% 11/15/

9 2017 Non-Formulary Drugs DRUG CRESTOR ELIQUIS EXELON PATCH Ibandronate NEXIUM TEKTURNA VOLTAREN GEL ALTERNATIVES Use generic PRADAXA, XARELTO Use generic Fosamax Use generic, OTC Irbesartan, losartan, valsartan Use generic 11/15/

10 2017 Drug Changes Tier 3 to Tier 4 DRUG AZOR* BENICAR* BENICAR HCT* BRILINTA NASONEX ALTERNATIVES Amlodipine/valsartan (generic EXFORGE) Irbesartan, losartan, valsartan Irbesartan HCT, losartan HCT, valsartan HCT clopidogrel Use generic, OTC *potential generic in /15/

11 2017 Drug Changes Tier 1 to Tier 2 DRUG diltiazem tabs indapamide isosorbide mononitrate LEVOXYL propranolol torsemide ALTERNATIVES verapamil furosemide levothyroxine atenolol, metoprolol furosemide Use Mail Order 1 copay for 90 days 11/15/

12 Complete Plans - Oahu 90-day supply from HMSA s network mail-order pharmacy Tier Complete Complete Plus Tier 1 Preferred Generic $4.50 $4 Tier 2 Generic $12 $11 Tier 3 Preferred Brand $94 $90 Tier 4 Non-Preferred Drug $200 $190 Tier 5 Specialty Drugs 25% 33% Mail order is fast and convenient Call 1 (855) Members can save money on maintenance medications New prescriptions sent from the doctor s office Patient will receive a call to confirm consent to ship the medication, verify It is important that the patient responds to these calls to get the medication shipped 11/15/

13 Standard Plans Neighbor Islands 90-day supply from HMSA s network mail-order pharmacy Tier Standard Standard Plus Tier 1 Preferred Generic $5 $4 Tier 2 Generic $20 $11 Tier 3 Preferred Brand $94 $90 Tier 4 Non-Preferred Drug $200 $190 Tier 5 Specialty Drugs 25% 33% Mail order is fast and convenient Members can save money on maintenance medications Call 1 (855) New prescriptions sent from the doctor s office Patient will receive a call to confirm consent to ship the medication, verify It is important that the patient responds to these calls to get the medication shipped 11/15/

14 Medicare Annual Enrollment Period October 15, 2016 December 7, 2016 Enrollment effective January 1, 2017 ANY Medicare beneficiary from any carrier can switch: From MAPD to MAPD From MAPD to PDP with Original Medicare From MA-only to MAPD 11/15/

15 Akamai Advantage Dual Care (PPO SNP) Annual Akamai Advantage Provider Training October 12, 2016

16 Agenda 1. Akamai Advantage Dual Care Plan Eligibility How to identify a Akamai Dual Care Member Benefits What is covered? Claims Filing and Billing QMB Balance Billing Law 2017 Plan Updates 2. Model of Care HMSA s Goals for Dual Care Members What is a Health Risk Assessment (HRA)? What is an Individualized Care Plan (ICP)? What is an Interdisciplinary Care Team (ICT)? 3. Dual Care Quality Metrics 4. HMSA Provider Resources 20

17 Akamai Advantage Dual Care Plan - Eligibility Must be eligible for Medicare and Medicaid May be Qualified Medicare Beneficiary (QMB) Only or (QMB) Plus dual eligibility status May have HMSA Akamai Dual Care and HMSA QUEST Integration May have HMSA Akamai Dual Care and QUEST Integration with another health plan Allowed to change MA D-SNP anytime during the year as long as Medicaid eligibility is maintained 21

18 Akamai Advantage Dual Care Plan Continued Eligibility If a member loses Medicaid eligibility, the member may have deemed continued eligibility for the month HMSA is notified of the member s Medicaid ineligibility, plus one full calendar month Effective January 1, 2017, HMSA Akamai Advantage Dual Care members who are in a deemed continued eligibility status will be responsible for copayments, coinsurance and deductibles under HMSA s Akamai Advantage Dual Care Plan 11/15/

19 Akamai Advantage Dual Care Membership Card Plan Name appears at the top right corner of the front of the card No member premium (after Low Income Subsidy) 23

20 HHIN How to identify Akamai Advantage Dual Care Member? 11/15/

21 HHIN How to identify Akamai Advantage Dual Care Member? Click on coverage code 696 to view plan description for Akamai Advantage Dual Care members 11/15/

22 Akamai Advantage Dual Care Plan - Benefits 1. Dual Care offers Original Medicare with some added benefits (after QUEST Integration coordination) a. $0 copay Annual Physical Exam b. $0 copay health education and wellness c. $0 copay for HMSA Online Care 2. Care Coordination and support services through a Care Manager such as a Registered Nurse or Social Worker 3. Medicaid will pay member cost shares for Original Medicare benefits, for QMB only and QMB Plus dual eligible 4. Prior authorizations are the same as on individual Akamai Advantage plans In general, Medicare pays primary and Medicaid is always the payer of last resort. For Original Medicare benefits, Medicaid covers the Part A & B deductibles, Part B premium, and member cost shares: Medicare pays 80% 100% coverage Medicaid pays 20% Member pays $0 26

23 Akamai Advantage Dual Care Plan Benefits Dual Care member premium: $0 after low income premium subsidy Maximum Out Of Pocket (MOOP): $6,700 Benefit Highlights Dual Care In-Network Cost Share QUEST Integration Pays Member Pays Inpatient Hospital Care Original Medicare cost share* Original Medicare cost share $0 Skilled Nursing Facility Original Medicare cost share* Original Medicare cost share $0 PCP Office Visit 20% 20% $0 Specialist Office Visit 20% 20% $0 Emergency Room 20% 20% $0 Urgent Care 20% 20% $0 Outpatient Surgery 20% 20% $0 *In 2016, the Original Medicare cost share for Part A inpatient hospital is: $1,288 deductible for each benefit period Days 1-60: $0 for each benefit period Days 61-90: $322 per day of each benefit period Days 91 and beyond: $644 per lifetime reserve day (up to 60 days over your lifetime) Beyond lifetime reserve days: all costs *In 2016, the Original Medicare cost share for a skilled nursing facility stay is: Days 1-20: $0 for each benefit period Days : $ per day of each benefit period Days 101 and beyond: all costs * Subject to change in

24 Akamai Advantage Dual Care Plan Claims Filing/Billing Providers should not bill HMSA Akamai Advantage Dual Care Plan members for coinsurance, copayments or deductibles for medical services File claims to HMSA Akamai Advantage Dual Care Plan 1 st, then bill HMSA QUEST Integration 2 nd File claims to HMSA Akamai Advantage Dual Care Plan 1 st, then bill other QUEST Integration Plan 2 nd Benefits covered by QUEST Integration that are not covered by Original Medicare should only be billed to QUEST Integration 28

25 Qualified Medicare Beneficiary (QMB) Balance Billing Law Effective 2016 QMB program is a Medicare Savings Program that exempts Medicare beneficiaries from Medicare cost-sharing liability Ensure billing software and staff exempt QMB or QMB Plus patients from Medicare cost-share billing Medicare Advantage providers are prohibited from discriminating against patients based on QMB status. Identify QMB or QMB Plus individuals at: 11/15/

26 2017 Akamai Advantage Dual Care Updates Dental Benefits: Effective January 1, 2017 Annual Max: Plan pays up to $1,000 for covered dental services Benefit In Network Two Dental Exams per year $0 Two Cleanings per year $0 One set of x-rays $0 Two Denture Adjustments per year $0 One Denture Repair, per Arch, per year $0 Deemed Eligible Period : Effective January 1, 2017 if a member loses Medicaid eligibility, the member may have deemed continued eligibility for the month HMSA is notified of the member s Medicaid ineligibility, plus one full calendar month. During this period, members will be responsible for all Medicare copay, co-insurance and deductibles. 30

27 Care Manager Support Annual Akamai Advantage Provider Training October 12, /15/

28 Model of Care Akamai Advantage Dual Care member is at the center MEMBER Health Risk Assessment (HRA) Individualized Care Plan (ICP) Interdisciplinary Care Team (ICT) 32

29 Goals of Care Management Support Improve access to essential services such as medical & behavioral health care and social services Improve access to: Affordable care Preventive Health Services Improve coordination of care through assignment of an HMSA Care Manager Improve seamless transitions of care across health care settings, providers, and health services Ensure appropriate use of services Improve health outcomes 11/15/

30 Model of Care Support for your vulnerable patients Determined by HRAs and clinical judgment Most Vulnerable Somewhat Vulnerable Examples of criteria for most vulnerable 5 or more chronic comorbid conditions (diabetes, congestive heart failure, hypertension, etc.) Terminal condition 5 or more ER visits within the past 6 months Severe dementia Least Vulnerable 34

31 Health Risk Assessment and Care Plan Health Risk Assessment (HRA)* 1. Conducted by HMSA Care Manager or PCP 2. Frequency: a. Initial within 90 days b. Reassess at least annually c. Health events 3. Used to Risk Stratify 4. Methodology a. In-person b. Telephonic c. Mail 5. Used to formulate ICP 35 * Must be evidence-based Individualized Care Plan (ICP)* 1. Based on HRA results 2. Aerial algorithms and clinical judgment 3. Developed with input from ICT 4. Modified as needed 5. Communicated to member, providers and ICT 6. Shared during care transitions 35

32 Interdisciplinary Care Team (ICT) The composition of the team is individualized according to the member s needs and preference. Core team members Member Examples of other team members Family Members/Caregiver Specialist HMSA Service Coordinator HMSA Medical Director Dietician Pharmacist Gerontologist PCP Behavioral Health 36

33 DSNP Quality Metrics

34 DSNP includes all Medicare Metrics Preventative Screenings Breast Cancer Colorectal Cancer Chronic Disease Monitoring and Control Diabetes Hypertension Rheumatoid Arthritis Osteoporosis Medication Oversight Medication Adherence Medication Reconciliation Post Discharge Medication Therapy Management

35 Dual Special Need Plan (DSNP) Metrics Health Risk Assessment Care for Older Adults Medication Review Functional Assessment Pain Assessment Advance Care Planning

36 Care for Older Adults: Dual Special Need Once per calendar year Four part assessment: Medication Review Functional Status Assessment Pain Assessment Advance Care Planning COA form available with coding and checklist assessments Complete the assessments Add completed form to your medical record File on a claim

37 CMS Emphasis on Medication Oversight Medication Reconciliation Post Discharge All Akamai Advantage Members Within 30 days of hospital discharge Medication Therapy Management 3 Chronic Conditions 8 or more Medications Refer to Pharmacy Vendor Medication Review Dual Special Needs Enrollees Once per calendar year

38 HMSA Provider Resources HMSA Provider E-Library: HMSA Care Managers: Phone Fax Toll Free: Toll Free: HMSA Provider Services Phone Fax Toll Free: Toll Free: /15/

39 APPENDIX 43

40 Acronyms AEP Annual Election Period LIS Low Income Subsidy CMS C-SNP D-SNP EOC ESRD HRA ICP ICT I-SNP Centers for Medicare and Medicaid Services Chronic Condition Special Needs Plan Dual eligible Special Needs Plan Evidence of Coverage End Stage Renal Disease Health Risk Assessment Individualized Care Plan Interdisciplinary Care Team Institutional Special Needs Plan MAPD MOC MOOP NCQA OOPM QI QMB SB SEP SNP Medicare Advantage Part D Model of Care Maximum Out of Pocket National Committee for Quality Assurance Out of pocket maximum QUEST Integration Qualified Medicare Beneficiary Summary of Benefits Special Election Period Special Needs Plan 44

41 Provider Attestation for Model of Care Training I attest that my organization and its contracted providers have received the HMSA Akamai Dual Care Plan Model of Care training. CMS Regulation 42 CFR (f)(2)(ii). I attest that my organization has established a mechanism for compliance with the provider training requirement. Your organization must establish a process for compliance, including but not limited to: dissemination to providers the HMSA Akamai Dual Care Plan MOC training, maintenance of all documentation including rosters, and a process for annual re-training I attest that within sixty (60) days receipt of this notice, my organization/practice will provide HMSA Akamai Dual Care Plan a roster of all providers/staff who received the training and a signed Attestation for HMSA Akamai Dual Care Plan Model of Care Training. Providers that render services for members in the Dual-Special Needs Program (D-SNP) program are required to take the HMSA Akamai Dual Care Plan MOC training. Signature: Printed Name: Date: Provider Name: to: AkamaiD-SNPAttestation@hmsa.com 45

42 CMS Rules Provider Practices Need to Know Annual Akamai Advantage Provider Training October 12, /15/

43 CMS Rules Provider Practices Need To Know You may (but you aren t required to): Provide the names of plan sponsors that you contract with or participate. Help patients apply for the low-income subsidy. Make plan marketing materials available in common areas. If you display marketing materials for some plans, you have to accept requests from all plans you participate with. 11/15/

44 CMS Rules Provider Practices Need To Know You may (but you aren t required to): Refer patients to other sources of information such as the State Health Insurance Assistance Program (SHIP), State Medicaid office, and Social Security office, or CMS website at or MEDICARE Share information with patients from CMS website, includingthe Medicare and You Handbook or Medicare Options Compare, or other documents that were written by or previously approved by CMS 11/15/

45 CMS Rules Provider Practices Need To You may NOT: Know Offer anything of value to induce plan enrollees to select you as their provider. Offer inducements to persuade beneficiaries to enroll in a particular plan or organization. Conduct health screenings when distributing information to patients. 11/15/

46 CMS Rules Provider Practices Need To Know You may NOT: Steer beneficiaries in any way to a limited number of plans. Mail marketing materials on behalf of plans. Offer sales/appointment forms. Accept enrollment applications. Make phone calls or direct, urge or attempt to persuade beneficiaries to enroll in a specific plan based on financial or any other interests of the provider 11/15/

47 Thank you! 51

48 Questions? 11/15/