Medica Health Care Plans, Inc. 1 Provider Handbook

Transcription

1 MHP Provider Handbook Table of Contents Introduction Your Participating Provider Handbook How to Reach Us & Key Contact Information Provider Resources on the Internet Section I: How Medica Health Care Plans (MHP) works Overview of MHP as a Coordinated Health Care Plan MHP Participating Provider Network Data Collection The Member and MHP Member Rights & Responsibilities Primary Care Physicians (PCP) and the Member Network Participation Participation in Quality Initiatives Provide Access to Records Resolving Disputes Informing Members about Advance Directives Risk Management Section II: MHP Medica Advantage Plan Benefits Covered Services Medicare Advantage Plans offered by MHP Emergency, Post Stabilization and Urgently Needed Services Renal Dialysis Services Prescription Drug Benefit Overview Pharmacy and Therapeutic Committee Formulary Coverage Limitations (Pharmacy) Prescription Benefit Utilization Management Coverage Determinations Requesting Coverage Determinations Standard Timeframes and Notice Requirements for Coverage Determinations Medication Therapy Management Program Section III: MHP Membership Marketing Guidelines Enrollment Eligibility Requirements Enrollment Elections Verification of Benefits Disenrollment Member Capitation Listing Section IV: Medical Management and Quality Improvement Programs Quality Assurance Credentialing Medical Records Access to Care Prior Authorization PCP Referral Form Medica Health Care Plans, Inc. 1

2 MHP Provider Handbook Table of Contents Medical Management Concurrent Review Direct Access Services Complex and Serious Medical Conditions Health Risk Assessment Preventive Health Care Guidelines Screening and Interventions for High Risk Population Section V: MHP Billing and Payment Overview Submitting Encounter Data Submitting Claims Electronic Submission When to File a Claim Dual Eligible Enrollees and Cost Sharing Where to send Paper Claims or Encounters Coding Criteria Disputing Claims Section VI: MHP Appeals and Grievances Section VII: MHP Administrative Forms Medica Health Care Plans, Inc. 2

3 Medica HealthCare Plans, Inc. (MHP) Introduction Your Participating Provider Handbook The purpose of the MHP Provider Handbook is to furnish Participating Providers with the protocols, procedures and policies needed to effectively carry out its contractual responsibilities under the terms and conditions of its Participating Provider Agreement. The term Participating Provider means Provider, a hospital, physician, ambulatory surgical center, home health care agency, pharmacy, multi-specialty group practice, or any other health care provider which or who has entered into an agreement with, or is otherwise engaged by, MHP to provide Covered Services to Members. Any such Participating Provider may be designated as a Participating Hospital, Participating Physician, Participating Pharmacy, etc. Updates and revisions to the Medica HealthCare Plans Provider Handbook are distributed separately via US Mail or Via Facsimile and may be placed on the website as an updated An update / revision can be a change, addition, deletion or correction to protocols, procedures and policies and may be communicated via Provider Bulletins or replacement pages to this handbook. Providers are encouraged to regularly check the website for updates and to read the Provider Bulletins for updates to this Provider Handbook. Updates to the Provider Handbook should be filed in the Handbook as it is the provider s responsibility to follow correct protocols, procedures and policies and to be in compliance with their corresponding Participating Agreement. Any questions regarding the material content of this Provider Handbook or further clarification regarding the policies and procedures applicable to you, as a Participating Provider, should be directed to the Department of Provider Relations or to your designated Provider Relations Representative. Medica Health Care Plans, Inc. 3

4 Medica HealthCare Plans, Inc. How to Reach Us Compliance Help Line: Tel: (305) Claim Status & Provider Appeals: Tel: (305) (800) Medical Management: Tel: (305) (ACCESSIBLE 7 DAYS A WEEK 24 HOURS A DAY) (866) Fax: (305) Member Services: For calls within Miami Dade County: Tel: (305) Toll Free: (800) TTY within Miami Dade County: Tel: (305) TTY Toll Free: (800) Member Eligibility and Benefits: For calls within Miami Dade County: Tel: (305) Toll Free: (800) TTY within Miami Dade County: Tel: (305) TTY Toll Free: (800) Provider Relations: Tel: (305) (800) Administrative Correspondence Corporate Office Medica HealthCare Plans, Inc Ponce De Leon Boulevard, Suite 650 Coral Gables, Fl Tel: (305) Fax: (305) Medica Health Care Plans, Inc. 4 Broward County Office Medica HealthCare Plans, Inc Sheridan Street, Suite 301 Hollywood, Fl Tel: (954) Fax: (954)

5 Claim Submission Address: Provider Appeals & Dispute (Claims) Web Site Address: EDI Support: Medica HealthCare Plans, Inc. P.O Box Coral Gables, FL Att: Claims Department Medica HealthCare Plans, Inc. Provider Appeals & Dispute Department P.O. Box Coral Gables, Fl Medica Health Care Plans, Inc. 5

6 Provider Resources on the Internet Medica HealthCare Plans, Inc. ALL FLORIDA GOVERNMENT & AGENCIES Agency for Health Care Administration (AHCA) Children s Medical Services Department of Children and Families (DCF) Medicaid Information at DCF Department of Elder Affairs (DOEA) Department of Health (DOH) Florida Administrative Code (FAC) Florida Health Statistics Florida KidCare Florida Statutes MEDICAID FISCAL AGENT: EDS Government Healthcare Provider Handbooks Fee Schedules Administrative Forms FEDERAL GOVERNMENT: Code of Federal Regulations Department of Health and Human Services CMS (Centers for Medicare and Medicaid Services) Medicare Social Security Administration (SSA) U.S. Government Official Web Portal Go to Provider Support, then Handbooks Go to Provider Support, then Fees Go to Provider Support, then Medicaid Forms Medica Health Care Plans, Inc. 6

7 Section I: How Medica HealthCare Plans, Inc. (MHP) Works Overview of MHP as a Coordinated Health Care Plan MHP is a Florida for profit corporation licensed and certified in the state of Florida through the Florida Department of Financial Services and the Agency for Healthcare Administration to operate as a duly licensed Provider Sponsored Organization ("PSO") with a Medicare Advantage contract in accordance with Chapter 641, Parts I and III of the Florida Statutes and the Federal Medicare Advantage Plan laws and regulations (42 CFR Part 422). MHP is a coordinated health care plan that includes a network of providers that are under contract or arrangement with the organization to deliver the benefit package approved by the Centers for Medicare and Medicaid Services (CMS) to eligible Medicare beneficiaries in the designated service areas of Miami Dade and Broward Counties within the state of Florida. As a coordinated care plan, MHP may incorporate mechanisms to control utilization, such as referrals from a Primary Care Physician (PCP) and prior authorization from the Health Plan for an enrollee to receive covered benefits and services. MHP must provide enrollees with all original Medicare-covered services except hospice, by furnishing the benefit package directly or through arrangements with Participating Providers, or by paying on behalf of enrollees for the benefit. In addition, to the extent applicable, MHP will also furnish, arrange, or pay for supplemental benefits. Supplemental benefits are non-drug plan benefits, not covered by original Medicare, but may be covered by MHP such as dental, vision, transportation, etc. MHP may also provide prescription drug coverage under Part D. In return for providing covered health care benefits to eligible Medicare beneficiaries, MHP is reimbursed by CMS an advance monthly per capita payment for aged and disabled enrollees based on the bidding methodology established by the Medicare Prescription Drug, Improvement, and Modernization Act (MMA). Payment for enrollees of MHP is fully adjusted for various actuarially determined factors including adjustments applicable under the CMS-HCC risk adjustment model which takes into account the member s diagnoses to measure relative risk due to health status. The CMS-HCC models function by categorizing International Classification of Diseases, 9 th Edition, Clinical Modification (ICD-9-CM) codes into disease groups called Hierarchical Condition Categories (HCCs). Each HCC includes diagnosis codes that are related clinically and have similar cost implications. The CMS-HCC models are prospective in the sense that they use diagnosis information from a base year to predict costs for the next year. Risk adjustment using diagnoses provides higher payments for enrollees at risk for being sicker, and lower payments for enrollees predicted to be healthier. Medica Health Care Plans, Inc. 7

8 The CMS-HCC risk adjustment model consists of a set of risk factors (relative cost factors) for each HCC and each demographic characteristic in the model. CMS uses demographic and diagnostic information from original Medicare and from all Medicare Advantage (MA) organizations a beneficiary may have joined to determine the appropriate risk score for each beneficiary. The risk score is computed for each beneficiary for a given year and applied prospectively. The risk score generally follows the beneficiary for one calendar year. When MHP forwards beneficiary enrollment information to CMS, CMS then sends MHP the appropriate risk scores for the beneficiary, as well as the resultant payment. MHP Participating Provider Network The success of MHP in providing or arranging for the provision of quality health care services for its members depends on a strong relationship with its Provider Network of participating Primary Care Physicians (PCP), medical specialists, hospitals, skilled nursing facilities, home health agencies, ambulatory clinics and many other providers and suppliers that make up its comprehensive network of participating health care providers. MHP provides for the participation of health care providers through reasonable procedures that include: Written notice of rules of participation including terms of payment, credentialing, and other rules directly related to participation decisions; Written notice of material changes in participation rules before the changes are put into effect; and Written notice of adverse participation decisions and a process for appeal As a Medicare Advantage organization, MHP has oversight responsibility for contractors, subcontractors, and related entities with which it maintains a contract for the provision of covered health care benefits and services; It is the responsibility of MHP to ensure through written arrangements with Participating Providers that all applicable laws, regulations, and other instructions are followed. MHP has established policies and procedures that ensure communication with the physicians who have agreed to provide services subject to the terms and conditions of the member s health care plan offered by MHP regarding the organization s medical policy, quality assurance/improvement programs and medical management procedures and makes certain that the following standards are met: 1. Practice guidelines and utilization management guidelines: A. Are based on reasonable medical evidence or a consensus of health care professionals in the particular field; B. Consider the needs of the enrolled population; Medica Health Care Plans, Inc. 8

9 C. Are developed in consultation with contracting physicians; and D. Are reviewed and updated periodically by pertinent MHP committees. 2. The guidelines are communicated to providers, and, as appropriate, to enrollees. 3. Decisions with respect to utilization management, enrollee education, coverage of services, and other areas in which the guiding principles apply are consistent with the guidelines. MHP coordinates the provision of covered benefits through the Department of Medical Management which works directly with participating providers to deliver quality heath care benefits and services in a cost effective and timely manner. MHP will not prohibit or otherwise restrict a Provider acting within the scope of his/her lawful scope of practice, from advising, or advocating on behalf of, an individual who is a patient and member enrolled under MHP. However, this general rule may not require MHP to cover, furnish, or pay for a particular medical service or procedure. Participating Providers have the operational and technical support of the Departments of Network Development and Provider Relations. Network Development s primary responsibility is to ensure that contracts are established and maintained with providers and suppliers of health care and health care related services to enable the delivery of the benefit package(s) approved by CMS. The Department of Provider Relations provides MHP s Provider Network, and their office staff, training on policies and procedures affecting their participation with MHP and monitors the Network Providers compliance with operational standards and practices. Additionally the department lends support in addressing the providers concerns and issues relating to their participation with MHP. Both departments assist Network Providers with any questions or concerns pertaining to their participation with MHP. Data Collection Medicare Advantage organizations are required to maintain a health information system that collects, analyzes and integrates all data necessary to compile, evaluate and report certain statistical data related to costs, utilization, quality, and other matters as CMS may require from time to time. As a participating provider, you are required to submit all data necessary for MHP to fulfill these obligations, within the required CMS time frames. During the course of performing these functions, Network Providers may use or disclose Protected Health Information ( PHI ) subject to the terms and conditions stipulated in their MHP Provider Agreement and Business Associate Amendment provided that such use or disclosure does not violate the HIPAA Privacy Regulations, GLB or other federal or state privacy laws applicable to MHP. You are required to certify in writing at the time of submission to MHP that all data including, but not limited to, encounter data and other information that CMS may specify, is truthful, reliable, accurate and complete. Medica Health Care Plans, Inc. 9

10 The Member and MHP Upon enrollment, an MHP member selects a Primary Care Physician (PCP) to receive all of his/her health services from or through their PCP in order for health services to be covered. Except for emergency, post-stabilization, urgently needed, and out-of-area renal dialysis health services, the member must receive all health care services through MHP s Provider Network. As stated above and for certain direct access services, routine or elective medical services not ordered, coordinated, or provided by or under the direction of the member s Primary Care Physician (PCP) are not covered services and neither Medicare nor MHP will pay for such services. Members of MHP will be treated with dignity and respect and will have their right to privacy regardless of race, physical or mental disability, ethnicity, gender, sexual orientation, creed, age, religion or national origin, cultural or educational background, economic or health status, English proficiency, reading skills or source of payment. A copy of the Members rights should be prominently displayed in the PCPs office. As a Member of MHP Members have a right to: Be treated with courtesy and respect, with appreciation of their individual dignity, and with protection for their need for privacy. A prompt and reasonable response to questions and requests from MHP and its network of contracted providers. Know their healthcare providers, and responsible parties in the delivery of health care to include: a. The provider s office address and telephone numbers, except private or back line numbers. b. The specialty and subspecialty authorized by the plan to participate by provider while contracted with the plan; c. Hospital affiliations (restrictions, sanctions, status or any other information provided by the hospital is to remain confidential). d. The name of the boards(s) certifying the provider, with respective issuance and expiration dates; and the names of medical schools, internships, residences, and fellowship programs attended by the provider, with respective attendance dates. e. Information on the providers credentialing process. f. Information about the absence of provider malpractice insurance coverage. A language interpreter service available upon request. Medica Health Care Plans, Inc. 10

11 Know what patient support services are available. Know what their patient responsibilities are. To receive complete information regarding their diagnosis, evaluation, planned course of treatment, alternatives, risks, and prognosis from their health care provider and participate in decisions of their health care. When it is medically inadvisable to give such information to a member, the information is provided to a person designated by the member or a legally authorized person. To participate in decisions involving their health care, except when such participation is contraindicated for medical reasons. To refuse any treatment, except as otherwise mandated by law. Upon his/her request, receive full information and necessary counseling on the availability of known financial resources for their care. To receive information regarding ownership of the health plan. To receive information regarding criteria used to make medical decisions. Offer suggestions to the health plan about policies regarding grievances procedures and external appeals process. Upon his/her request, receive a reasonable estimate of charges for medical care. Access medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment. To appropriate privacy. Treatment for any medical condition that may deteriorate from failure to obtain medical treatment. Know if the medical treatment is for the purposes of experimental research and to give their consent or refusal to participate in the experimental research. Express complaints, grievances and appeals through the grievance and appeals procedures established by MHP. Select a Primary Care Physician of their choice from MHP s Network of Participating Providers. Access to a second medical opinion, if requested, by either a contracted physician or non-contract physician in the organization s service area. Upon request, change primary or specialty physicians. Medica Health Care Plans, Inc. 11

12 To use advance directives. As Members of MHP, Members have a responsibility to: Provide his/her health care provider, to the best of their ability, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, allergies and other matters concerning your health. Follow the treatment plan recommended by the health care provider. Keep medical appointments and when unable to, notify the health care provider or facility. Be responsible for their actions when refusing treatment or not following the health care provider s instructions. Assure that financial obligations of their health care are fulfilled as promptly as possible including co-payments, deductibles, co-insurance amounts, non-covered services and benefits. Follow health care facility rules and regulations affecting patient care and conduct. Be respectful of all the health care providers and staff, as well as other members/patients. Learn about MHP and their health care coverage through MHP s member education material and Evidence of Coverage Certificate (EOC). Learn and adhere to the proper use of MHP s services and procedures for accessing medical treatment. Consult their Primary Care Physician and obtain his or her direction prior to receiving medical care unless it is a medical emergency. Provide a responsible adult for transportation to home from a facility and remain with him/her for 24 hours, if required by the physician. Inform his/her physician about any living will, power of attorney or other directive that could affect his/her care. Advise MHP if they are leaving MHP s service area. Primary Care Physicians (PCP) and the Member MHP believes in a strong Primary Care Physician (PCP) and patient relationship based on trust and respect. One of MHP s goals is to reinforce this concept and emphasize the importance of it. The role of the primary care physician as a care giver and coordinator Medica Health Care Plans, Inc. 12

13 of covered healthcare benefits and services is essential to the overall management of the member s health care. Primary Care Physicians (PCP) are responsible, but not limited to, actively participating in delivering or coordinating the following components in the overall health care of MHP members: Promoting health care maintenance for the treatment of illness and injury. Prevention and early detection of disease. Practicing and promoting preventive health care. Issuing Referrals to specialists when medically appropriate and obtaining prior authorization when required subject to the terms and conditions of the member s health care benefit plan. Coordinating the member s covered health care benefits and services in and out of the contracted Participating Provider Network. Maintaining a central medical record for each member. Ensuring continuity of care. Submitting encounter information timely; clearly identifying applicable diagnosis to the highest level of specificity and medical services rendered at the time of service. The PCP should communicate to the member matters concerning their health status, plans for medical care and treatment options, including the risks, benefits and consequences of treatment and non-treatment and provide the member with the opportunity to refuse treatment and to express preferences about future medical treatment. If you, as a PCP, are unable to provide treatment to a member because of religious grounds or morals, please contact Provider Relations at the number found on the How to Reach Us page of this section for assistance in this regard. Network Participation MHP contracts with a number of health care professionals, hospitals, skilled nursing homes, home health agencies, and other health care providers and suppliers to provide or arrange for the provision of covered healthcare services and benefits to MHP members. As an MHP contracted participating provider you have the responsibility to abide by the provisions of your Provider Participation Agreement. Some of these responsibilities include but are not limited to: Promoting health care maintenance for the treatment of illness and injury. Prevention and early detection of disease. Practicing and promoting preventive health care. Obtaining prior authorization when required subject to the terms and conditions of the member s health care benefit plan. Coordinating the member s covered health care benefits and services in and out of the contracted Participating Provider Network through the member s PCP or Medical Management as may be applicable. Ensuring continuity of care. Medica Health Care Plans, Inc. 13

14 Providing medical consult reports or hospital discharge summaries to member s PCP within (7) days of the date of service or date of discharge. Submitting clean claims within 180 days from the date of service; clearly identifying applicable diagnosis to the highest level of specificity and medical services rendered at the time of service. Provide Official Written Notice to the Department of Network Development at the following address: Corporate Office Medica HealthCare Plans, Inc. Network Development Department 4000 Ponce De Leon Boulevard, Suite 650 Coral Gables, Fl Tel.: (305) Fax: (305) You must provide written notice to the department of Network Development of the following events immediately following your knowledge of the occurrence: Cancellation of termination of liability insurance or reduction of coverage limits to amounts less than those required by MHP. Change in business ownership, name, address, phone or federal tax ID number. Bankruptcy or insolvency. Any indictment, arrest or conviction or any criminal charge to you or your business. Any suspension, exclusion, debarment or any other sanction from the state or federally funded health care program. Loss or suspension of your Professional License or DEA/CDS Certification. Disciplinary activity held against your Professional License or other certification. Electing the opt-out option allowed by Medicare and signing private contracts with Medicare beneficiaries. Medica Health Care Plans, Inc. 14

15 Participation in Quality Initiatives You are expected to participate and cooperate with our quality assessment and improvement initiatives, and to comply with accepted clinical guidelines, patient safety standards and data confidentiality procedures. You are expected to participate in the submission of encounter data that supports The Healthcare Effectiveness Data and Information Set (HEDIS); a widely used set of performance measures in the managed care industry, developed and maintained by NCQA. The submission of HEDIS data is a Centers for Medicare and Medicaid Services (CMS) requirement. Provide Access to Records You must provide access to medical, financial or administrative records related to the health care services and benefits you provide to MHP members within the specified timeframe given and requested by MHP for cases such as fraud and abuse, a member grievance and appeal, a regulatory accreditation agency requirement, a medical record audit, etc. Resolving Disputes If you have a concern or complaint about MHP, direct your concerns in writing to the Department of Provider Relations. A Provider Relations representative will work directly with you to resolve the matter. If your issue relates to matters generally administered by MHP, the process and procedures applicable to the resolution of such matters shall prevail. Disputes or Appeals regarding claims must be directed to the Provider Appeals and Grievance Department at the following address: (See Section V, Billing and Payment for further information about disputing claims) Medica HealthCare Plans, Inc. Provider Appeals & Dispute Department P.O. Box Coral Gables, Fl If MHP has a concern or complaint about you, MHP will communicate such matters in writing to you including issuing you a corrective action plan if applicable. If the matter in dispute cannot be resolved through informal or formal discussions between you and MHP, an arbitration proceeding may be filed as stipulated in your Provider Participation Agreement. Arbitration proceedings under MHP s agreement with Medica Health Care Plans, Inc. 15

16 you will be conducted in Miami Dade County. Arbitration will be conducted pursuant to the rules and regulations of the American Health Lawyers Association Alternative Dispute Resolution Service Rules of Procedures for Arbitration ( AHLA Arbitration Service ) Inform Members of Advance Directives The Federal Self Patient Determination Act (PSDA) gives members the legal right to make choices about their medical care in advance of debilitating illness or injury through an advance directive. Pursuant to the PSDA, physicians and providers including hospitals, skilled nursing facilities, hospices, home health agencies and others must provide written information to patients on State law about advance directives and about the provider s own policies regarding advance directives. The following guidelines delineate MHP s position with respect to Florida Law and rules relative to advance directives. These guidelines shall not condition treatment or admission upon whether or not the individual has executed or waived an advance directive. MHP respects the right of every competent adult to make decisions concerning his or her own health, including the right to choose or refuse medical treatment. MHP will not condition the provision of covered health care benefits or services or otherwise discriminate against an individual based on whether or not the individual has executed an advance directive. MHP requires that its participating providers maintain a copy of a member s advance directive as part of the member s medical record if the member has provided it. The medical record should also note if the member has not executed an Advance Directive. MHP does not require for a member to have an advance directive and the member may cancel an advance directive at any time. In the event of a conflict between MHP s policies and procedures or a provider s policies and procedures and the individual s advance directive, the following provisions shall be made: 1. A health care provider or facility that refuses to comply with a patient s advance directive, or the treatment decision of his or her surrogate, shall make reasonable efforts to transfer the patient to another health care provider or facility that will comply with the directive or treatment decision. Florida Law does not require a health care provider or facility to commit any act which is contrary to the provider s or facility s moral or ethical beliefs, if the patient: Is not in an emergency condition; and Has received written information upon admission informing the patient of the policies of the health care provider or facility regarding such moral or ethical beliefs. 2. A health care provider or facility that is unwilling to carry out the wishes of the patient or the treatment decision of his or her surrogate because of moral or ethical beliefs must within 7 days either: Medica Health Care Plans, Inc. 16

17 Transfer the patient to another health care provider or facility. The health care provider or facility shall pay the costs for transporting the patient to another health care provider or facility; or If the patient has not been transferred, carry out the wishes of the patient or the patient s surrogate, unless the patient s family, the health care facility, or the attending physician, or any other interested person who may reasonably be expected to be directly affected by the surrogate or proxy s decision concerning any health care decision believes: A. The surrogate or proxy s decision is not in accord with the patient s known desires or the provisions of Chapter 765, F.S.; B. The advance directive is ambiguous, or the patient has changed his or her mind after execution of the advance directive; C. The surrogate or proxy was improperly designated or appointed, or the designation of the surrogate is no longer effective or has been revoked; D. The surrogate or proxy has failed to discharge duties, or incapacity or illness renders the surrogate or proxy incapable of discharging duties; E. The surrogate or proxy has abused powers; or F. The patient has sufficient capacity to make his or her own health care decisions. The patient s family, the health care facility, or the attending physician, or any other interested person who may reasonably be expected to be directly affected by the surrogate or proxy s decision concerning any health care decision may seek expedited judicial intervention pursuant to rule of the Florida Probate Rules, if any of the issues described above are applicable. Any practitioner or facility transferring the patient to another practitioner or facility shall contact the Department of Medical Management and notify of such transfer prior to transferring the patient. The Department of Medical Management shall coordinate future services with contracted providers that are willing to execute the wishes of the patient or his/her surrogate. Risk Management MHP as part of its administrative function has established an internal Risk Management Program. The risk manager provides implementation and oversight of the program. The program documents, investigates and analyzes the frequency and causes of general categories and specific types of incidents. The program assures the development of appropriate measures to minimize the risk of injuries and incidents to patients. An incident report must be completed and reported to the Risk Manager within 24 hours of the occurrence. Serious reportable incidents (Code 15), such as unexpected death, Medica Health Care Plans, Inc. 17

18 brain damage, surgical errors, and other occurrences require that the Risk Manager report to the Agency for Healthcare Administration (AHCA). All incident reports will be reviewed and investigated by the Risk Manager. This includes the analysis of enrollee grievances which relate to patient care and quality of medical services. The Risk Manager will make recommendations for appropriate corrective actions and/or prevention education to the appropriate committees. A copy of the Incident Report with directions is included in this Handbook. The Risk manager is available to you for assistance or concerns regarding incident reporting. Medica Health Care Plans, Inc. 18

19 Section II: MHP Medicare Advantage Plan Benefits Covered Services MHP covered services means those medical, hospital, ancillary and other professional health care services to which Members are entitled under the terms of a Medicare Advantage Plan (MA), are Medically Necessary and for which MHP has the obligation to pay, as described and set forth in the applicable MHP MA Plan in which a Member has enrolled. Original Medicare Basic Benefits is defined as all Medicare-covered benefits (except hospice services). Participating Providers shall not represent to any Member that any non-covered Service is a Covered Service or that such non-covered service should or will be paid by MHP. Except as may be otherwise stated herein, nothing in the Participating Provider Agreement shall prohibit a Provider from seeking payment from a Member for non- Covered Services. Provider may render a non-covered Service to a Member only if the following conditions are met: (i) Provider advises the Member in writing in advance that the service is a non-covered Service; (ii) Provider advises the Member in writing that MHP will not pay for the service, and (iii) the Member consents to the service and agrees in writing to be responsible for payment. The health care plans offered by MHP cover all of Medicare Part A and Part B basic benefits, excluding hospice services, as well as additional benefits traditionally not covered by original Medicare, in the designated service areas of Miami Dade and Broward Counties within the state of Florida. For a complete Summary of Benefits and to view the Referral and Authorization requirements for each Medicare Advantage Plan offered by MHP, please visit our website at You may also call Member Services directly to verify member benefits and eligibility at: Member Eligibility and Benefits: For calls within Miami Dade County: Tel: (305) Toll Free: (800) All covered services must be medically necessary and provided or coordinated by the member s primary care physician, except for emergency, post-stabilization, out-of-area renal dialysis and urgently needed health services. All services must be provided in accordance with professionally recognized standards of health care. Medica Health Care Plans, Inc. 19

20 The Medicare Advantage Plans offered by MHP include: MedicareMax: MedicareMax is a traditional gatekeeper plan with benefits that include comprehensive medical benefits with low or no copays, a Point of Service benefit that allows members to see providers outside of the participating provider network subject to a maximum per calendar year, unlimited routine transportation, coverage for all generic and preferred brand name medications, through the coverage gap, and $0 plan premium. MedicareMax Direct: MedicareMax Direct is a plan in which no referrals are required to see participating specialists. This is also referred to as open access. Benefits include comprehensive medical benefits with low or no copays, unlimited routine transportation, a Point of Service benefit that allows members to see providers outside of the network subject to a maximum per calendar year, coverage for all generic and preferred brand name medications through the coverage gap, and $0 plan premium. MedicareMax ValueRX: MedicareMax ValueRX is a plan in which no referrals are required to see participating specialists. Benefits include reimbursement of the Part B premium by up to $96.40 a month, comprehensive medical benefits with low or no copays, a Point of Service benefit that allows members to see providers outside of the participating provider network subject to a maximum per calendar year, routine transportation, a Point of Service benefit that allows you to see providers outside of the network, and a Medicare Part D prescription drug benefit. MedicareMax Value: MedicareMax Value is a traditional gatekeeper plan with benefits that include reimbursement of the Medicare Part B premium up to $96.40 per month, comprehensive medical benefits with low or no copays, a Point of Service benefit that allows members to see providers outside of the participating provider network subject to a maximum per calendar year, unlimited routine transportation, and $0 plan premium. MedicareMax Value is a plan designed for Medicare beneficiaries that already have creditable prescription drug such as through active employee coverage or through VA benefits, or for people that do not want Medicare Prescription Drug Coverage. MedicareMax Plus: MedicareMax Plus is a Medicare Special Needs Plan and is only available for Medicare beneficiaries with Medicaid. MedicareMax Plus is a traditional gatekeeper plan with benefits that include a Point of Service benefit that allows for coverage outside of the participating provider network with no calendar year maximum, comprehensive medical and dental benefits, routine transportation, meals, and up to $20 a month for over the counter items and products. Medica Health Care Plans, Inc. 20

21 Point of Service Benefits (POS) Point of Service (POS) is a benefit offered by MHP to its Medicare enrollees. Under the POS benefit option, MHP members have the option of receiving specified services outside of MHP s participating provider network. Requirements of PCP Referrals and prior authorization from MHP may apply for entitlement to covered healthcare benefits and services under the POS benefit option. Pursuant to the member s MA Plan, POS benefits may be covered up to a maximum per calendar year. Emergency, Post-Stabilization and Urgently Needed Services: Medically necessary emergency health services are covered worldwide. An emergency medical condition is when the member reasonably believes that his /her health is in serious danger. A medical emergency includes severe pain, a bad injury, a serious illness, or a medical condition that is quickly getting much worse. An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child; Serious impairment to bodily functions; or Serious dysfunction of any bodily organ or part. Emergency services are defined as covered inpatient and outpatient services that are: Furnished by a provider qualified to furnish emergency services. Needed to evaluate or stabilize an emergency medical condition. In the event of an emergency, the member should seek immediate care, or call 911 for assistance. Prior authorization is not required. MHP provides coverage for post-stabilization care. Post-stabilization care is covered services related to an emergency medical condition that are provided after a member is stabilized in order to maintain the stabilized condition or to improve or resolve the member s condition. The attending provider determines when the condition is no longer an emergency and the member is considered stabilized for discharge or transfer. Continuation of care after the condition is no longer an emergency will require coordination with MHP. Post-stabilization care in or out of MHP s service area is covered if: Medica Health Care Plans, Inc. 21

22 Prior authorization is issued by MHP. Automatically approved because MHP did not respond to the request by the provider of post-stabilization services for prior authorization within one hour after the Health Plan was asked to approve further post-stabilization care, or Automatically approved because MHP could not be reached for prior authorization despite reasonable efforts. Automatic approval of post-stabilization care continues to be covered until MHP has responded to the request and arranged for discharge or transfer. MHP s financial responsibility for post stabilization care services that have not been pre approved ends when: An MHP Provider Network physician with privileges at the hospital assumes the health care of the member. An MHP Provider Network physician assumes responsibility for the member s care through transfer, and; The MHP utilization management staff and the ER attending physician reach an agreement concerning the member s care; or The member is discharged. Urgently needed health services are covered when members are temporarily outside of the service area. Urgently needed services are also covered when obtained from any provider within the service area in extraordinary cases in which participating providers are unavailable or inaccessible due to an unusual event. In non-extraordinary cases, urgently needed health services in the service area are covered when ordered, provided, or arranged under the direction of the primary care physician. Renal Dialysis Services MHP will cover renal dialysis services while the member is temporarily out of MHP s service area. Prescription Drug Benefit Overview MHP provides coverage of Part D drugs through the prescription drug program. The goal of Medica HealthCare Plans, Inc s prescription drug program is to provide safe, appropriate, accessible, and cost effective drugs to its members. The Pharmacy Services Department operates to ensure positive drug therapy outcomes for its members by working in collaboration with plan providers and members. Medica Health Care Plans, Inc. 22

23 Pharmacy and Therapeutics Committee The Pharmacy and Therapeutics (P&T) Committee is an evidence-based formulary review forum that establishes policies on the coverage and use of drugs under the prescription benefit program. Utilization management tools and formulary drug coverage decisions are made by the P&T Committee using scientific and economic considerations with the goal of achieving safe, appropriate, and cost effective drug therapy. The P&T Committee has a key role in defining policies for utilization management activities such as access to non-formulary drugs, prior authorization, step therapy, quantity level limits and generic substitution. These tools are used to assure medically appropriate and cost-effective access to drugs. Formulary The MHP Formulary is designed to serve as a guide for prescribers in the selection of therapeutically appropriate and cost-effective drugs. The MHP Formulary was developed through the collaboration of the Pharmacy & Therapeutics (P&T) Committee that includes input from the Medical Director and the Pharmacy Director. This Committee, composed also of other practicing physicians and pharmacists, reviews all medications in the different therapeutic classes and focuses primarily on clinical efficacy and safety. The P&T Committee has a key role in defining policies for utilization management activities such as access to non-formulary drugs, prior authorization, step therapy, quantity level limits and generic substitution. The Formulary development and maintenance is a dynamic process. Therefore, the P&T Committee periodically reviews new and existing medications and drug classes to ensure that the formulary remains responsive to the needs of MHP members and prescribers. The Abridged Formulary represents a condensed version of the complete MHP Formulary. This condensed version was prepared to reflect the most commonly prescribed therapeutic classes and their respective generic and Preferred Brand medications. For a complete, updated formulary of all covered medications, please visit our Website at MHP may add or remove drugs from our formulary during the benefit year. You may obtain updated information about the drugs covered by Medica HealthCare Plans, Inc, on our Website at or you may call Customer Service at , Monday through Friday 8:00 am to 5:00 pm. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we will notify you as well as the members who take the drug that it will be removed at least 60 days before the date that the change becomes effective. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. Coverage Limitations The following is a list of non-covered (excluded) drugs and/or categories: Medica Health Care Plans, Inc. 23