Working with Anthem Subject Specific Webinar Series

Transcription

1 Working with Anthem Subject Specific Webinar Series Special Session 2015 Medicare Advantage Dual Eligible Special Needs Plans Access to Audio Portion of Conference: Dial-In Number: Conference Code: # Please Mute Your Phone Use the mute button or press *6 This presentation contains proprietary information of Anthem Blue Cross and Blue Shield. It is intended for Anthem providers. Any redistribution or other use is strictly forbidden.

2 2015 Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs) Agenda Housekeeping & Announcements Overview Managed Care Organization (MCO) Contracts & Agreements State SNP Agreement Models Dual Eligible Aid Categories Anthem Dual Advantage (HMO SNP) Plan Identification, Eligibility & Benefits Precertification Claims Model of Care (MOC) Learn More Questions 2

3 Housekeeping & Announcements Housekeeping Handouts & Navigation 1. Select items by checking the boxes Click here for handouts 2. Select a destination on your computer 3. Press OK to download Control your view Full Screen 3

4 Overview Anthem Dual Advantage (HMO SNP) Effective 01/01/2015 Dual Special Needs Plans o Special Medicare Advantage ( Part C ) plans that enroll only dual eligibles o Dual eligibles Covered by Medicare and also qualify for some type of state Medicaid benefits. o Three types of Special Needs Plans: 1. Chronic Special Needs Plans (CSNP) for individuals with (specific) severe or disabling chronic conditions; 2. Institutional Special Needs Plans (ISNP) for institutionalized beneficiaries (long-term care facility, for example); 3. Dual Special Needs Plans (DSNP) for individuals who are eligible for both Medicare and Medicaid 4

5 Managed Care Organization (MCOs) Contracts and Agreements MCO holds a Medicare Contract with CMS Medicare Part A, B and D benefits Supplemental benefits Approved D-SNP and Model of Care MCO holds a Medicaid/Special Needs Plan (SNP) agreement with State Medicaid Office Sets aid categories eligible for SNP: Full Benefit Dual Eligible (FBDE), Qualified Medicare Beneficiary Plus (QMB+), Qualified Medicare Beneficiary (QMB) and/or Specified Low-Income Medicare Beneficiary Plus (SLMB+) Coverage for Medicare cost sharing or Medicaid Long Term Care (LTC) or Home and Community Based services (HCBS) depend on the level of SNP agreement between the State and the Health Plan How providers bill for Medicare cost sharing and services depend on the level of SNP agreement between the State and the Health Plan DSNPs are NOT Medicare Medicaid Plans (MMP) 5

6 State SNP Agreements 3 Principle Models Agreements specify benefits, cost sharing, member protections, exchange of member eligibility and provider information. State can impose additional coordination & reporting requirements 6

7 State SNP Agreements All Anthem DSNP plans for 2015 are all Model 1. We hold Medicaid/SNP agreement with State Medicaid Office Sets aid categories eligible for SNP: FBDE, QMB+, QMB No coverage for Medicare cost sharing or Medicaid LTC or HCBS Services Providers bill Medicaid program for cost sharing and services 7

8 State SNP Agreements Wisconsin State Agmt Type Categories 2015 Service Areas by county Wisconsin Model 1 FBDE, QMB, QMB+ H ~ Anthem Dual Advantage (HMO DSNP) Kenosha, Milwaukee, Waukesha Categories Full Benefit Dual Eligible (FBDE) o Individual who is eligible for Medicaid either categorically or through optional coverage groups, such as Medically Needy or special income levels for institutionalized or home and communitybased waivers o Does not meet the income or resource criteria for a QMB or SLMB 8

9 State SNP Agreements Categories continued Qualified Medicare Beneficiary (QMB) o Individual who is entitled to Medicare Part A, has income that does not exceed 100% of the Federal Poverty Limit (FPL) and has resources which do not exceed three times the Supplemental Security Income (SSI) limit, adjusted annually for inflation. o Medicaid pays the Medicare Part A premiums, if any, Medicare Part B premiums and (to the extent consistent with the Medicaid State plan) Medicare deductibles and coinsurance for Medicare services provided by Medicare providers 9

10 State SNP Agreements Categories continued Qualified Medicare Beneficiary (QMB+) o Individual who meets all the standards for QMB eligibility, meets the financial criteria for full Medicaid coverage and is entitled to all benefits available to a QMB as well as all benefits available under the State Medicaid plan to a fully eligible Medicaid recipient OR o Individual who is eligible for Medicaid either categorically or through optional coverage groups, such as Medically Needy or special income levels for institutionalized or home and community-based waivers, and does not meet the income or resources criteria for a QMB or SLMB

11 Anthem Dual Advantage (HMO SNP) Dual Eligible Aid Categories Coverage FBDE QMB & QMB (+) Part B premium covered by state? Yes Yes Medicare cost sharing covered by state? Yes Yes Medicaid benefits provided? Yes QMB+ only Can join our Medicare dual eligible SNP? Yes Yes 11 11

12 Anthem Dual Advantage (HMO SNP) Dual Advantage (Dual Eligible SNP) Medicare Part A and B coverage Supplemental benefits Copays for most services Must be Medicaid eligible Medicaid pays cost sharing No OON benefit* Part D prescription drug coverage *All plans have coverage for Emergency and Urgent care. Out-of-area renal dialysis always is available from any provider. See Summary of Benefits under 2015 Benefits from the Provider Home page at for more information

13 Anthem Dual Advantage (HMO SNP) Wisconsin Member Identification Plan/Product identification Unique alpha prefix VOT Unique Member Identification cards 13 13

14 Anthem Dual Advantage (HMO SNP) Eligibility and Benefits Telephonic at EDI 270/271 Transactions Availity Multi-Payer Portal 14 14

15 Anthem Dual Advantage (HMO SNP) Precertification Same requirements as other Medicare Advantage plan members Precertification List and Form available by selecting Provider Forms from the Provider Home page at Telephonic at Online via Availity to My Payer Portals > Anthem Medicare Advantage Provider Self Service 15 15

16 Anthem Dual Advantage (HMO SNP) Precertification Online via Availity to My Payer Portals > Anthem Medicare Advantage Provider Self Service 16 16

17 Claim Processing Claim Submission Submit claims to Anthem as you would for any other Anthem Medicare Advantage member (electronic is preferred) Claim Status EDI 276/277 Transactions Via secure Availity web portal Claim Processing Claims are processed in accordance with member benefits Reimbursed at contracted Anthem Medicare Advantage HMO rates Payment details on Anthem Provider Remittance Advice (paper or electronic) 17 17

18 Claim Processing Claim Processing continued Submit Anthem Remittance Advice to Medicaid carrier Medicaid carrier may be the state Medicaid plan or a Medicaid Managed Care Organization There is no automated cross-over process so submission is required even if the Medicaid carrier is Anthem Providers are not allowed to balance bill any D-SNP member

19 Model of Care (MOC) The MOC is a CMS requirement for organizations that apply to offer a Special Needs Plan. These goals and objectives must be communicated, measured and tracked. These updates will be included in our Medicare Provider Guidebook available on the Provider Home page of our public Medicare Advantage Provider website In addition to specific goals and objectives, the MOC will: Include a specialized provider network and nationally-recognized clinical practice guidelines; Conduct Health Risk Assessments to identify the special needs Add services for the most vulnerable beneficiaries including, but not limited to those beneficiaries who are frail, disabled, or near the end-of- life

20 Model of Care (MOC) Interdisciplinary Care Team (ICT) A component of the MOC The ICT is a team of caregivers from different professional disciplines and/or services who work together to coordinate and/or deliver services focused on care planning, optimizing quality of life and support for the individual and/or family

21 Learn More Public Anthem Medicare Advantage Provider Website Important Medicare Advantage Updates Dual Eligibility Special Needs Plan Provider Training 2015 Benefits Provider Forms Medicare Managed Care Manual (Chapter 16-B: Special Needs Plans) Guidance/Guidance/Manuals/Downloads/mc86c16b.pdf 21 21

22 2015 Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs) 22 22

23 Working with Anthem Subject Specific Webinar Series Please complete the Webinar Evaluation Survey o Individuals completing the evaluation survey within 2 business days will be eligible for a Blue Prize package. o Winner will be notified by within 3 business days Thank you for attending Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin ("BCBSWi") which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association