2014 Medicare Advantage Prescription Plans
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1 2014 Medicare Advantage Prescription Plans HealthWest PHO Brenda Rose Provider Network Consultant December 19, 2013
2 About Humana Humana is one of nation s largest publicly traded health benefits companies with 12.3 million medical members 8.2 million specialty product members Offers a wide array of plans for employer groups, government programs and individuals Offers a range of specialty products, including dental and vision plans Operates more than 400 medical centers Operates 270 worksite medical facilities
3 Humana Medicare PPO Plans LPPO and RPPO Key Features Benefit Summary 3
4 Some Key Features of Medicare PPO No referral required In Network and Out of Network coverage May have out of network deductible Higher member responsibility for out of network providers List of participating providers in Humana.com/Physician Finders Plus Member request (not required) to select Primary Physician Participating primary physicians will see their name displayed on the back of member ID cards Non participating provider or specialist will be noted in Humana systems, NOT on ID cards. Selection of new primary physician at any time New ID card generated Member notified when provider terms and asked to select a new provider
5 Some Key Features of Medicare PPO Cont. Criteria for listing PCP on member ID card: Members provides this information during Open Enrollment or from Humana member outreach; Goal Provider chosen must be participating with Humana and the Member s LOB; and, Provider must be a Family Practitioners, General Practitioners, Internal Medicine physicians, Pediatricians and OB/GYNs. Strengthen member primary physician relationship and engagement Increase use of preventive services Improved coordinated care and outcomes Improved Quality (HEDIS) measures
6 Sample of Humana Choice (PPO) ID Card Plan Type Primary Physician
7 2014 Atlanta LPPO Plan H Humana Choice MA PD LPPO Benefits (IN /OON) Premium / Maximum Out Of Pocket (IN) $0 (Ded) IN NETWORK $50/$6700 OON (Ded) /Combined MOOP (IN/OON) Out of Network Ded $1,000/$10,000 Inpatient Acute (IN/OON) Skilled Nursing Facility IN/OON PCP/Specialist Visit IN/OON Emergency Room Services IN/OON Outpt Surgeries IN/OON ASC/Outpatient Hospital Outpatient Hi Tech Imaging IN/OON Outpt Basic Radiology Svs (PCP/SP/FS/OH) IN/OON Outpt Diagnostic Tests/Procedures (PCP/SP/OH) IN/OON Outpt Laboratory Svs (PCP/SP/FS/OH) IN/OON Outpt Chemotherapy Drugs IN/OON $260 copay days (1 7) / 30% coinsurance per admit $0/day (1 7) $25/day (8 20) $150/day (21 100) / 30% coinsurance $15/$40 copay / 30% coinsurance $65 copay (waived if admitted within 24hrs) $250 ASC/ $250 Outpatient Hospital / 30% coinsurance Office / FS Radiology/Outpatient Hospital $200 Copay / 30% coinsurance $15/$40/$40/$50 / 30% coinsurance $15/$40/$100 / 30% coinsurance $15/$40/$40/$50 / 30% coinsurance 20% / 30% coinsurance Counties :Bartow, Carroll, Cherokee, Clayton, Cobb, Coweta, Dawson, DeKalb, Douglas, Fayette, Floyd, Forsyth, Fulton, Gwinnett, Haralson, Henry, Meriwhether, Newton, Paulding, Pickens, Rockdale, Walton
8 2014 GA/SC RPPO Plan R Same in and out of network benefits! Humana Choice MA PD RPPO Benefits (SAME IN/ OON Benefits) Premium / Maximum Out Of Pocket (IN) $77/$6700 (I/O) OON (Ded) /Combined MOOP (IN/OON) $0/$6700 (I/O) Inpatient Acute (IN/OON) $260/day (1 7) Skilled Nursing Facility IN/OON $0/day (1 7) $25/day (8 20) $150/day (21 100) PCP/Specialist Visit IN/OON $20/ $45 copay Emergency Room Services IN/OON Outpt Laboratory Services (PCP/SP/FS/OH) IN/OON Outpatient Hi Tech Imaging IN/OON Outpt Basic Radiology Svs (PCP/SP/FS/OH) IN/OON Outpt Diagnostic Tests/Procedures (PCP/SP/OH) IN/OON Outpt Surgeries IN/OON (PCP/SP/ASC/OH) Outpt Chemotherapy Drugs IN/OON $65 copay (waived if admitted within 24hrs) $20/ $45/ $0/ $45 copay Office & OH $200 Copay / FS Radiology $150 Copay $20/ $45/ $45/ $50 copay $20/ $45/ 25% coins $20/ $45/ $225/ $260 copay 20% coinsurance
9 2014 GA/SC RPPO Plan R Humana Choice MA (ONLY) RPPO Benefits (IN /OON) Premium / Maximum Out Of Pocket (IN) $0/$5900 OON (Ded) /Combined MOOP (IN/OON) Out of Network (Ded) $500/$7500 Inpatient Acute (IN/OON) $900 copay/admit / $1250 copay/admit Skilled Nursing Facility IN/OON PCP/Specialist Visit IN/OON Emergency Room Services IN/OON Outpt Laboratory Svs (PCP/SP/FS/OH) IN/OON $0/day (1 7) $25/day (8 20) $150/day (21 100) /30% coins $15/$45 copay / $45/$45 copay $65 copay (waived if admitted within 24hrs) $15/ $45/ $0/ $45 copay / $45/$45/30%/30% coins Outpt Diagnostic Tests/Procedures (PCP/SP/OH) IN/OON $15/ $45/ $50 Copay / $45/$45/ 30% coins Outpt Basic Radiology Svs (PCP/SP/FS/OH/) IN/OON $15/ $45/ $45/ $50 copay / $45/$45/30%/30% coins Outpatient Hi Tech Imaging IN/OON Outpt Surgeries IN/OON (PCP/SP/ASC/OH) Outpt Chemotherapy Drugs IN/OON Office & OH $100 Copay FS Radiology $50 Copay / 30% coins $15/ $45/ $100/ $150 copay / $45/$45/30%/30% coins 20% / 30% coinsurance
10 Medicare Preauthorization Summary 2013 Key Items 2014 Updates 10
11 Medicare Advantage Preauthorization Summary Humana Gold Plus (HMO) and Medicare PPO Inpatient Admissions (Acute Hospital; Acute Rehab; LTAC; SNF; MH-partial/residential) Before Admission/Next Business Date Website (Humana.com) or IVR Plastic Surgery/Cosmetic Surgery Hi-Tech Imaging (MRI, MRA, CT, CTA, SPECT, PET, Nuclear Test & Cardiac Caths) HealthHelp Radiation Therapy HealthHelp Outpatient Therapy Services (PT; OT; ST) Authorization Authorization Authorization Authorization Authorization Durable Medical Equipment (DME over $750 ) Authorization Pain Management Procedures OrthoNet Cardiac Devices HealthHelp Facility-Based Sleep Studies (PSG) Authorization Authorization Authorization Full list is at Humana Gold Choice PFFS plans are notification only
12 National Vendors Utilization Programs
13 National Vendors: Utilization Management Vendors Diagnostic imaging Radiation therapy Specific cardiac services Call for Humana radiology services authorizations Or go online at and use the outpatient radiology authorization and referral link Pain management Online Log into the Provider Self Service Center (Humana.com or Availity.com) Call OrthoNet at Fax OrthoNet at
14 LifeSynch Behavioral Health Network Primary care physician (PCP) calls number on back of Humana member ID card. PCP tells customer service representative the level of care for authorization. PCP coordinates care with appropriate LifeSynch associate. LifeSynch locates in network provider. LifeSynch coordinates referrals and precertifications for covered services Provider lookup at Humana.com in Physician Finder, Lifesynch.com or
15 Apria and Edgepark Medical Supply Companies Apria National Home Medical Equipment Includes: Home oxygen services CPAP/BiPAP equipment and supplies Home tube feeding Outpatient negative pressure wound therapy Providers can contact their local Apria branch for referrals or call Local alternatives to national contract (this is where you list special local contracts with hospital systems; check with Contracting to be sure you are sharing current information) Edgepark Medical Supplies Insulin pumps or
16 RightSource DME / Coram / Rotech / CSS Right Source (Preferred Provider Diabetic Monitoring Supplies) $0 copay Free shipping to members or TTY: 711 Coram Home Infusion Therapy Apria affiliated company or Rotech DME Mobility needs wheelchairs and assist devices CCS Medical Supplies or Update : Amedisys National contract termination for home health as of 9/30/2012. Refer to in network home health provider in your market.
17 Golden Living Nursing Centers / Hanger Prosthetics Golden Living Skilled Nursing Facilities Locations throughout Humana markets Hanger Prosthetic and Orthotics or Oncology Analytics (effective 10/07/2013) or
18 Laboratory and Prescription Home Delivery Service Laboratory LabCorp Quest Diagnostics Local alternative to national contract RightSourceRx Mail Order Pharmacy Significant saving to Humana members Discounts for Brands $0 copay for 90 day supply for many generics To submit a new prescription: o Transmit directly to RightSourceRx.com o Call o Fax prescription fax form (online fax form at RightSourceRx.com) Drugs with quantity limits or require prior authorization must be approved by Humana Clinical Pharmacy Review (HCPR) at Pharmacies and technicians available for member questions Refill reminders via phone or
19 Humana.com Availity.com
20 Humana.com Provider Resources Integrated Provider Solutions 20
21 Administrative Simplification Simplify Today Registered Access Eligibility & Benefits Verification Benefit Estimator Member Care Alerts and Summary Referral & Authorizations Claims Tools Medical Records Management Code Edit Questions Fee Schedules Electronic Remit Advice (ERA 835) Auto posting through vendors Electronic Funds Transfer (EFT) Direct deposit 21 BRANDED Humana.com Overview
22 Humana.com Registered User Access
23 Availity.com Multiple payers One website One log in Integrated Provider Solutions 12/3 0/
24 Referral & Authorizations Referral / Authorization Associated Links Referral & Authorization Submission Authorization Management (Inquiry and Update) 24
25 Submitting an Referral/Authorization Additional Links Links for : FAQ Help See Demo 25
26 Authorization Management Select: Authorization Management 26
27 Authorization Management Inquiry Tabs for : Current Authorizations Search Authorizations Message / Alerts 27
28 Electronic Remittance Advice (ERA) & Electronic Funds Transfer (EFT) Electronic Remittance Advice (ERA) Benefits Save time spent on manual processes, such as opening mail and calling customer service Reduce paper mail from Humana Take advantage of an automated process for health care providers (available to those who can accept autoposting transactions through a participating vendor, billing agency or clearinghouse) View remits on Humana.com Receive HIPAA compliant ERA transactions Electronic Funds Transfer (EFT) Benefits Get paid up to seven days faster Receive Humana payments via direct deposit into the bank account of your choice Setup is easy! Save time by registering for EFT and ERA at the same time either on Humana.com or Availity.com For more information deployment@humana.com NC HFMA Health Insurance Institute, Greensboro, NC October 1,
29 Getting on Electronic Remittance and Fund Transfer (ERA/EFT) To access the ERA/EFT Setup Change Request Application, providers should: Click the ERA/EFT Setup Change Request link from the secure section of the Provider Self Service Center Choose Tools and Resources from the public section of the provider website and then click on Electronic Remittance Providers should enter the required information: Name Phone number Tax identification number Details of two checks from Humana
30 Medicare Programs Medicare Contacts
31 Clinical Management Programs Promote healthy living Provide guidance to members with complex conditions Medicare Health Risk Assessment (HRA) Episodic Case Management Renal Disease Management (VillageHealth at (800) or HumanaCares Complex Care Management ( ) SeniorBridge Health Achieve Field Case Management Disease Management Humana Clinical Programs Bariatric management program Medication therapy management (MTM) Transplant management HumanaFirst Nurse Advice Line Utilization Management (UM) Post Acute Care & Onsite Review Nurse (OSRN) Transition of Care Visit:
32 Contacts You Need to Know Medicare customer service: See back of member s ID card Authorization/IVR: Provider relations: (fee schedule requests, demographic changes, credentialing status) Medicare case management & Concurrent review Disease management program information: RightSourceRx pharmacy: Provider Consulting Team Brenda Rose (North Georgia Market) Karen Andrews (East Georgia Market) Kimberly Bryant (West Georgia Market) Iris Johnson (Georgia Frontline Leader) brose5@humana.com kandrews1@humana.com kbryant1@humana.com ijohnson2@humana.com
33 Questions & Answers Providing our members and providers Perfect Experience
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