Benefits Why AmeriHealth Caritas VIP Care Plus Was Created
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1 Benefits
2 Benefits Why AmeriHealth Caritas VIP Care Plus Was Created The Medicare Medicaid Plan, AmeriHealth Caritas VIP Care Plus, was created to coordinate Medicare and Medicaid services, simplify the delivery system and to streamline payment to the provider. The goals of creating this plan are: Improve health outcomes. Keep beneficiaries in the community. Provide coordination for members to improve health outcomes. 2
3 First Choice VIP Care PLUS covers all Original Medicare and Michigan Medicaid Medical Benefits Medicare Parts A and B benefits Medicare Part D prescription drug benefits Michigan Medicaid benefits Long Term Services and Supports (LTSS) benefits AmeriHealth Caritas VIP Care Plus does not charge a copayment for Original Medicare and Michigan Medicaid Medical Benefits to the member. 3
4 Benefits Medicare vs. Medicaid: Which Program Pays for What Service? PLAN NAME MEDICARE PARTS A & B MEDICARE PART D MEDICAID Medicaid Michigan Department of Community Health NA NA X Medicare Fee for Service or Medicare Advantage (MAPD) AmeriHealth Caritas VIP Care Plus Medicare Medicaid Plan X X Not applicable for non-dual Medicare beneficiaries FFS for dual eligible beneficiaries X X X 4
5 Benefits Medicare Part A and B Benefits * ** Ambulance Services Cardiac and Pulmonary Rehabilitation Services Catastrophic Coverage Chiropractic Care Dental Services Diabetes Program and Supplies Diagnostic Tests, X-Rays, Lab Services, and Radiology Services Doctor Office Visits Durable Medical Equipment Emergency Care Hearing Services Home Health Care Hospice - Initial Consultation Inpatient Hospital Care Inpatient Mental Health Care Out-of Network Catastrophic Coverage Out-of-Network Initial Coverage Outpatient Mental Health Care Outpatient Rehabilitation Outpatient Services/Surgery Outpatient Substance Abuse Care Pharmacy LTC Pharmacy Mail Order Prescriptions Out-of-Network catastrophic Prescriptions Outpatient Prescription Drugs Podiatry Preventive Services and Wellness/Education Prosthetic Devices Skilled Nursing Facility Urgent Care *Exceptions may apply, see provider manual for full list of benefits. ** Referral or prior authorization may be required. 5
6 Benefits Medicaid Benefits Dental Services. Durable Medical Equipment. Family Planning Services. Home Health. Home and Community Based Services. Medical Services. Non Emergency Medical Transportation. Nursing Facility Care. Pharmacy Services (Tier 3) Prosthetics. Sexually transmitted infections screening and counseling. Vision care. *Exceptions may apply, see provider manual for full list of benefits. ** Referral or prior authorization may be required. 6
7 Carved Out Medicare Benefit Hospice Services. 7
8 Home and Community Based Services
9 Medicaid Waivers Waivers are state specific Medicaid programs that allow for services to be provided outside of nursing homes. To avoid confusion, it is worth mentioning that waivers are also referred to as 1915 waivers (for the Social Security Act), home and community based services (HCBS) waivers, waiver services, waiver programs and by any number of other state-specific names. 9
10 What are Long Term Services and Supports (LTSS) benefits LTSS (also known as HCBS services) are a variety of services and supports that help elderly individuals and/or individuals with disabilities meet their daily needs for assistance and improve the quality of their lives. Examples include assistance with bathing, dressing and other basic activities of daily life and self-care, as well as support for everyday tasks such as laundry, shopping, and transportation. LTSS are provided over an extended period, predominantly in homes and communities, but also in facility-based settings such as nursing facilities. 10
11 LTSS/HCBS Services Include:: Adaptive and assistive device services Adult day health Assisted living service Choices -home care attendant service Chore services Community transition service Emergency response service Enhanced community living Home care attendant Home delivered meals Home medical equipment and supplies Home modification, maintenance and repair Homemaker Independent living assistance Non Medical transportation Nursing service Nutritional consultation Personal care Pest control Respite Social work counseling 11
12 Benefits 24/7/365 Nurse Line If members are unable to reach their PCP s office, registered nurses are available 24/7days to assist members through the Nurse toll-free Call Line AmeriHealth Caritas VIP Care Plus Nurse Call Line:
13 Integrated Care Bridge overview What is the Integrated Care Bridge (ICB)? A web-based care coordination platform that is accessible for members and providers that allows secure access to the member s care plan. Allows all members and participants of the Integrated Care Team (ICT) to access and update information when appropriate. Providers can access the ICB through the NaviNet portal and members may access the ICB through the Member portal both which are accessible on the AmeriHealth Caritas VIP Plus website. 13
14 Benefits Additional Information For additional information on benefits, please refer to the Provider Manual or call Provider Services at
15
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