Medicare Advantage Dual Care Model of Care STARs March 20, 2019
Agenda Medicare Advantage Plan Updates for 2019 Akamai Advantage Dual Care Plan Eligibility How to identify a Dual Care Member Benefits What is covered Claims Filing and Billing Model of Care Service Coordination HMSA s Goals for Dual Care Members Health Risk Assessment (HRA) Individualized Care Plan (ICP) Interdisciplinary Care Team (ICT) DSNP Quality Metrics HMSA Provider Resources 2
Medicare Advantage - New in 2019 CMS enrollment periods Re-branding of HMSA s Medicare Advantage products Akamai Advantage PPO (including Dual Care) Essential Advantage - HMO
HMSA Medicare Advantage Plans Benefits Financial protection Silver&Fit membership at no additional cost Coverage while traveling Vision exam and eyewear Preventive care No-cost annual wellness visits Prescription drug coverage
New CMS Open Enrollment (OEP) MA-OEP, effective 1/1/19 From January 1 st through March 31 st Annual; replaces MADP (Medicare Advantage..Disenrollment Period) One time only during this window, plans are not permitted to solicit beneficiary changes Plan effective the 1 st of the month following the election date
LIS/Dual Eligible SEP (Special Enrollment Period) New in 2019 For those with Medicare A+B and Medicaid; also LIS with or without Medicaid Only once per quarter, in the 1 st 9 months of the calendar year Plan effective the 1 st of the month following election date
Medicare Advantage Dual Care Plan Eligibility Must be eligible for Medicare and Medicaid May be Qualified Medicare Beneficiary (QMB) Only or have (QMB) Plus dual eligibility status May have HMSA Akamai Advantage and HMSA QUEST Integration May have HMSA Akamai Advantage and QUEST Integration with another health plan Note: DSNP members are allowed to change MA D-SNP anytime during the year as long as Medicaid eligibility is maintained 7
Medicare 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 HMSA MA Dual Care members who are in a deemed continued eligibility status will be responsible for copayments, coinsurance and deductibles under HMSA s MA Dual Care Plan 3/18/2019 8
Medicare Advantage Dual Care Plan Membership Card Plan Name appears at the top right corner of the front of the card No member premium (after Low Income Subsidy) 9
HHIN Identifying Medicare Advantage Dual Care Members 3/18/2019 10
HHIN Identifying Medicare Advantage Dual Care Members Click on coverage code 696 to view plan description for MA Dual Care members 3/18/2019 11
3/18/2019 12 https://hiweb.statemedicaid.us/eligandenrollment/memberverificationhi.aspx
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. 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% Medicaid pays 20% 100% coverage Member pays $0 13
2019 Dual Care (PPO-SNP) Benefits New SEP (Special Enrollment Period) Still requires QMB/QMB+ eligibility (Qualified..Medicare Beneficiary) Supplemental Dental maximum raised to..$2,500 Members with certain chronic conditions..have enhanced dental benefits (e.g., stroke, oral cancer, diabetes)
2019 Akamai Advantage Dual Care Benefits Dental Benefits: Effective January 1, 2018 Annual Max: Plan pays up to $2,500 for covered dental services Enhanced Dental Care: Not a benefit effective 1/1/18 Benefit In Network Two Dental Exams per year $0 Two Cleanings per year $0 One set of Bitewing X-rays $0 One Full Mouth or Panoramic X-rays every 5 years $0 Two Denture Adjustments per year $0 One Denture Repair, per Arch, per year $0 One Filling per Tooth Surface, per year $0 One Root Canal per Tooth, per year $0 One Periodontal Scaling & Root Planing, per quadrant, per year $0 15
Max Out of Pocket (MOOP) Accumulation Dual Care MOOP: $6,700 in-network Medicaid will pay member cost shares for Original Medicare benefits, for QMB and QMB Plus dual eligible. 16
Akamai Advantage Dual Care Plan Claims Filing/Billing Tips 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 17
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: https://hiweb.statemedicaid.us/eligandenrollment/memberverificationhi.aspx 3/18/2019 18
Service Coordination Dual Eligible Special Needs Plan (D-SNP) 3/18/2019 DRAFT 19
Goals of Service Coordination 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 Service Coordinator Improve seamless transitions of care across health care settings, providers, and health services Ensure appropriate use of services Improve health outcomes 3/18/2019 20
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) 3/18/2019 21
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 22
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 d. Via PCP 5. Used to formulate ICP 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 * Must be evidence-based 23 23
What is an Interdisciplinary Care Team? The team consists of family members, health care providers and others who can help the member achieve their health and wellness goals. The composition of the team is individualized according to the member s needs and preference. The team meets intermittently to ensure that the ICP is on track and is achieving the member s goal. 3/18/2019 24
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 Dietitian Pharmacist Gerontologist PCP Behavioral Health 25
What can Providers expect? HMSA can partner with PCPs by: Providing service coordination for challenging patients by: o Focusing on care gaps Working with PCPs and their staff to provide: o COPD management information/plan for applicable patients o Collaborating with PCPs to accurately complete patient Health Risk Assessment to ensure timely access to patient care Communicate updates to Interdisciplinary Care Team PCPs can partner with HMSA by: Focusing on care gaps Collaborating with HMSA RNs to ensure accurate/timely HRA completion Providing medical records when requested Discussing Advanced Care Planning/POLST with DSNP patients Discussing COPD management information/plan for applicable patients Participating as a critical member on the Interdisciplinary Care Team 26
DSNP Quality Metrics
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
Four (4) Dual Care Specific Star Metrics Health Risk Assessment Care for Older Adults Medication Review Functional Assessment Pain Assessment Advance Care Planning
Care for Older Adults Star Metrics Once per calendar year DSNP members turning 66 this year and older Use your Coreo dashboard to identify eligible patients Four part assessment: 1. Medication Review 2. Functional Status Assessment 3. Pain Assessment 4. Advance Care Planning
Care for Older Adults: Closing the Gap Complete an Annual Wellness Visit using an HMSA Health Risk Assessment form and Document current medication list and your medication review Requires two codes for full credit: 1159F and 1160F File a claim using CPT II codes
Medicare Stars Resources Provider Resource Center / Medicare Star Ratings E-library https://hmsa.com/portal/provider/zav_pel.aa.med.100.htm Forms: Dual Care Health Risk Assessment Form Care for Older Adults Worksheets Patient Medication Review Form Medicare Star Ratings: Measure Reference Guides Code Set & Description Annual Wellness Visit Toolkit Coreo Medicare Star Measures dashboard
HMSA Provider Resources HMSA Provider E-Library: https://www.hmsa.com/portal/provider/ HMSA Service Coordinators: Monday Friday 7:30 4:30 Phone Fax 948-6997 944-5604 Toll Free: 1-844-223-9856 Toll Free: 1-855-856-4176 HMSA Provider Services Phone Fax 948-6330 948-6887 Toll Free: 1-800-790-4672 Toll Free: 1-800-540-1668 3/18/2019 33
HMSA Provider Reminders Notify HMSA of changes in your practice, such as: Practice Location Address Appointment Phone Number Patient Acceptance Status Email Hours of operation Be sure to notify HMSA 30-days in advance of any practice changes by: 1. Calling (808) 952-7847 on Oahu or 1 (800) 603-4672 ext. 7847 toll free on the Neighbor Islands 2. Mail to: HMSA Provider Data Administration P.O. Box 860 Honolulu, HI 96808-0860 3. Email: provider_data@hmsa.com Timely notification to HMSA will ensure: Payments and correspondence are sent to the correct address We market your practice using the correct address in our provider directory 34
Acronyms AEP Annual Election Period LIS Low Income Subsidy CMS C- SNP Centers for Medicare and Medicaid Services Chronic Condition Special Needs Plan MAPD MOC MOOP Medicare Advantage Part D Model of Care Maximum Out of Pocket D- SNP EOC Dual eligible Special Needs Plan Evidence of Coverage NCQA OOPM National Committee for Quality Assurance Out of pocket maximum ESRD End Stage Renal Disease QI QUEST Integration HRA Health Risk Assessment QMB Qualified Medicare Beneficiary ICP Individualized Care Plan SB Summary of Benefits ICT Interdisciplinary Care Team SEP Special Election Period I-SNP Institutional Special Needs Plan SNP Special Needs Plan 35
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 422.102 (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: Email to: AkamaiD-SNPAttestation@hmsa.com 36
Thank you! 37