2013 Medicare Advantage
Prescription Plans
Gwinnett PHO
Brenda Rose
Provider Network
Consultant
October 30, 2012
Agenda
1.
Humana Medicare Advantage Prescription Drug Plans
(MAPDs)
2.
How Humana MAPDs work
3.
What’s new at Humana
4.
How Humana makes it easy to navigate
5.
Humana’s commitment to well-being and quality care
6.
Humana is your partner
Insert date via Header and Footer option
Insert form number via Header and Footer option or delete, if not needed
2
About Humana
•
Humana is one of the nation’s largest publicly traded health
benefits companies with
– 10.1 million medical members
– 7 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 300 medical centers
•
Operates more than 240 worksite medical facilities
3
Open Access HMO Rules






How Does It Work?
How Are Benefits Administered?
Key Features
Benefit Summary
Network Hospitals
HMO Reciprocity
Insert date via Header and Footer option
Insert form number via Header and Footer option or delete, if not needed
4
How Does an Open Access Medicare HMO Work?
•
Members select their own Primary Care Physician (PCP) from our list of
Humana Gold Plus® Medicare HMO PCPs.
•
Humana Gold Plus® (HMO) ID card has the member’s PCP and contact
information
•
PCP referrals are not required for in-network specialists for covered service
•
Members must receive care from Humana Gold Plus® (HMO) providers for innetwork benefit
•
No benefit coverage when services are delivered by providers not contracted
for Medicare HMO (Humana Gold Plus®), except in an emergency
•
Out-of-network service requires a Humana authorization for benefit coverage
•
Claims submitted by providers not contracted for Medicare HMO (Humana
Gold Plus®) are denied for payment
Benefit Summary:
Health Benefits at $0 Copayment
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Routine Physical Exam
Welcome to Medicare Visit
Annual Wellness Exam
Pap Smear & Pelvic Exam
Prostate Cancer Screening
Colorectal Cancer Screening
Mammogram Screening
Bone Mass Measurement Screening
Immunizations/Vaccinations
Obesity Screening and Therapy
Cardiovascular Screening
Cardiovascular Behavioral Therapy
STI Screening and Counseling
Abdominal Aortic Aneurysm Screening
•
Depression Screening
•
Alcohol Misuse Screening and
Counseling
•
Diabetic Screening
•
EKG Screening
•
Glaucoma Test
•
HIV Screening
•
Nutrition Therapy (Diabetic and ESRD)
•
Smoking Cessation
•
Diabetic Self-Monitoring Training
•
Diabetic Monitoring Supplies (preferred
DME provider-RightSource)
Reciprocity:
What is the reciprocity for this Open Access HMO?
•
This Open Access HMO has reciprocity with other Humana
Gold Plus® Medicare HMO plans in Georgia.
•
The Medicare HMO member can seek care from providers in
the Humana Gold Plus® Medicare HMO network in (State and
Market). The covered service will be paid at in-network level.
If the provider is not in the Humana Medicare HMO network,
the covered will be denied for payment.
•
The Medicare HMO member will be covered for all
emergencies at in-network benefit level.
ATLANTA HMO, DE-SNP HMO AND C-SNP HMO
MAPD - HMO Benefits (In-Network Only)
PCP/ Specialist/Chiropractor Office Visit
Rx Drugs (Tiers I , II, III, IV)
PCP/ Specialist/Chiropractor Office Visit
Rx Drugs (Tiers I , II, III, IV)
Atlanta DE-SNP MHMO (H4141-003)
20% coinsurance
$0/$0 copay/100%/100% coinsurance
Transportation (one-way trips)
$0 (24 one way trips per year)
MAPD - C-SNP HMO Benefits
PCP/ Specialist/Chiropractor Office Visit
Transportation (one-way trips)
$10/$35/$20 copay
$3/$6/$45/$92 copay
MAPD - DE-SNP HMO Benefits
Rx Drugs (Tiers I , II, III, IV)
Atlanta-MHMO (H4141-001)
Atlanta C-SNP MHMO (H4141-009)
$5/$35/$20 copay
$3/$6/$40/$95 copay
$0 (24 one way trips per year)
APPROVED COUNTIES
Bartow, Cherokee, Cobb, Coweta, DeKalb, Douglas, Fayette, Floyd,
Forsyth, Fulton, Gwinnett, Henry, Paulding and Pickens
8
Network Hospitals:
Atlanta Humana Gold Plus HMO Plan
•
DeKalb Medical Center
•
Piedmont Hospital
•
Emory University Hospital
•
Piedmont Henry Hospital
•
Emory University Hospital Midtown
•
Piedmont Mountainside Hospital
•
Emory University Hospital John Creek
•
Piedmont Newnan Hospital
•
Emory Adventist Hospital
•
Eastside Medical Center
•
St Joseph’s Hospital of Atlanta
•
Gwinnett Medical Center
•
Wellstar Cobb Hospital
•
Northside Hospital
•
Wellstar Douglas Hospital
•
Northside Hospital Forsyth
•
Wellstar Kennestone Hospital
•
Northside Hospital Cherokee
•
Wellstar Paulding Hospital
•
Piedmont Fayette Hospital
•
Wellstar Windy Hill Hospital
Sample of Humana Gold Plus (HMO) ID Card
Plan Type
Primary Physician
10
Humana Gold Plus (HMO) C-SNP
(Diabetes/Cardiovascular Disorder/Chronic Heart Failure)
•
Key Features:
 Member has at least one of 3 conditions
 Pre-qualification form with disease-specific questions
 Verification Chronic Condition (VCC) form signed by physician
 Signed VCC must be received within first month of coverage
 Plan must verify condition(s) within 1st month
 Member will be dis-enrolled if at least one condition is not verified
 Year-round enrollment for applicant with one of these 3 conditions
 Member cost share is based on plan benefits
Some Key Features of HMO DE-SNP/Chronic SNP– Cont.

HMO authorization rules apply

No referrals for In-network specialists

No out-of network coverage except for emergent/urgent care

Access to Humana Gold Plus (HMO) network

Member must present their Medicaid ID card at time of service
Verification of Chronic Condition
(IMPORTANT: PLEASE RETURN WITHIN <10> DAYS OF ORIGINAL RECEIPT)
The applicant listed below has applied for a special needs Medicare plan through
Humana. This plan will provide the applicant with additional benefits related to his or her
condition, such as supplemental drug coverage. For the applicant to qualify, a physician
or physician’s office must confirm his or her diagnosis by completing this form. Humana
appreciates your assistance. For questions, please call <1-800-457-4708>. TTY users
should call <711>. You can call us <seven days a week from 8 a.m. to 8 p.m.>
Applicant’s name:
DOB:
Applicant’s address:
Humana ID: <UMID>
Customer number: <#>
Sub group#: <#>
Proposed effective date: <Date>
My signature below authorizes information about my chronic condition to be shared
with Humana.
Applicant’s signature
Date
To Be Completed by the Physician/Physician’s Office
By signing this form, you confirm the patient has been diagnosed with:
None
Diabetes
Chronic Heart Failure
Chronic Lung Disease:
Asthma, Chronic Bronchitis,
Emphysema, Pulmonary
Fibrosis, Pulmonary
Hypertension
Cardiovascular Disease
Confirmation provided by:
Signature
Date
Printed name or stamp
Title
Physician name
Phone
Verification Chronic Condition
(VCC) Form
Please return this form to:
Humana
<P.O. Box 14309>
<Lexington, KY 40512-4309>
<Or Fax to 1-877-889-9936>
A Coordinated Care plan with a Medicare Advantage contract, available to anyone who
meets the specific eligibility requirements of the SNP and is enrolled in both Part A and
Part B of Medicare. To qualify for a Chronic Disease SNP, physician diagnosis of the
disease must be verified. People who do not have the condition will be disenrolled.
Humana Medicare PPO Plans
LPPO and RPPO


14
Key Features
Benefit Summary
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 may be requested to select Primary Physician (not required)
Participating primary physicians will see their name displayed on the back of
member ID cards
– Non-participating providers or specialist swill 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
Some Key Features of Medicare PPO– Cont.
•
Criteria for listing PCP on member ID card:
–
Member provide this information during Open Enrollment or from
Humana member outreach;
–
Provider chosen must be participating with Humana and the Member’s
LOB; and,
–
Provider must be a Family Practitioner, General Practitioner, Internal
Medicine physician, Pediatrician or OB/GYN
Goal
•
Strengthen member-primary physician relationship and engagement

Increased use of preventive services

Improved coordinated care and outcomes

Improved Quality (HEDIS) measures
2013 LPPO BENEFITS
Atlanta
(H5214-003)
Aiken, SC/Augusta GA
(H5214-004)
Athens
(H5214-008)
Columbus
(H5214-009)
PCP/Specialist
Chiropractor Visit
IN/OON
$15/$40/$20 copay 30% OON
$15/$40/$20 copay
30% OON
$20/$40/$20 copay 30%
OON
$15/$35/$20 copay/
30% OON
Rx Drugs
(Tiers I , II, III, IV)
$6/$12/$45/$90
copay
$5/$12/$45/$90
copay
$4/$10/$45/$90
copay
$4/$12/$45/$90
copay
MAPD-LPPO
Benefits
Approved Counties
Barrow; Bartow; Carroll;
Cherokee; Clayton; Cobb;
Coweta; Dawson; DeKalb;
Douglas; Fayette; Floyd;
Forsyth; Fulton; Gwinnett;
Haralson; Henry; Meriwether;
Newton; Paulding; Pickens;
Rockdale; Walton
GA:Burke; Columbia;
Glascock; Hancock;
Jefferson; McDuffie;
Richmond; Taliaferro;
Warren; Washington;
Wilkes; SC:Aiken;
Barnwell; Edgefield;
McCormick;
Newberry; Saluda
Clarke; Greene; Jackson;
Madison;
Morgan; Oconee;
Oglethorpe
AL:Chambers; Lee;
Randolph; Russell;
GA:Chattahoochee
Harris; Marion;
Muscogee; Randolph;
Stewart; Talbot;
Troup; Webster
2013 RPPO BENEFITS
MAPD-RPPO
Benefits
Region 8 GA & SC (R5826-064)
MA Only
Region 8 GA & SC (R5826-077) (Same
IN/OON Benefits)
PCP/Specialist
Chiropractor Visit IN/OON
$20/$45/$20 copay
$45/$45/$40 copay OON
$20/$45/$20 copay
Not Available
$4 /$12 copay/100% /100%
coinsurance
Rx Drugs
(Tiers I , II, III, IV)
Approved Counties
GA:Statewide; SC:Statewide
GA:Statewide; SC:Statewide
Insert date via Header and Footer option
Insert form number via Header and Footer option or delete, if not needed
18
Sample of Humana Choice (PPO) ID Card
Plan Type
Primary Physician
Sample of Humana Choice GA/SC Regional (PPO) Card
(Statewide)
R5826 –004 (Traditional RPPO MAPD – IN/OON Benefits)
R5826 – 077 (Non-traditional MAPD – Same IN/OON Benefits)
Humana Medicare PFFS Plans


21
Key Features
Benefit Summary
Some Key Features of Medicare PFFS
•
No referral required
•
Members in any PFFS plan (Non-Network / Partial Network/ Full Network)
can see any contracted or non-contracted providers throughout the nation.
Non-Network plan – Members can be seen by any provider who agrees to treat
and accept Humana Terms and Conditions
– Partial Network plan – There is a contracted network for DME/Home Health/Lab;
all other services treated as a non-network plan. Some plans may have in-network
and out-of-network benefit levels between contract vs. non-contracted
DME/HH/Lab
– Full Network plan – There is a contracted network for all services; benefit levels are
administered based on in-network and out-of-network status
–
•
List of contracted PFFS providers in Humana.com/Physician Finders Plus
•
Member may be requested to select Primary Physician (not required)
2013 PFFS BENEFITS
MAPD-MA
PFFS-Benefits
South GA
(H2944-114) MAPD
Partial Network
South GA
(H8145-117) MA Only
Full Network
South GA PFFS (H8145079) MAPD
South GA
(H2944-193)
MA Only
PCP/Specialist
Chiropractor Visit
IN/OON
$20/$40/$20 copay
20% coinsurance
$15/$35/$20 copay
20% coinsurance
Rx Drugs
(Tiers I , II, III, IV)
$6/$12/$45/$90 copay
Not Available
$5/$12/$45/$90 copay
Not Available
Atkinson; Bacon; Baker;
Ben Hill; Brantley; Brooks;
Calhoun; Candler; Clinch;
Cook; Crisp; Decatur; Early;
Echols; Franklin; Gilmer;
Glascock; Grady;
Habersham; Hall; Hancock;
Heard; Irwin;
Jenkins; Johnson; Lanier;
Lowndes;
Mitchell; Peach; Pulaski;
Quitman; Randolph;
Seminole; Terrell; Tift;
Towns; Treutlen; Turner;
Twiggs; Upson; Walton;
Washington; Wayne;
Wilcox
Barrow; Chatham;
Chattooga; Clayton; DeKalb;
Elbert; Forsyth; Fulton;
Gwinnett; Hart; Henry;
Jackson; Jefferson; Lincoln;
Morgan; Muscogee; Polk;
Rockdale; Talbot; Taliaferro;
Warren; White; Wilkes
Approved Counties
Barrow; Chatham;
Chattooga; Clayton;
DeKalb; Elbert; Forsyth;
Fulton; Gwinnett;
Hart; Henry; Jackson;
Jefferson; Lincoln;
Morgan; Muscogee; Polk;
Rockdale; Talbot;
Taliaferro; Warren; White;
Wilkes
Atkinson; Bacon; Baker;
Ben Hill;
Brantley; Brooks; Calhoun;
Candler; Clinch; Cook;
Crisp; Decatur; Early;
Echols; Floyd; Franklin;
Gilmer; Glascock; Grady;
Habersham Hall; Hancock;
Heard; Houston; Irwin;
Jenkins; Johnson; Lanier;
Lowndes; Lumpkin;
Meriwether; Mitchell;
Peach; Pulaski; Quitman;
Randolph; Seminole;
Stephens; Terrell; Thomas;
Tift; Towns; Treutlen;
Turner; Twiggs; Upson;
Walton; Washington;
Wayne; Wilcox
Sample ID Cards for PFFS Plans
Non-Network PFFS
Partial Network PFFS
Full Network PFFS
A Network PFFS, Partial Network PFFS and Non-network
PFFS plan would not be marketed in the same county.
24
Medicare Preauthorization
Summary

25
HMO and PPO
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 800-523-0023
Authorization
Plastic Surgery/Cosmetic Surgery
Authorization
Hi-Tech Imaging (MRI, MRA, CT, CTA, SPECT, PET, Nuclear Test & Cardiac Caths) HealthHelp
Authorization
Radiation Therapy HealthHelp
Authorization
Outpatient Therapy Services (PT; OT; ST)
Authorization
Durable Medical Equipment (DME over $750 )
Authorization
Pain Management Procedures OrthoNet
Authorization
Cardiac Devices HealthHelp
Authorization
Facility-Based Sleep Studies (PSG)
Authorization
Full list is at www.humana.com/providers/referral/pre_authorization.aspx
Humana Gold Choice PFFS plans are “notification” only
• National Vendors
• Utilization Programs
National Vendors:
Utilization Management Vendors
Diagnostic imaging
Radiation therapy
Specific cardiac services
Call 1-866-825-1550 for Humana radiology services authorizations
– Or go online at www.healthhelp.com/humana 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 1-888-605-5344
Fax OrthoNet at 1-888-605-5345
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
1-800-777-6330
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 1-800-962-7742
•
Local alternatives to national contract – refer to the Provider
Directory
•
Edgepark Medical Supplies
•
Insulin pumps
•
https://www.edgepark.com or 1-888-394-5375
RightSource DME / Coram / Rotech / CCS
Right Source (Preferred Provider -Diabetic Monitoring Supplies)
• $0 copay
• Free shipping to members
• www.rightsourcerx.com or 1-800-379-0092 TTY: 711
Coram –Home Infusion Therapy
• Apria-affiliated company
• www.coram.com or 1-800-423-1411
Rotech –DME
• Mobility needs –wheelchairs and assist-devices
• www.rotech.com
CCS Medical Supplies
• www.ccsmed.com or 1-800-260-8193
Golden Living –Nursing Centers / Hanger Prosthetics
Golden Living – Skilled Nursing Facilities
•
www.goldenliving.com
•
Locations throughout Humana markets
Hanger Prosthetic and Orthotics
•
www.hanger.com or 1-877-442-6437
Laboratory and Prescription Home Delivery Service
Laboratory
• LabCorp
• Quest Diagnostics
• Local alternative 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)
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 1-800-379-0092
o Fax prescription fax form 1-800-379-7616 (online fax form at RightSourceRx.com)
• Drugs with quantity limits or that require prior authorization must be approved by
Humana Clinical Pharmacy Review (HCPR) at 1-800-555-2546
• Pharmacies and technicians available for member questions
• Refill reminders via phone or email
• Medicare Programs
• Medicare Contacts
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) 767-0063 or www.villagehealthdm.com)
HumanaCares – Complex Care Management (1-800-622-9529)
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: www.humana.com/providers/clinical/health/
•
•
•
•
•
•
•
•
•
Humana Medicare Rewards Program
•
Members complete five eligible health care activities during a calendar year
–
•
•
Eligible to receive five $10 gift cards from restaurants, gas stations, movie theaters
and retailers. Gift-card suppliers include Cracker Barrel Old Country Store®,
Applebee’s®, AMC Theatres®, Shell®, BP®, ExxonMobil® and Chevron®
Eligible Health Care Activities
–
For 2012, the following screenings and tests qualify for rewards:
–
Adult Wellness Visit (new for 2012)
- Cardiovascular Disease Screening
–
Flu Shot
- Routine Screening Mammogram
–
Pneumonia Vaccine
- Routine Pap Smear and Pelvic Exam
–
Hepatitis B Vaccine
- Colorectal Cancer Screening
–
Welcome to Medicare Visit
- Prostate Cancer Screening
–
Glaucoma Eye Exam
- Glucose Diabetes Screening
–
Bone Mass Osteoporosis Test
Encourage your Humana Medicare Advantage patients to call 800-968-2281 if they
have questions
Contacts You Need to Know
Medicare customer service:
See back of member’s ID card
Authorization/IVR:
1-800-523-0023
Provider relations:
1-800-626-2741
(fee schedule requests, demographic changes, credentialing status)
Medicare case management & Concurrent review
1-800-322-2758
Disease management program information:
1-800-620-9529
RightSourceRx pharmacy:
1-800-379-0092
Provider Consulting Team
Brenda Rose (North Georgia Market)
Karen Andrews (East Georgia Market)
Kimberly Bryant (West Georgia Market)
Iris Johnson (Georgia Frontline Leader)
423-531-6707
brose5@humana.com
770-350-2273
kandrews1@humana.com
770-350-2115
kbryant1@humana.com
770-350-2283
ijohnson2@humana.com
Tools for Providers
Availity.com and
Humana Members
Overview of eTools
Jilliann Billingsley and Marchelle Sumpter–
eBusiness Consultant
Introduction
•
Availity.com Multi-Payer Web Portal
•
HIPAA compliant health plan transactions in real-time on the web and in batch via Electronic Data
Interchange (EDI) at no cost to health care professionals
–
Eligibility and Benefits Inquiry
–
CareRead
–
Referral and Authorization Submission
–
Referral and Authorization Inquiry
–
Claim Status Inquiry
–
Claim Reconciliation Tool*
–
Claim Correction
–
Claim Attachment
–
Remittance Information
–
Fee Schedules*
–
Medical Records Management*
–
Service Fund HMO Reports*
Insert date via Header and Footer option
Insert form number via Header and Footer option or delete, if not needed
39
ERA/EFT
•
Electronic Remit Advice (ERA)
–
•
HIPAA Transaction 835
Electronic Fund Transfer (EFT)
–
HIPAA Transaction 837
PMS
Vendor
Humana
File Sent
Web Portal
Insert date via Header and Footer option
Insert form number via Header and Footer option or delete, if not needed
40
Questions &
Answers
Providing our members and providers
Perfect Experience