2021 medicare benefits training - ihcs corp...2020/11/05 · nch providers will fax inpatient...

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2021 Medicare Benefits Training

COMPANY CONFIDENTIAL | FOR INTERNAL USE ONLY | DO NOT COPY


Service Area & Plan Products

2020-2021

Important Plan Changes

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SHP Medicare Plans Service Areas

2021 Service Areas:• Miami-Dade • Polk• Orange • Osceola • Seminole• Broward• Hillsborough• Pinellas• Pasco• Hernando• Palm Beach

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2021 Benefit Overview

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Simply CompleteDUAL SPECIAL NEEDS PLAN

Special Needs Plan for Dual Eligible Medicare and Medicaid beneficiaries.

Offered in all counties within the service area.

Simply MoreA comprehensive HMO Plan for Medicare

beneficiaries.Offered in all counties within the service area.

Simply Level CHRONIC SPECIAL NEEDS PLAN

Special Needs Plan for Medicare Beneficiaries who have been diagnosed with Diabetes Mellitus, Cardiovascular disease and Congestive heart failure. Offered in all counties within the service area.


2021 Benefit Overview

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SimplyComfortINSTITUTIONAL EQUIVALENT SPECIAL NEEDS PLAN

Special Needs Plan for Medicare beneficiaries living in the community but require the same level of care as someone

in a Nursing Home.*Monthly Plan premium is $28.50

Simply CareINSTITUTIONAL SPECIAL NEEDS PLAN

Special Needs Plan for Medicare beneficiaries residing in a Nursing Home.

*Monthly Plan premium is $28.50

Simply SelectLIS PLAN

Special Needs Plan for Medicare beneficiaries who have LIS.Offered in all counties within the service area except

Miami-Dade and Polk.*Monthly Plan premium is $28.50

Simply ExtraREBATE PLAN

A comprehensive HMO Plan for Medicare beneficiaries.Part B premium will be reduced by $100.00 everymonth. There is no paperwork for member to complete. *Member will receive a monthly increase of $100, $90 or $75 on Social Security Check once Social Security Administration completes the necessary processing.


Simply Extra

What is Simply Extra?

Simply Extra is a comprehensive HMO Plan for Medicare beneficiaries. Members’ Part B premium will be reduced by $100, $90 or $75 based on member’s service area and such will be reduced monthly. There is no paperwork for member to complete.

Member will receive a monthly increase of $100, $90 or $75 on Social Security Check once Social Security Administration completes the necessary processing.

Offered in the following counties:

Miami-Dade $100.00

Broward $90.00

Palm Beach $75.00

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2021 Simply Healthcare Plans

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2020- 2021 Plan Crosswalk

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CountiesPBP

ContractPlan No.

2020-2021Plan Name Type of Plan Availability

Miami-Dade H5471

064 Simply Complete (HMO SNP) Dual Eligible SNP Offered 2020 & 2021

065 Simply More (HMO) Standard Offered 2020 & 2021

067 Simply Care (HMO I- SNP) Institutional SNP Offered 2020 & 2021

068Simply Comfort (HMO IE-SNP)

Institutional Equiv SNP Offered 2020 & 2021

069 Simply Level (HMO C-SNP)Chronic SNP – Diabetes, CHF, CardiovascularDisease

Offered 2020 & 2021

103 Simply Extra (HMO) Standard Offered 2020 & 2021

Polk H5471

066Simply Complete (HMO D-SNP)

Dual Eligible SNP Offered 2020 & 2021


Offered 2020 & 2021

071 Simply More (HMO) Standard Offered Offered 2020 & 2021


091Simply Comfort (HMO IE-SNP)

Institutional Equiv SNP Offered 2020 & 2021



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Counties PBP

ContractPlan No.


BrowardH5471

076 Simply Complete (HMO SNP) Dual Eligible SNP Offered 2020 & 2021



080 Simply Level (HMO C-SNP)

Chronic SNP –Diabetes, CHF, CardiovascularDisease

Offered 2020 & 2021

081 Simply Comfort (HMO IE-SNP)Institutional EquivSNP

Offered 2020 & 2021

100 Simply Select (HMO LIS) LIS only Offered 2020 & 2021

104 Simply Extra (HMO)Standard

Offered 2020 & 2021

Orange - Osceola -Seminole

H5471

073 Simply Level (HMO C-SNP)

Chronic SNP –Diabetes, CHF, CardiovascularDisease

Offered 2020 & 2021


072Simply Complete (HMO D-SNP)

(D-SNP) Full Duals only

Offered 2020 & 2021


093 Simply Comfort (HMO IE-SNP)Institutional EquivSNP

Offered 2020 & 2021

098Simply Select (HMO LIS)

LIS onlyOffered 2020 & 2021



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CountiesPBP

ContractPlan No.


HillsboroughPinellasPasco

Hernando

H5471

082 Simply Complete (HMO D-SNP) (D-SNP) Full Duals only Offered 2020 & 2021


Offered 2020 & 2021



095 Simply Comfort (HMO IE-SNP) Institutional Equiv SNP Offered 2020 & 2021


Palm Beach H5471

084 Simply Complete (HMO D-SNP) (D-SNP) Full Duals only Offered 2020 & 2021


Offered 2020 & 2021



097 Simply Comfort (HMO IE-SNP) Institutional Equiv SNP Offered 2020 & 2021


105 Simply Extra (HMO)Standard

Offered 2020 & 2021


Coordination of Benefits

DSNP Eligibility

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Dual SNP Plans

12Simply Healthcare Plans - COMPANY CONFIDENTIAL | FOR INTERNAL USE ONLY | DO NOT COPY

There are three principal models of D-SNPs:

• Care coordination SNPs do not cover Medicaid benefits but are required to coordinate

delivery of their members’ Medicare and Medicaid services as directed by the state.

Some states also pay care coordination SNPs to cover their enrollees’ Medicare cost

sharing.

• Highly-integrated (HIDE) SNPs provide full Medicare benefits and some or most

Medicaid covered services through capitation arrangements with the state.

• Fully Integrated Dual Eligible (FIDE) SNPs are D-SNPs that provide Medicare benefits

and contract with the state Medicaid agency for coverage of primary, acute, and long-

term care benefits and services, consistent with state policy, under risk-based financing.

*Simply HealthCare Plans is a HIDE

Starting in 2021, all D-SNPs will be subject to new rules aimed at promoting greater

integration. DSNPs will be required to meet one of three integrated service models for

coordinating and/or integrating Medicare services with Medicaid long term services and

supports (LTSS) and/or behavioral health and other Medicaid covered services.


2021 DSNP Eligibility


Simply Complete

Miami-Dade, Polk

• QI

• QMB

• SLMB

• QMB+ (Full Medicaid)

• SLMB+ (Full Medicaid)

• MS (Full Medicaid)

Simply Complete

Broward, Orange, Osceola, Seminole, Hillsborough, Pinellas, Pasco, Hernando, Palm Beach

QMB

•QMB+ (Full Medicaid)

•SLMB+ (Full Medicaid)

•MS (Full Medicaid)


Transportation Benefits

2020- 2021


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Routine Supplemental Transportation Benefit

Non-emergency, routine transportation services should be scheduled at least 72 hours in advanced.

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***Ride2MD is Statewide

MCT

• Miami Dade

• Broward

A2C

• Polk

• Orange

• Osceola

• Seminole

• Hillsborough

• Pinellas

• Hernando

• Pasco

• Palm Beach


Transportation Benefits- MCT

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CountiesPBP

ContractPlan No. Plan Name

2020 TransportationBenefit

2021 TransportationBenefit

Miami-Dade H5471

064 Simply Complete (HMO D-SNP) Unlimited Unlimited

065 Simply More (HMO) Unlimited Unlimited

067 Simply Care (HMO I-SNP) Unlimited Unlimited

068 Simply Comfort (HMO IE-SNP) 24 one-way 24 one-way

069 Simply Level (HMO C-SNP) Unlimited Unlimited

103 Simply Extra (HMO) 12 one-way 12 one-way

Orange - Osceola -Seminole H5471

073 Simply Level (HMO C-SNP) 24 one-way, 24 one-way

074 Simply More (HMO) 24 one-way 24 one-way


092 Simply Care (HMO I-SNP) 12 one-way 12 one-way


098 Simply Select (HMO LIS) 24 one-way 24 one-way

Polk H5471


070 Simply Level (HMO C-SNP) 24 one-way 24 one-way


090 Simply Care (HMO I-SNP) 12 one-way 12 one-way



Transportation Benefits- TMS/A2C

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CountiesPBP

ContractPlan No. Plan Name

2020

Transportation Benefit

2021

Transportation Benefit

BrowardH5471

076 Simply Complete (HMO SNP) Unlimited Unlimited

077 Simply More (HMO) Unlimited Unlimited

079 Simply Care (HMO I- SNP) 12 one-way 12 one-way

080 Simply Comfort (HMO IE SNP) 24 one-way 24 one-way

081 Simply Level (HMO CH-SNP) 24 one-way 24 one-way

100 Simply Select (HMO LIS) Unlimited Unlimited


Hillsborough

Pinellas

Pasco

Hernando

H5471


075 Simply Level (HMO CH-SNP) 24 one-way 24 one-way


094 Simply Care (HMO I- SNP) 12 one-way 12 one-way

095 Simply Comfort (HMO IE SNP) 24 one-way 24 one-way

099 Simply Select (HMO LIS) 24 one-way 24 one-way

Palm Beach H5471

084 Simply Complete (HMO D-SNP) Unlimited Unlimited085 Simply Level (HMO CH-SNP) Unlimited Unlimited083 Simply More (HMO) Unlimited Unlimited096 Simply Care (HMO I- SNP) 22 one-way 22 one-way097 Simply Comfort (HMO IE SNP) 24 one-way 24 one-way

101 Simply Select (HMO LIS) Unlimited Unlimited



New Century Health

2020- 2021


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New Century Health

New Century Health provides Cardiology, Hematology, and Oncology services to our Medicare Members in Miami-Dade, Broward, and Palm Beach Counties for 2020-2021.

The PCP can refer the member to a cardiologist, oncologist or hematologist in the NCH Network.

All other counties, the member can be referred to a direct provider.

NCH Providers will fax inpatient authorization requests with supporting documentation to Simply Healthcare Plans at 866-495-1986 or 866-959-1537 in order to obtain Facility authorization.

NCH Providers will send in-office and outpatient requests via NCH’s Provider Portal at https://my.newcenturyhealth.com.

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https://my.newcenturyhealth.com/


Beacon Health Options

2020-2021


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Behavioral Health Benefits

Behavioral Health Services are covered by Beacon Health Options.

Covered services include: Inpatient mental health and substance abuse services Outpatient mental health and substance abuse services (Group and

Individual sessions) Partial hospitalization services

Copayments for these services may vary, based on plan benefit package and county.

More information regarding the mental and substance abuse benefits is available to both members and providers in the plan’s Evidence of Coverage and Summary of Benefits.

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How can Members access Behavioral Health Benefits?

Members can go directly to any participating Beacon Health Options provider for behavioral health services.

If members require assistance in locating a mental health provider or have questions regarding their behavioral benefits, the member may: Call SHP Member Services at 1-877-577-0115, Call Beacon Health Options at (877) 698-7787or Visit https://www.beaconhealthoptions.com/members/dashboard/

Behavioral Health Providers submit authorization and claims directly to Beacon Health Options.

Members and non-par provider can file an appeal with the health plan if they do not agree with Beacon Health Options denial on an authorization request.

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https://www.beaconhealthoptions.com/members/dashboard/


Pharmacy Benefits

2020- 2021


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Pharmacy- Important Changes (Ingenio RX)

• Customer Care Representative should warm transfer member to Ingenio Rx by calling 833-272-9771. Calls to this number are free. Hours are 24 hours a day, seven days a week.

• Pharmacy Representatives can assist Medicare members with their Part D related questions this includes Part D appeals & grievances.

• Member can submit Part D appeal or grievance in writing via:

Fax: 888 458 1406

Written:

Simply Healthcare - Medicare Complaints, Appeals and Grievances

Mailstop: OH0102-B325

4361 Irwin Simpson Rd

Mason, OH 45040



Continuity of Care

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Continuity of Care

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Continuity of Care (CoC) refers to the health plan’s responsibility to ensure that new members are able to continue active treatment with their current Provider.

This means ensuring a seamless continuation of care despite the fact that the enrollee’s coverage plan or provider network may have changed.

Examples of active treatment are, but are not limited to:

Chemotherapy

Previously scheduled follow-up appointments attributed to surgery (even if provider is non-participating for both medical and dental)

Continued services post-hospitalization (e.g. outpatient or home health therapies)

Follow-up after starting a new medication

Continued behavioral health treatment

DME approved by previous health plan but not delivered.


Continuity of Care

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Appointments scheduled and procedures approved prior to member’s effective date will be honored under the 60 day continuity of care timeframe.

Members can also get a transition supply for prescription drugs consisting of a 30 day supply within the first 90 days of enrollment.

New members with continuity of care needs may call the Simply Healthcare Plans Member Services Department if they are in active treatment.

Medicare Specialists will submit an Organization Determination (OD) for medical services. Once received, this request will be reviewed by the respective department. The OD is to be emailedto the Utilization Management Team.
http://www.simplyhealthcareplans.com/medicare/prescription-drug-benefit/formularies/2017-transition-policy

2021 medicare benefits training - ihcs corp...2020/11/05 · nch providers will fax inpatient...

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