akamai advantage annual provider training - 10/11/2017€¦ · akamai advantage annual provider...
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Akamai Advantage Annual Provider Training
October 11, 2017
Your Presenters Today
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Leslie Sylva Wendell Oumaye Valerie Sonoda Peter Wong
Agenda
Akamai Advantage Plans for 2018 Akamai Advantage Drug Plans for 2018 Medicare Plan Enrollment Periods Essential Advantage (HMO) Plan
Member Eligibility Referrals Prior Authorization
Dual Special Needs (DSNP) Plan Model of Care CMS Rules For Providers
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2018 Akamai Advantage Plans
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OAHU NEIGHBOR ISLANDS
• Complete (706-735) • Standard (708-725)
• Complete Plus (707-740) • Standard Plus (709-730)
• Essential Advantage (HMO:T-C-885)
Akamai Advantage Dual Care (D-SNP – 696-785) – All Islands All plans are comprehensive and include Part D prescription
drug coverage
Why will consumers choose Akamai Advantage?
Large statewide provider network Comprehensive benefits – all Original Medicare
benefits, drug coverage, and more Financial protection – Maximum Out-of-Pocket limit Predictable costs
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CY 2018 Akamai Advantage Plans - OAHU In-Network Complete Complete Plus Essential
Advantage Premium $57 $147 $20 MOOP $6,700 $3,400 $5,000 Combined MOOP $10,000 $5,100 Not a Benefit
PCP Visit $30 $10 $20 Specialist Visit $50 $30 $50 Fitness Silver&Fit Silver&Fit Silver&Fit
Inpatient Hospital
Days 1-6: $300/day Days 7-60: $44/day Days 61-90: $0/day No additional days.
Days 1-7: $280/day Days 8-90: $0/day $0 for additional
days
Days 1-6: $300/day Days 7-60: $44/day Days 61-90: $0/day No additional days.
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CY 2018 Akamai Advantage Plans - OAHU
In-Network Complete Complete Plus Essential Advantage
Annual Wellness Visit $0 $0 $0
Outpatient Services/Surgery
$150 deductible, then 20% 20% $150 deductible,
then 20%
Ambulance $250 $225 $250
Routine Eye Exams
$30 (1 per year)
$10 (1 per year)
$20 (1 per year)
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CY 2018 Akamai Advantage Plans - NI
In-Network Standard Standard Plus
Premium $92 $192
MOOP $6,700 $3,400
Combined MOOP $10,000 $5,100
PCP Visit $30 $10
Specialist Visit $50 $40
Inpatient Hospital Days 1-6: $300/day Days 7-60: $44/day Days 61-90: $0/day No additional days
Days 1-7: $300/day Days 8-90: $0/day
$0 for additional days
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CY 2018 Akamai Advantage Plans - NI
In-Network Standard Standard Plus
Annual Wellness Visit $0 $0
Outpatient Services/Surgery
$150 deductible, then 20% 20%
Ambulance $250 $225
Routine Eye Exams $30 (1 per year)
$10 (1 per year)
Fitness Silver&Fit Silver&Fit
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2018 Akamai Advantage Dual Care All Islands
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Co-pay/Deductible/Max Premium $0 MOOP $6,700 Medical Benefits (Medicare –covered)
$0
Part D No Deductible Cost-sharing depends on LIS Level
Fitness None Routine Vision/Eyewear (Non-Medicare required)
None
2018 Akamai Advantage Dual Care All Islands
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Benefit Dental (non-Medicare-covered)
$0/2 Exams/1 year $0/2 Cleanings/1 year
$0/1 Set Bitewing X-Rays/1 year $0/1 Full Mouth or Panoramic X-Rays/5 years
$0/2 Denture Adjustments/1 year $0/1 Denture Repair per Arch/1 year $0/1 Filling per Tooth Surface/1 year
$0/1 Root Canal per Tooth/1 year $0/1 Periodontal Scaling & Root Planing Procedure
per Quadrant/1 year
Annual Maximum Benefit Plan pays up to $1,500
Enhanced Dental Care Effective January 1, 2018 - Not a benefit
Part D Drug Benefits – OAHU Mail Order
90-day supply from HMSA’s network mail-order pharmacy
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Tier Complete Complete Plus Essential Advantage
Tier 1 - Preferred Generic $4.50 $4.00 $4.50
Tier 2 –Generic $12.00
$11.00
$12.00
Tier 3 – Preferred Brand $94.00 $90.00
$94.00
Tier 4 – Non-Preferred Drug $200.00 $190.00 $200.00
Tier 5 – Specialty Drugs 25% 33% 25%
• Mail order is fast and convenient • Members can save money on maintenance medications
New prescriptions sent from the doctor’s office • Patient will receive a call to confirm consent to ship the medication, verify • It is important that the patient responds to these calls to get the
medication shipped
Call 1 (855) 479-3659
Part D Drug Benefits – NI Mail Order
90-day supply from HMSA’s network mail-order pharmacy
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• Mail order is fast and convenient • Members can save money on maintenance medications
New prescriptions sent from the doctor’s office • Patient will receive a call to confirm consent to ship the medication, verify • It is important that the patient responds to these calls to get the
medication shipped
Tier Standard Standard Plus
Tier 1 – Preferred Generic $5 $4 Tier 2 –Generic $20 $11 Tier 3 – Preferred Brand $94 $90 Tier 4 – Non-Preferred Drug $200 $190 Tier 5 – Specialty Drugs 25% 33%
Call 1 (855) 479 - 3659
2018 Part D Copayments/Cost Shares Retail
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Essential Advantage
Complete Complete Plus
Standard Standard Plus
Tier 1 Preferred Generic
$4.50 $4.50 $4.00 $5.00 $4.00
Tier 2 Generic $12.00 $12.00 $11.00 $20.00 $11.00
Tier 3 Preferred Brand
$47.00 $47.00 $45.00 $47.00 $45.00
Tier 4 Non-Preferred Drugs
$100.00 $100.00 $95.00 $100.00 $95.00
Tier 5 Specialty 25% 25% 33% 25% 33%
Internal Use Only
2018 Non-Formulary Drugs
DRUG ALTERNATIVES EFFIENT* BRILINTA, clopidogrel
EMEND caps use generic
INVEGA use generic
LANTUS BASAGLAR
NASONEX fluticasone, flunisolide, OTC
NEORAL use generic
PULMICORT neb soln use generic Generic VYTORIN use simvastatin + ezetimibe
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2018 Drug Changes – Tier 3 to Tier 4 DRUG ALTERNATIVES
DEXILANT esomeprazole, omeprazole, pantoprazole, OTC
PRADAXA ELIQUIS, XARELTO
RELPAX* sumatriptan, rizatriptan, naratriptan, zolmitriptan
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2018 Positive Tier Changes DRUG TIER CHANGE
Cetirizine syrup Tier 2 → Tier 1
Escitalopram Tier 2 → Tier 1
Isosorbide mononitrate Tier 2 → Tier 1
ELIQUIS Tier 4 → Tier 3
TRULICITY Tier 4 → Tier 3
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Medicare Annual Enrollment Period
October 15, 2017 – December 7, 2017
Enrollment effective January 1, 2018
ANY Medicare beneficiary from any carrier can switch:
From MAPD to MAPD
From MAPD to PDP with Original Medicare
From MA-only to MAPD
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Essential Advantage (HMO) New!
Annual Akamai Advantage Provider Training October 11, 2017
Introducing Essential Advantage (HMO)
A new, HMO Medicare Advantage plan developed in partnership by HMSA and Hawaii Pacific Health. Offers an exclusive provider network that coordinates all care for Essential Advantage HMO members. Low monthly premium of $20.00 A plan that promotes good health and overall well-being for our Medicare members on Oahu. Coming soon! The plan becomes effective January 1, 2018. 11/27/2017 20
Essential Advantage (HMO) Plan - Eligibility
Same eligibility requirements as AA Complete and Complete Plus (Oahu) plans Member must have Medicare Part A & B Member cannot have end-stage renal disease (ESRD)
with some exceptions Member must reside in the City and County of
Honolulu Member must continue to pay their Part B premium in
addition to the Essential Advantage premium
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Essential Advantage (HMO) Plan Membership Card
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• Plan Name appears at the top right corner of the front of the card • Coverage Code: Medical T-C
HHIN – How to verify Essential Advantage Member Eligibility?
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Prior Authorizations
Essential Advantage has the same prior authorizations required for some services as the Akamai Advantage PPO plans. Reminder: A prior authorization is a process through which the
provider is required to obtain advance approval from HMSA to cover a service. Reminder: Submit a pre-service determination for services to
be provided by Non-Contracting Providers (NCP). Example: Non-Contracting Laboratory Referrals
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Referrals Referrals are required for most in-network services from a
Primary Care Provider (PCP). Hawaii Pacific Health will monitor these referrals with their systems. Referrals are required for most out-of-network services except
for urgent and emergency services. HMSA will monitor these referrals and claims will only process with an approved referral in HMSA’s systems. A referred provider can order lab services without another
referral. Other services must be referred by PCP. Reminder: A referral is a process through which the member’s
primary care provider (PCP) or other provider requires the member to obtain a service from another provider for the service to be covered.
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Services that do not require a Referral
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In-Network Emergency services Urgently needed services Ambulance DME Prosthetics Diabetic supplies and services Part B drugs Medicare-covered zero dollar preventive
services Medicare-covered diabetes self
management training Medicare diabetes prevention program Kidney dialysis services that you get at a
Medicare-certified dialysis facility
Out-of-Network Ambulance Emergency services Urgently needed services from providers
when network providers are temporarily unavailable or inaccessible
Kidney dialysis services that you get at a Medicare-certified dialysis facility when temporarily outside the plan’s service area
Essential Advantage (HMO) Plan Claims Filing/Billing Providers should bill HMSA Essential Advantage (HMO) Plan
members for coinsurance, copayments or deductibles for medical services File claims to HMSA Essential Advantage (HMO) Plan
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HMSA - CMS 1500 Claims (Professional) P.O. Box 44500 Honolulu, HI 96804-4500 HMSA - UB-04 Claims (Facility) P.O. Box 32700 Honolulu, HI 96803-2700
Akamai Advantage Dual Care (PPO SNP)
Annual Akamai Advantage Provider Training October 11, 2017
Akamai Advantage Dual Care Membership Card
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• Plan Name appears at the top right corner of the front of the card • No member premium (after Low Income Subsidy)
Akamai Advantage Dual Care Plan Claims Filing/Billing 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 1st ,
then bill HMSA QUEST Integration 2nd File claims to HMSA Akamai Advantage Dual Care Plan 1st, then
bill other QUEST Integration Plan 2nd Benefits covered by QUEST Integration that are not covered by
Original Medicare should only be billed to QUEST Integration
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HMSA - CMS 1500 Claims (Professional) P.O. Box 44500 Honolulu, HI 96804-4500 HMSA - UB-04 Claims (Facility) P.O. Box 32700 Honolulu, HI 96803-2700
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
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Care Manager Support
Annual Akamai Advantage Provider Training October 11, 2017
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MEMBER
Health Risk Assessment
(HRA)
Individualized Care Plan
(ICP)
Interdisciplinary Care Team
(ICT)
Model of Care
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Akamai Advantage Dual Care member is at the center
Goals of Care Management Support 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 Care Manager Improve seamless transitions of care across health care
settings, providers, and health services Ensure appropriate use of services Improve health outcomes
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Most Vulnerable
Somewhat Vulnerable
Least Vulnerable
Model of Care Support for your vulnerable patients
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Determined by HRAs and clinical
judgment
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
Health Risk Assessment and Care Plan
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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
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
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Interdisciplinary Care Team (ICT)
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Member
HMSA Medical Director
PCP
HMSA Service
Coordinator
“Core” team members
Examples of other team members
Family Members/Caregiver
Specialist
Dietician
Pharmacist
Gerontologist
Behavioral Health
The composition of the team is individualized according to the member’s needs and preference.
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: [email protected] 38
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• 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: [email protected] • 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
HMSA Provider Reminders
HMSA Provider Resources
HMSA Provider E-Library: https://www.hmsa.com/portal/provider/ HMSA Care Managers:
HMSA Provider Services
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Phone Fax
948-6997 944-5604
Toll Free: 1-844-223-9856 Toll Free: 1-855-856-4176
Phone Fax
948-6330 948-6887
Toll Free: 1-800-790-4672 Toll Free: 1-800-540-1668
APPENDIX
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Acronyms
AEP Annual Election Period
CMS Centers for Medicare and Medicaid Services
C-SNP Chronic Condition Special Needs Plan
D-SNP Dual eligible Special Needs Plan
EOC Evidence of Coverage
ESRD End Stage Renal Disease
HRA Health Risk Assessment
ICP Individualized Care Plan
ICT Interdisciplinary Care Team
I-SNP Institutional Special Needs Plan
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LIS Low Income Subsidy
MAPD Medicare Advantage Part D
MOC Model of Care
MOOP Maximum Out of Pocket
NCP Non-Contracted Provider
NCQA National Committee for Quality Assurance
OOPM Out of pocket maximum
QI QUEST Integration
QMB Qualified Medicare Beneficiary
SB Summary of Benefits
SNP Special Needs Plan
CMS Rules Provider Practices Need to Know
Annual Akamai Advantage Provider Training October 11, 2017
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CMS Rules Provider Practices Need To Know
You are required to: Complete Medicare Fraud, Waste & Abuse Training annually at https://hmsa.com/portal/provider/zav_IN.Medicare-INDEX.htm
MMG Ch3., Section 70.5.1
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CMS Rules Provider Practices Need To Know
You may (but you aren’t required to): Provide the names of plan sponsors that you contract with or
participate. Help patients apply for the low-income subsidy. Make plan marketing materials available in common areas. If
you display marketing materials for some plans, you have to accept requests from all plans you participate with.
MMG Ch3., Section 70.5.1
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CMS Rules Provider Practices Need To Know
You may (but you aren’t required to): Refer patients to other sources of information such as the
State Health Insurance Assistance Program (SHIP), State Medicaid office, and Social Security office, or CMS’ website at http://www.medicare.gov/ or 1-800-MEDICARE
Share information with patients from CMS’ website, including
the “Medicare and You” Handbook or “Medicare Options Compare”, or other documents that were written by or previously approved by CMS
MMG Ch3., Section 70.5.1
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CMS Rules Provider Practices Need To Know
You may NOT: Offer anything of value to induce plan enrollees to select you
as their provider. Offer inducements to persuade beneficiaries to enroll in a
particular plan or organization. Conduct health screenings when distributing information to
patients.
MMG Ch3., Section 70.5.1
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CMS Rules Provider Practices Need To Know
You may NOT: Steer beneficiaries in any way to a limited number of plans. Mail marketing materials on behalf of plans. Offer sales/appointment forms. Accept enrollment applications. Make phone calls or direct, urge or attempt to persuade beneficiaries to enroll in a specific plan based on financial or any other interests of the provider MMG Ch3., Section 70.5.1
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Thank you!
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