Akamai Advantage Dual Care/MOC Provider Training

October 21, 2015

New! Akamai Advantage Dual Care (PPO SNP)

Akamai Advantage Provider Training October 21, 2015

Agenda

1. What is a D-SNP? 2. Akamai Advantage Dual Care Plan

Eligibility – How to identify a Akamai Dual Care Member Benefits – What is covered? Claims Filing – How are claims filed?

3. Model of Care HMSA’s Goals for Dual Care Members What is a Health Risk Assessment (HRA)? What is an Individualized Care Plan (ICP)? What is an Interdisciplinary Care Team (ICT)?

4. HMSA Provider Resources

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What is a D-SNP?

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The Dual-eligible Special Needs Plan (D-SNP) is a Medicare Advantage product for members eligible for both Medicare and Medicaid

1. HMSA’s new D-SNP will be named “Akamai Advantage Dual Care” 2. Akamai Advantage Dual Care does not combine or integrate Medicare and Medicaid

benefits into a single plan. 3. Members must be enrolled in Akamai Advantage Dual Care for their Medicare coverage. 4. Members may have separate QUEST Integration (QI) coverage with HMSA or another plan

for their Medicaid coverage. 5. Medicaid “fills in the gaps” in Original Medicare by helping to pay member premiums and

cost sharing, and covering benefits not offered under Medicare Examples of benefits which Medicaid covers (when medically necessary) which are not offered under Original Medicare: extended Skilled Nursing Facility (SNF) stays, transportation services, home-delivered meals, environmental accessibility adaptations (home adaptations such as ramps, grab-bars, etc.).

Akamai Advantage Dual Care Plan - Eligibility

Must be eligible for Medicare and Medicaid May be Qualified Medicare Beneficiary (QMB) Only or

(QMB) Plus dual eligibility status May have HMSA Akamai and HMSA QUEST Integration May have HMSA Akamai and QUEST Integration with

another health plan Allowed to change MA D-SNP anytime during the year

as long as Medicaid eligibility is maintained

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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)

HHIN – How to identify Akamai Advantage Dual Care Member?

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HHIN – How to identify Akamai Advantage Dual Care Member?

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Click on coverage code 696 to view plan description for Akamai Advantage Dual Care members

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 d. Increased access to SNF with Prior Authorization (no requirement for prior 3-

day acute stay) 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

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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:

Medicaid pays 20% Medicare pays 80% 100% coverage

Member pays $0

Claims Filing – Visit HMSA Provider Resource Center https://hmsa.com/portal/provider/zav_IN.PH-Claims_Filing.htm

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Click on General Claims Filing link to see CMS 1500 Claims Filing Instructions

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 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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Max Out of Pocket (MOOP) Accumulation Dual Care MOOP: $6,700 in-network, $10,000 combined in and out of network Medicaid will pay member cost shares for Original Medicare benefits, for

QMB and QMB Plus dual eligibles.

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.

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Care Manager Support

Akamai Advantage Provider Training October 21, 2015

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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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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

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

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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Health Risk Assessment (HRA)

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.

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Interdisciplinary Care Team (ICT)

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Member

HMSA Medical Director

PCP

HMSA Care Manager

“Core” team members

Examples of other team members

Caregiver

Specialist

Dietician

Pharmacist

Gerontologist

Behavioral Health

Individualized Care Plan via Cozeva

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Click on patient name to view Individualized Care Plan

Care Coordination via Cozeva

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Select “case summary” to view individualized care plan

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

NCQA National Committee for Quality Assurance

OOPM Out of pocket maximum

QI QUEST Integration

QMB Qualified Medicare Beneficiary

SB Summary of Benefits

SEP Special Election Period

SNP Special Needs Plan

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: Akamai D-SNP Attestation@hmsa.com 26

Thank you!

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