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
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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.
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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.
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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
070 Simply Level (HMO C-SNP)Chronic SNP – Diabetes, CHF, CardiovascularDisease
Offered 2020 & 2021
071 Simply More (HMO) Standard Offered Offered 2020 & 2021
090 Simply Care (HMO I- SNP) Institutional SNP Offered 2020 & 2021
091Simply Comfort (HMO IE-SNP)
Institutional Equiv SNP Offered 2020 & 2021
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2020- 2021 Plan Crosswalk
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Counties PBP
ContractPlan No.
2019-2020Plan Name Type of Plan Availability
BrowardH5471
076 Simply Complete (HMO SNP) Dual Eligible SNP Offered 2020 & 2021
077 Simply More (HMO) Standard Offered 2020 & 2021
079 Simply Care (HMO I- SNP) Institutional 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
074 Simply More (HMO) Standard Offered 2020 & 2021
072Simply Complete (HMO D-SNP)
(D-SNP) Full Duals only
Offered 2020 & 2021
092 Simply Care (HMO I- SNP) Institutional SNP 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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2020- 2021 Plan Crosswalk
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CountiesPBP
ContractPlan No.
2019-2020Plan Name Type of Plan Availability
HillsboroughPinellasPasco
Hernando
H5471
082 Simply Complete (HMO D-SNP) (D-SNP) Full Duals only Offered 2020 & 2021
075 Simply Level (HMO C-SNP)Chronic SNP – Diabetes, CHF, CardiovascularDisease
Offered 2020 & 2021
078 Simply More (HMO) Standard Offered 2020 & 2021
094 Simply Care (HMO I- SNP) Institutional SNP Offered 2020 & 2021
095 Simply Comfort (HMO IE-SNP) Institutional Equiv SNP Offered 2020 & 2021
099 Simply Select (HMO LIS) LIS only Offered 2020 & 2021
Palm Beach H5471
084 Simply Complete (HMO D-SNP) (D-SNP) Full Duals only Offered 2020 & 2021
085 Simply Level (HMO C-SNP)Chronic SNP – Diabetes, CHF, CardiovascularDisease
Offered 2020 & 2021
083 Simply More (HMO) Standard Offered 2020 & 2021
096 Simply Care (HMO I- SNP) Institutional SNP Offered 2020 & 2021
097 Simply Comfort (HMO IE-SNP) Institutional Equiv SNP Offered 2020 & 2021
101 Simply Select (HMO LIS) LIS only Offered 2020 & 2021
105 Simply Extra (HMO)Standard
Offered 2020 & 2021
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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.
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2021 DSNP Eligibility
13Simply Healthcare Plans - COMPANY CONFIDENTIAL | FOR INTERNAL USE ONLY | DO NOT COPY
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)
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Transportation Benefits
2020- 2021
Important Plan Changes
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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
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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
072 Simply Complete (HMO D-SNP) Unlimited Unlimited
092 Simply Care (HMO I-SNP) 12 one-way 12 one-way
093 Simply Comfort (HMO IE-SNP) 24 one-way 24 one-way
098 Simply Select (HMO LIS) 24 one-way 24 one-way
Polk H5471
066 Simply Complete (HMO D-SNP) Unlimited Unlimited
070 Simply Level (HMO C-SNP) 24 one-way 24 one-way
071 Simply More (HMO) 24 one-way 24 one-way
090 Simply Care (HMO I-SNP) 12 one-way 12 one-way
091 Simply Comfort (HMO IE-SNP) 24 one-way 24 one-way
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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
104 Simply Extra (HMO) 12 one-way 12 one-way
Hillsborough
Pinellas
Pasco
Hernando
H5471
082 Simply Complete (HMO D-SNP) Unlimited Unlimited
075 Simply Level (HMO CH-SNP) 24 one-way 24 one-way
078 Simply More (HMO) 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
105 Simply Extra (HMO) 12 one-way 12 one-way
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New Century Health
2020- 2021
Important Plan Changes
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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/
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Beacon Health Options
2020-2021
Important Plan Changes
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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/
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Pharmacy Benefits
2020- 2021
Important Plan Changes
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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
24Simply Healthcare Plans - COMPANY CONFIDENTIAL | FOR INTERNAL USE ONLY | DO NOT COPY
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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.
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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
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