connectedcare 2017: how hanges to lue ross’ qhp individual ... · connectedcare 2017: how hanges...

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association An Independent Licensee of the Blue Cross and Blue Shield Association ©2014 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association

©2016 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association.

Confidential and proprietary Blue Cross of Idaho.

ConnectedCare 2017: How Changes to Blue Cross’ QHP Individual and Family Plans will impact Providers and Members.

Medicare Advantage updates.

Presented by Portneuf Quality

Alliance &

Blue Cross of Idaho October , 2016

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 2

Presentation Outline

Today, we will cover:

• Partnership Expansion between PQA and Blue Cross

• Product Details

• PCP Assignment Process

• Continuity of Care

• Referrals

• Out-of-Network

• Marketing Materials

• Website Overview

• Medicare Advantage Updates

• Question and Answer Period

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 3

Expansion of partnership between PQA and Blue Cross

The Portneuf Quality Alliance (PQA) and Blue Cross of Idaho (BCI) have redesigned benefits and networks for 2017

• Discontinuation of Individual and Family QHPs that use the Blue Cross PPO network

• Metal level plans sold through the Health Insurance Exchange and directly through Blue Cross

• Expansion of the PQA ConnectedCare Plan

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association

Product Details

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 5

2017 QHP network overview

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 6

PQA 2017 individual QHPs

• 6 Basic Plans

• 2 Bronze

• 2 Silver

• 1 Gold

• 1 Catastrophic

• Basic Benefits

• In-Network Individual Deductibles between $1,200 and $7,150

• Out-of-Network Individual Deductible $50,000

• ER visits subject to deductible

• 7-tier Rx benefit splits covered prescriptions into preferred and non-preferred in each level

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 7

In Eastern Idaho

Hospital: Portneuf Medical Center

Hospital: Mountain View Hospital

Hospital: Bear Lake Memorial Hospital, Caribou Memorial Hospital, Franklin County Medical Center, Lost Rivers Hospital, Madison Memorial Hospital, Minidoka Memorial Hospital, Nell J. Redfield Memorial Hospital, Power County Hospital District, Steele Memorial Hospital, Teton Valley Health Care

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 8

PQA 2017 individual ACA plans

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 9

The importance of Coordinated Care

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 10

Care coordination benefits members AND providers in many beneficial ways – while lowering the cost of care and increasing quality and outcomes

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©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 11

How coordinated care benefits us all

1. This service model pays for better outcomes

2. Network relies on YOUR professional experience. YOU know what’s best for the patient.

3. Great service experience for OUR (PQA and Blue Cross) customers

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 12

Responsibilities of PCPs and Specialists

• As a member of a Clinically Integrated Network (CIN) communication between providers is essential

• Utilize in-network providers when referring care

• PCPs to provide relevant medical information to Specialists

• Specialist to coordinate with PCPs regarding diagnosis and recommended treatment plan

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association

PCP Assignment Process

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 14

Here is how it works

• Blue Cross of Idaho will actively engage with PQA Network enrollees to prompt them to choose a Primary Care Provider (PCP)

• Phone calls

• Emails

• Direct mail

• Co-branded mail from Blue Cross and PQA

• We’ll partner with PCPs during January 2017 to try and reach out to those who haven’t selected a PCP.

• PCPs need to keep Blue Cross informed of their patient loads and notify us immediately by email notification to the Provider Relations rep when their panel is closed

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association

Continuity of Care

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 16

Members in midst of treatment/care

Transition of Care Authorizations

Members with tailored networks who receive care from an out-of-network provider during the initial transition period may have that care apply to their in-network benefits in the following scenarios:

• Continuation of care through the current period of active treatment (as defined below), or for up to 90 days, whichever is less.

• Continuation of care through the postpartum period (6 weeks) for members in their second or third trimester of pregnancy.

Following the initial transition period, in order to receive in-network benefits for that care, members must:

• Transition care to an in-network provider OR

• Obtain a gap-in-network authorization

Active Treatment: A member is undergoing an active course of treatment if the member has regular visits with the provider to monitor the status of an illness or disorder, provide direct treatment, prescribe medication, or other treatment to modify a treatment protocol. Active treatment does not include routine monitoring of a chronic condition.

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association

Referrals

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 18

Referral Specifics

• Referrals are required for all non-PCP care.

• Specialists will need to verify in the BCI online referral entry system that the referral has been approved

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 19

Referral Specifics

New Requirements for 2017

• Specialists will need to enter the referring PCP into Box 17 and NPI in Box 17b, or the respective field in an electronic submission of the submitted claim form.

• Out-of-Area services and providers will require a referral from the PCP.

• Providers will undergo a periodic audit by PQA and Blue Cross to ensure they are actively supporting the coordinated care approach.

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 20

Required Referrals

• Allergy/Immunology

• Audiology

• Behavioral health

• Cardiology

• Cardiac/Cardiothoracic surgery

• Colorectal surgery

• Dermatology

• Endocrinology

• ENT/Otolaryngology

• Gastroenterology

• General surgery

• Hand surgery

• Infectious disease

• Nephrology

• Neurology

• Neurosurgery

• Oncology/Hematology

• Oral surgery

• Orthopedics

• Pain management

• Plastic surgery

• Podiatry

• Psychiatry/Psychology

• Pulmonology

• Rheumatology

• Urology

• Vascular surgery

Visits or services by specialists/non-primary care providers; non-primary care specialties include, but are not limited to:

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 21

No Referral Needed

• Home health, home IV, hospice • Independent lab tests • Optometry • Pathology • PT/OT/ST • Radiology/Imaging services

(mammograms, x-rays, ultrasounds, MRIs, CT scans, PET scans) *NOTE - professional or interventional radiology services may be subject to referrals as specialists

• Registered dieticians • Psychotherapy

• Visits or services by primary care providers or generalists; primary care specialties include the following:

• Family practice • General practice • Internal medicine • OB/GYN • Pediatricians

• Anesthesia • Chiropractic • DME suppliers • Emergency or urgent care services

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 22

Members who reside outside-of-service area

• Idaho Residents Living Out-of-Area

• Subscribers enrolling in a Qualified Health Plan must meet Blue Cross of Idaho’s residency requirements as outlined in the member contract.

• Idaho Residents Who Reside Outside their Tailored Network Service Area for Part of the Year

• In order for out-of-area services to apply to an in-network benefit, gap-in-network referrals are required, and subject to BCI approval as outlined in the Gap-in-Network Authorization Criteria. The requirement to seek care within the tailored network may be waived if it is not geographically feasible to receive services within the tailored network for a portion of the year, and services cannot be postponed until the member returns to the service area.

• Dependents Who Reside Outside of the Network Service Area

• Eligible dependents of a primary subscriber (also known as a policyholder or enrollee) may reside outside the service area, for example to attend school. In such cases, it is the responsibility of the primary subscriber to contact customer service to provide this information. Out-of-area services may be authorized at the in-network benefit level for these dependents, subject to BCI review of:

• Confirmation of the dependent’s out-of-state residency

• Requested services or procedures

• Providers are contracting in a Blue Cross of Idaho tailored network or the BCBSA BlueCard network.

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 23

Out-of-network: Gap Authorization

Gap-in-network Authorization Criteria 1. Referral received from member’s PCP 2. Requested service is Covered and Medically Necessary 3. Requested service is not available within the member’s tailored network and,

a) Documentation of such provided by PCP and, b) When requested, documentation by an in-network specialist verifies the

requested specialized services cannot be provided within the member’s tailored network.

4. Referral is to a provider/facility: a) Within another BCI-contracting QHP tailored network* or, b) When (a) is not available, provider/facility is contracting in the standard BCI

network* or, c) When (a) and (b) are not available, referral is to a provider/facility contracting

with another Blue Cross Blue Shield plan (i.e., “BlueCard” network) *Or within a county contiguous to Idaho when the member is geographically remote (defined as 30 miles or more) from an alternate BCI-contracting provider, AND the specialty provider is geographically closer to the member than the BCI-contracting provider.

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association

Marketing Materials

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 25

Sales materials

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 26

New ID card design

New ID card designs reinforce the network, need for referrals and PCP, and underscore the out-of-network aspects of the plans

Sample Card; Logo Design Not Finalized

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 27

We are developing detailed communication plans for all affected audiences

Brokers

• Weekly broker blasts

• Fall broker training

• Hosted webinars

• Monthly Q&A briefs

• Comprehensive product training at Online Learning Center

Public Relations

• Op-eds and guest columns

• Press releases

• Editorial board meetings; Interviews

Providers

• Provider website educational materials

• Hosted webinars with Q&A with Provider Services; Monthly Q&A briefs

• Online Learning Center training module

Members and Shoppers

• Complete members and shoppers website update

• Questions on member portal; Monthly Q&A briefs

• Renewal packet

• Member handbook and ID card

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 28

Media/Public awareness of plans

• Blue Cross of Idaho CEO Charlene Maher recently conducted an exclusive one-on-one interview with The Associated Press, focusing on the benefits of coordinated care and the QHP healthcare networks

• Media coverage is anticipated around the following dates:

• Anonymous shopping for plans (with rates) began Oct. 1

• Open enrollment period runs Nov. 1 through Jan. 31

• Coverage begins Jan. 1

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association

Website Overview

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 30

New Blue Cross Provider Directory

• Brand-new provider directory from leading industry vendor, Vitals

• ID card provider code integrated with network search fields

• In final product testing; tool available October 1

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association

Medicare Advantage

2017 What’s Changing

• We’re reducing our Medicare Advantage (MA) Idaho footprint due to low membership in rural counties

• MA Plans are no longer offered outside of Service Area 1 and 2 (Medicare Supplements will be available statewide)

• Members of True Blue Connected Care, Secure Blue Idaho and True Blue Freedom II received letters of non-renewal

• Members with plans that are not available in 2017 received letters of non-renewal

• We are moving to a patient-centered healthcare model where a Primary Care Provider (PCP) helps our member navigate the health care system

• Secure Blue PPO without prescription coverage is still available in 2017

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 33

2017 Service Area 2

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 34

2017 Service Area 2 Benefits at a Glance

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 35

Medicare Advantage and the ABN

• In May 2014, CMS implemented new rules surrounding the discontinued use of the Advanced Beneficiary Notice (ABN) and the use of ABN modifiers for Medicare Advantage Plans

• Providers are required to obtain an Organizational Determination from the Plan so that Members are notified by the Plan of any non-covered services

• Any services billed with an ABN modifier will be processed based on the following guidelines:

Services that are non-covered as an exclusion of the member EOC or statutory exclusion by CMS, will be processed to deny as member liability

Services that are not identified as a non-covered exclusion of the Member EOC or statutorily non-covered by CMS, will be denied as provider liability unless an organizational determination is obtained prior to services being rendered. If an organizational determination is on file for a service and determined to be non-covered, claim will process the denial as member liability.

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 36

Medicare Advantage and the ABN

• National Coverage Determinations (NCD) Labs will require an organizational determination unless the test meets the CMS covered criteria

• NCD lab(s) that do not meet the CMS criteria and an organizational determination was not obtained, will deny as provider liability

• Services that require prior authorization and authorization is not obtained

• Services will deny as provider liability

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 37

Provider Engagement/Education Opportunities

Blue Cross of Idaho is committed to offering our providers tools and resources to help optimize patient health outcomes. This is consistent with CMS and/or NCQA audits, as well as various other initiatives and programs.

Please contact your area Provider Engagement Specialist to learn more about available tools and resources related to:

• Risk Score/HCC documentation and coding

• Risk Adjustment Data Validation Audits – for both Medicare Advantage and Qualified Health Plans

• Healthcare Quality Patient Assessment Form programs

• HEDIS/Stars programs

• Gaps in care

©2015 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association 38

Heather Beard, CPC, CPB, CEMC, CGIC

Counties: Bannock, Bear Lake, Bingham, Bonneville, Caribou, Cassia, Franklin, Fremont, Gooding, Jefferson, Jerome, Lincoln, Madison, Oneida, Power, Teton and Twin Falls

Email: PR6668@bcidaho.com

P: 866-283-5723 Ext. 8309

P: 208-286-3602 Ext. 8309

F: 208-286-2563

Provider Engagement Specialist

Contacts

• Internal • Jennifer Lucy, CPC

PR7205@bcidaho.com P: 208-286-3602 Ext. 8310 P: 866-283-5723 Ext. 8310 F: 208-286-3560

• External • Heather Beard

PR6668@bcidaho.com P: 208-286-3602 Ext. 8309 P: 866-283-5723 Ext. 8309 F: 208-286-3563

An Independent Licensee of the Blue Cross and Blue Shield Association ©2014 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association

©2016 by Blue Cross of Idaho, an Independent Licensee of the Blue Cross and Blue Shield Association.

Confidential and proprietary Blue Cross of Idaho.

Presented by Portneuf Quality

Alliance & Blue Cross of Idaho October 2016, 2016