Medicare Advantage Participating Provider Training

Provider Experience

Part A Part B Part C Part D

Also known as Hospital Insurance program, covers inpatient hospital, skilled nursing facility, some health visits and hospice care

The Supplementary Medical Insurance program, helps pay for physician, outpatient, some home health and preventive services

Also known as the Medicare Advantage program, allows beneficiaries to enroll in a private plan, such as a health maintenance organization (HMO) or preferred provider organization (PPO), as an alternative to traditional Medicare

The outpatient prescription drug benefit is a voluntary benefit delivered through private plans that contract with Medicare; enrollment in Part D is voluntary Private plans can be

either stand-alone prescription drug plans (PDPs) or Medicare Advantage prescription drug plans (MA-PD)

The four parts that make up the Medicare Program are:

Medicare Overview

2 November 2018

Medicare Cost vs. Medicare Advantage

Medicare Cost Medicare Advantage

When Kaiser Permanente refers and/or authorizes services outside our Medical Centers, Kaiser Permanente is responsible for paying Original Medicare coinsurance and deductibles for our Cost members.

Members can use their Original Medicare cards to seek services from Medicare providers outside of the Kaiser network without a referral from their Kaiser provider.

Also known as Medicare Part C, Medicare Advantage covers Medicare Parts A, B, and D for participating members as well as benefits above and beyond what someone would receive under Medicare alone.

CMS pays Kaiser Permanente a capitated rate to manage the health care of a member. Members must use the Kaiser Permanente Medicare Advantage network and may not use their red, white, and blue Medicare card to receive services outside of the network.

Medicare members must have Medicare Part A and B to be eligible to join a Medicare Advantage plan that is offered in their area.

3 November 2018

2018 Medicare Advantage Launch2018 Kaiser Permanente Mid-Atlantic States

Medicare Service Areas

2018 January April July OctoberMA membership 1,600 2,700 3,600 4,300

Cost membership

73,100 72,400 72,200

Starting January 1, 2018, we began offering Medicare Advantage (MA) plans. As of May, we have enrolled ~3k Medicare Advantage members.

MA plans are offered to people who live in Washington, DC, as well as Anne Arundel, Baltimore, Baltimore City, Harford, Howard, Montgomery, and Prince George’s county in Maryland

Current individual (~48k) and group (~26k) members stayed in Cost unless they actively elected to move to a Medicare Advantage plan

4 November 2018

For 2019, we intend to close our Cost plans in counties where Medicare Advantage was launched for 2018. This includes DC, Anne Arundel, Baltimore, Baltimore City, Harford, Howard, Montgomery, and Prince George’s county in Maryland

As a result of our Cost plans being closed, we will automatically renew our members in the counties above in to new MA plans. This applies to group and individual members. There will be no Cost plan members in the area highlighted in blue with the exception of Charles County.

We will also launch Medicare Advantage new in Charles County for 2019.

All group membership in Charles County will be moved to Medicare Advantage in 2019

All Charles County residents who are newly enrolling in KP Medicare plans will enroll in Medicare Advantage

Existing individual Cost members in Charles County will be able to actively enroll in a Medicare Advantage plan if they choose to

All remaining parts of the service area will continue to offer Medicare Cost plans. This includes VA, Calvert, Frederick and Carroll.

2019 Medicare Advantage Launch2019 Kaiser Permanente Mid-Atlantic States

Medicare Service Areas

Looking ahead…We continue to evaluate the opportunity to expand Medicare Advantage into the rest of our Medicare service area

5 November 2018

Eligible Kaiser Permanente Medicare Advantage

members may receive PRIMARY and SPECIALTY care services at any Kaiser

Permanente location throughout the entire Kaiser

Permanente Mid-Atlantic service area, regardless of whether or not the location

is in the Medicare Advantage service area.

Kaiser Permanente Medicare Advantage members may also

see select Participating Primary and Specialty care

providers within Kaiser Permanente’s Medicare

Advantage Network.

Medicare Advantage Primary and Specialty Care Locations

6 November 2018

Medicare Advantage NetworkBecause a Medicare Advantage member can only utilize the network of the Medicare Advantage Organization (MAO), there are rigorous network adequacy guidelines (time and distance requirements) that all MAOs must meet. These vary by the population density of a given area as well as the type of provider.

The KP-MAS Medicare Advantage Network is its own network and differs from the Select network.

All providers in the Medicare Advantage network required to meet network adequacy must be listed in the provider directory.

With an approved authorization, Members may choose from any provider in the Medicare Advantage network.

7 November 2018

Kaiser Permanente Medicare Advantage members will be able to fill prescriptions at ANYKaiser Permanente pharmacy center location across the Mid-Atlantic States region.

Medicare Advantage Pharmacy Locations

Kaiser Permanente Medicare Advantage members also have the option to use non-Kaiser Permanente participating network Pharmacies in the KP-MAS service area, including but not limited to the following:

• Giant • Walmart• Target• CVS• Rite Aid• Walgreens• Contracted Independent Pharmacies

https://healthy.kaiserpermanente.org/static/health/en-us/pdfs/mid/Medicare_2018_MID/mid_ma_dcmd_pharmacy_directory.pdf

8 November 2018

ID Cards

MA Signature MA SelectCard Color White TanProvider Information included

No Yes

Rx Info Included Yes Yes

Members may have different ID cards depending on whether they are in a plan with the Medicare Advantage Signature network or the Medicare Advantage Select network. The differences appear in the card color as well as the information included on the card.

9 November 2018

Participating Providers enrolled with KP HealthConnect AffiliateLink may verify eligibility and benefit information online by logging on at: www.providers.kp.org/mas

Participating Providers or members may call Member Services at 1-855-249-5019 or for TTY 1-866-513-0008 regarding:• General enrollment questions• Clarification of eligibility verifications• Clarification of member benefits• Members terminated greater than 90 days• Members presenting with no Kaiser Permanente identification number• Clarification of claims issues

Enrollment and Eligibility

10 November 2018

Kaiser Permanente Medicare Plus (Cost)

Standard Plans

Kaiser Permanente Medicare Advantage

Standard Plans

Kaiser Permanente Medicare Plus (Cost)

High Plans

Kaiser Permanente Medicare Advantage

High Plans

Inpatient Hospital $850 per benefit period

$250/day for days 1-5; $0 unlimited thereafter

(STAY)Per admission

$350 per benefit period

$225/day for days 1-5; $0 unlimited thereafter

(STAY)Per admission

Skilled Nursing Facility: Days 0-20

Days 21-100$0

$160/day $0

$160/day $0

$110/day$0

$110 /day

Cost vs Advantage - Direct Pay / Individual

Note: The above copays are examples. Please verify eligibility and benefits prior to rendering services.

Benefit differences in 2019

11 November 2018

Cost vs Advantage – Group Plan ChangesMedicare Group Plan ChangesDue to the service area changes, employer groups will offer a Cost plan to their employees who reside in the Cost service area and Medicare Advantage to their employees who reside in the Medicare Advantage service area. Charles County group members will be in Medicare Advantage.

Although plan types may be different within the same group, cost sharing is the same between Cost and Advantage plans.

Inpatient Hospitalizations:- Medicare Advantage Group plans will administer a “per benefit period” structure. This

does not align with Medicare Advantage individual plans, which have a per day co-pay

12 November 2018

Appointment and Access StandardsPer the Medicare Managed Care Manual, Chapter 4 - Benefits and Beneficiary Protections, Section 110.1.1 – Provider Network Standards Hours of operation are convenient to, and do not discriminate against, enrollees. When medically necessary, services are available 24 hours a day, 7 days a week Examples of reasonable standards for primary care services are:

– (1) urgently needed services or emergency - immediately; – (2) services that are not emergency or urgently needed, but in need of

medical attention - within one week; and – (3) routine and preventive care - within 30 days

13 November 2018

Referrals and Authorizations

Specialty Care Referrals

• Initial Consultation• Referral must be authorized by PCP or Specialist• Referral valid for 90 days (3 months), or as otherwise specified on the

referral

• Additional Visits and Expired Referrals• After an approved initial consult you do not have to call the PCP to request

additional visits• Complete a Maryland Uniform Consultation Referral Form to initiate a new

request, fax to UMOC for processing• UMOC FAX Numbers: 1-800-660-2019 – Alternate Fax: 855-414-1693

14 November 2018

Referrals and AuthorizationsUtilization Management Operations Center (UMOC)

Referral Management Unit: 8:00am –4:30pm, weekdays

Concurrent Review Unit: 8:30am –5:00pm, weekdays

Home Care/DME Unit: 8:30am –5:00pm, weekdays

Emergency Care Center (ECC): 24/7, 365 days/year

Referrals, authorizations hospital observation & inpatient admissionsGeneral Number (listen for prompts): 1-800-810-4766Fax Numbers• Specialty Care Referrals: 1-800-660-2019 or 855-414-1693• Homecare/DME (Please send clinical information): 855-414-1695• Rehab Re-Authorizations (Please send clinical information): 855-414-1698• DCSM Concurrent Review: 855-414-1704• NOVA Concurrent Review: 855-414-2659• Baltimore Concurrent Review: 855-414-1702• Emergency Care Center: 855-414-2634

15 November 2018

Claims & Billing Procedures

Billing Address:Mid-Atlantic Claims AdministrationKaiser PermanenteP.O. Box 371860Denver, CO 80237-9998

Clearinghouse Payor IDs for KP:ChangeHealthcare: 52095Office Ally: 52095Availity: 54294OptimumInsight/Ingenix: NG008Relay Health: RH010

Timely Filing: 180 days (6 months) fromdate of serviceTimely appeals filing: 180 days (6 months) from date of denial“Clean Claim”: Standard format/completed fields, attachments, current industry standard data codingAll patient services must be billed on CMS 1500 or UB04

Kaiser Permanente is the primary payor for Medicare Advantage. Claims should be sent to Kaiser Permanente, not CMS. However, the same billing requirements for CMS are applicable to all claims billed to Kaiser Permanente. Please verify the member’s plan to ensure that the claim is submitted to the correct payor.

16 November 2018

Provider Appeals

All provider appeals should be sent to:Mid-Atlantic Claims AdministrationKaiser PermanenteP.O. Box 371860Denver, CO 80237-9998

17 November 2018