Brenda Rose Provider Network Consultant October 30, 2012 2013 Medicare Advantage Prescription Plans...

Brenda RoseProvider Network Consultant

October 30, 2012

2013 Medicare Advantage Prescription Plans

Gwinnett PHO

1. Humana Medicare Advantage Prescription Drug Plans (MAPDs)

2. How Humana MAPDs work

3. What’s new at Humana

4. How Humana makes it easy to navigate

5. Humana’s commitment to well-being and quality care

6. Humana is your partner

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Agenda

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• Humana is one of the nation’s largest publicly traded health benefits companies with– 10.1 million medical members– 7 million specialty-product members

• Offers a wide array of plans for employer groups, government programs and individuals

• Offers a range of specialty products, including dental and vision plans

• Operates more than 300 medical centers• Operates more than 240 worksite medical facilities

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About Humana

Open Access HMO Rules How Does It Work? How Are Benefits Administered? Key Features Benefit Summary Network Hospitals HMO Reciprocity

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How Does an Open Access Medicare HMO Work?

• Members select their own Primary Care Physician (PCP) from our list of Humana Gold Plus® Medicare HMO PCPs.

• Humana Gold Plus® (HMO) ID card has the member’s PCP and contact information

• PCP referrals are not required for in-network specialists for covered service

• Members must receive care from Humana Gold Plus® (HMO) providers for in-network benefit

• No benefit coverage when services are delivered by providers not contracted for Medicare HMO (Humana Gold Plus®), except in an emergency

• Out-of-network service requires a Humana authorization for benefit coverage

• Claims submitted by providers not contracted for Medicare HMO (Humana Gold Plus®) are denied for payment

• Routine Physical Exam • Welcome to Medicare Visit • Annual Wellness Exam• Pap Smear & Pelvic Exam • Prostate Cancer Screening• Colorectal Cancer Screening• Mammogram Screening • Bone Mass Measurement Screening• Immunizations/Vaccinations • Obesity Screening and Therapy• Cardiovascular Screening• Cardiovascular Behavioral Therapy• STI Screening and Counseling • Abdominal Aortic Aneurysm Screening

Benefit Summary:Health Benefits at $0 Copayment

• Depression Screening• Alcohol Misuse Screening and

Counseling• Diabetic Screening• EKG Screening • Glaucoma Test • HIV Screening • Nutrition Therapy (Diabetic and ESRD)• Smoking Cessation• Diabetic Self-Monitoring Training• Diabetic Monitoring Supplies (preferred

DME provider-RightSource)

• This Open Access HMO has reciprocity with other Humana Gold Plus® Medicare HMO plans in Georgia.

• The Medicare HMO member can seek care from providers in the Humana Gold Plus® Medicare HMO network in (State and Market). The covered service will be paid at in-network level. If the provider is not in the Humana Medicare HMO network, the covered will be denied for payment.

• The Medicare HMO member will be covered for all emergencies at in-network benefit level.

Reciprocity:What is the reciprocity for this Open Access HMO?

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MAPD - HMO Benefits (In-Network Only) Atlanta-MHMO (H4141-001)

PCP/ Specialist/Chiropractor Office Visit $10/$35/$20 copay

Rx Drugs (Tiers I , II, III, IV) $3/$6/$45/$92 copay

MAPD - DE-SNP HMO Benefits Atlanta DE-SNP MHMO (H4141-003)

PCP/ Specialist/Chiropractor Office Visit 20% coinsurance

Rx Drugs (Tiers I , II, III, IV) $0/$0 copay/100%/100% coinsurance

Transportation (one-way trips) $0 (24 one way trips per year)

MAPD - C-SNP HMO Benefits Atlanta C-SNP MHMO (H4141-009)

PCP/ Specialist/Chiropractor Office Visit $5/$35/$20 copay

Rx Drugs (Tiers I , II, III, IV) $3/$6/$40/$95 copay

Transportation (one-way trips) $0 (24 one way trips per year)

ATLANTA HMO, DE-SNP HMO AND C-SNP HMO

APPROVED COUNTIESBartow, Cherokee, Cobb, Coweta, DeKalb, Douglas, Fayette, Floyd, Forsyth, Fulton, Gwinnett, Henry, Paulding and Pickens

• DeKalb Medical Center

• Emory University Hospital

• Emory University Hospital Midtown

• Emory University Hospital John Creek

• Emory Adventist Hospital

• Eastside Medical Center

• Gwinnett Medical Center

• Northside Hospital

• Northside Hospital Forsyth

• Northside Hospital Cherokee

• Piedmont Fayette Hospital

Network Hospitals:Atlanta Humana Gold Plus HMO Plan

• Piedmont Hospital

• Piedmont Henry Hospital

• Piedmont Mountainside Hospital

• Piedmont Newnan Hospital

• St Joseph’s Hospital of Atlanta

• Wellstar Cobb Hospital

• Wellstar Douglas Hospital

• Wellstar Kennestone Hospital

• Wellstar Paulding Hospital

• Wellstar Windy Hill Hospital

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Sample of Humana Gold Plus (HMO) ID Card

Plan Type

Primary Physician

• Key Features: Member has at least one of 3 conditions Pre-qualification form with disease-specific questions Verification Chronic Condition (VCC) form signed by physician Signed VCC must be received within first month of coverage Plan must verify condition(s) within 1st month Member will be dis-enrolled if at least one condition is not verified Year-round enrollment for applicant with one of these 3 conditions Member cost share is based on plan benefits

Humana Gold Plus (HMO) C-SNP (Diabetes/Cardiovascular Disorder/Chronic Heart Failure)

Some Key Features of HMO DE-SNP/Chronic SNP– Cont. HMO authorization rules apply No referrals for In-network specialists No out-of network coverage except for emergent/urgent care Access to Humana Gold Plus (HMO) network Member must present their Medicaid ID card at time of service

Verification Chronic Condition (VCC) Form

Verification of Chronic Condition

(IMPORTANT: PLEASE RETURN WITHIN <10> DAYS OF ORIGINAL RECEIPT) The applicant listed below has applied for a special needs Medicare plan through Humana. This plan will provide the applicant with additional benefits related to his or her condition, such as supplemental drug coverage. For the applicant to qualify, a physician or physician’s office must confirm his or her diagnosis by completing this form. Humana appreciates your assistance. For questions, please call <1-800-457-4708>. TTY users should call <711>. You can call us <seven days a week from 8 a.m. to 8 p.m.>

Applicant’s name: DOB:

Applicant’s address:

Humana ID: <UMID> Customer number: <#> Sub group#: <#> Proposed effective date: <Date>

My signature below authorizes information about my chronic condition to be shared with Humana.

Applicant’s signature Date

To Be Completed by the Physician/Physician’s Office

By signing this form, you confirm the patient has been diagnosed with:

None Chronic Heart Failure Cardiovascular Disease Diabetes Chronic Lung Disease: Asthma, Chronic Bronchitis,

Emphysema, Pulmonary Fibrosis, Pulmonary Hypertension

Confirmation provided by:

Signature Date

Printed name or stamp Title

Physician name Phone

Please return this form to:

Humana

<P.O. Box 14309> <Lexington, KY 40512-4309> <Or Fax to 1-877-889-9936>

A Coordinated Care plan with a Medicare Advantage contract, available to anyone who meets the specific eligibility requirements of the SNP and is enrolled in both Part A and Part B of Medicare. To qualify for a Chronic Disease SNP, physician diagnosis of the

disease must be verified. People who do not have the condition will be disenrolled.

Humana Medicare PPO PlansLPPO and RPPO

Key Features Benefit Summary

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• No referral required

• In-Network and Out-of-Network coverage

• May have out-of-network deductible

• Higher member responsibility for out-of-network providers

• List of participating providers in Humana.com/Physician Finders Plus

• Member may be requested to select Primary Physician (not required)

– Participating primary physicians will see their name displayed on the back of member ID cards

– Non-participating providers or specialist swill be noted in Humana systems, NOT on ID cards.

– Selection of new primary physician at any time –New ID card generated– Member notified when provider terms and asked to select a new provider

Some Key Features of Medicare PPO

Some Key Features of Medicare PPO– Cont.

• Criteria for listing PCP on member ID card:– Member provide this information during Open Enrollment or from

Humana member outreach;

– Provider chosen must be participating with Humana and the Member’s LOB; and,

– Provider must be a Family Practitioner, General Practitioner, Internal Medicine physician, Pediatrician or OB/GYN

Goal

• Strengthen member-primary physician relationship and engagement

Increased use of preventive services Improved coordinated care and outcomes Improved Quality (HEDIS) measures

2013 LPPO BENEFITS

MAPD-LPPO Benefits

Atlanta (H5214-003)

Aiken, SC/Augusta GA (H5214-004)

Athens (H5214-008)

Columbus (H5214-009)

PCP/SpecialistChiropractor Visit IN/OON

$15/$40/$20 copay 30% OON $15/$40/$20 copay30% OON

$20/$40/$20 copay 30% OON

$15/$35/$20 copay/ 30% OON

Rx Drugs (Tiers I , II, III, IV)

$6/$12/$45/$90 copay

$5/$12/$45/$90 copay

$4/$10/$45/$90 copay

$4/$12/$45/$90 copay

Approved Counties Barrow; Bartow; Carroll; Cherokee; Clayton; Cobb; Coweta; Dawson; DeKalb;Douglas; Fayette; Floyd; Forsyth; Fulton; Gwinnett; Haralson; Henry; Meriwether;Newton; Paulding; Pickens; Rockdale; Walton

GA:Burke; Columbia; Glascock; Hancock; Jefferson; McDuffie; Richmond; Taliaferro; Warren; Washington; Wilkes; SC:Aiken;Barnwell; Edgefield; McCormick;Newberry; Saluda

Clarke; Greene; Jackson; Madison;Morgan; Oconee; Oglethorpe

AL:Chambers; Lee; Randolph; Russell;GA:Chattahoochee Harris; Marion;Muscogee; Randolph; Stewart; Talbot;Troup; Webster

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MAPD-RPPOBenefits

Region 8 GA & SC (R5826-064) MA Only

Region 8 GA & SC (R5826-077) (Same IN/OON Benefits)


$20/$45/$20 copay $45/$45/$40 copay OON

$20/$45/$20 copay


Not Available $4 /$12 copay/100% /100% coinsurance

Approved Counties GA:Statewide; SC:Statewide GA:Statewide; SC:Statewide

2013 RPPO BENEFITS

Sample of Humana Choice (PPO) ID Card

Plan Type Primary Physician

Sample of Humana Choice GA/SC Regional (PPO) Card(Statewide)

R5826 –004 (Traditional RPPO MAPD – IN/OON Benefits)R5826 – 077 (Non-traditional MAPD – Same IN/OON Benefits)

Humana Medicare PFFS Plans

Key Features Benefit Summary

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• No referral required

• Members in any PFFS plan (Non-Network / Partial Network/ Full Network) can see any contracted or non-contracted providers throughout the nation.– Non-Network plan – Members can be seen by any provider who agrees to treat and

accept Humana Terms and Conditions– Partial Network plan – There is a contracted network for DME/Home Health/Lab; all

other services treated as a non-network plan. Some plans may have in-network and out-of-network benefit levels between contract vs. non-contracted DME/HH/Lab

– Full Network plan – There is a contracted network for all services; benefit levels are administered based on in-network and out-of-network status

• List of contracted PFFS providers in Humana.com/Physician Finders Plus

• Member may be requested to select Primary Physician (not required)

Some Key Features of Medicare PFFS

2013 PFFS BENEFITSMAPD-MA

PFFS-BenefitsSouth GA

(H2944-114) MAPD Partial Network

South GA (H8145-117) MA Only

Full Network

South GA PFFS (H8145-079) MAPD

South GA (H2944-193)

MA Only


$20/$40/$20 copay 20% coinsurance $15/$35/$20 copay 20% coinsurance


$6/$12/$45/$90 copay Not Available $5/$12/$45/$90 copay Not Available

Approved Counties Atkinson; Bacon; Baker; Ben Hill; Brantley; Brooks; Calhoun; Candler; Clinch;Cook; Crisp; Decatur; Early; Echols; Franklin; Gilmer; Glascock; Grady;Habersham; Hall; Hancock; Heard; Irwin;Jenkins; Johnson; Lanier; Lowndes;Mitchell; Peach; Pulaski; Quitman; Randolph; Seminole; Terrell; Tift; Towns; Treutlen; Turner; Twiggs; Upson; Walton;Washington; Wayne; Wilcox

Barrow; Chatham; Chattooga; Clayton; DeKalb; Elbert; Forsyth; Fulton; Gwinnett; Hart; Henry; Jackson; Jefferson; Lincoln; Morgan; Muscogee; Polk; Rockdale; Talbot; Taliaferro; Warren; White; Wilkes

Barrow; Chatham; Chattooga; Clayton;DeKalb; Elbert; Forsyth; Fulton; Gwinnett;Hart; Henry; Jackson; Jefferson; Lincoln;Morgan; Muscogee; Polk; Rockdale; Talbot;Taliaferro; Warren; White; Wilkes

Atkinson; Bacon; Baker; Ben Hill;Brantley; Brooks; Calhoun; Candler; Clinch; Cook; Crisp; Decatur; Early; Echols; Floyd; Franklin; Gilmer; Glascock; Grady; Habersham Hall; Hancock; Heard; Houston; Irwin; Jenkins; Johnson; Lanier; Lowndes; Lumpkin; Meriwether; Mitchell; Peach; Pulaski; Quitman; Randolph; Seminole; Stephens; Terrell; Thomas; Tift; Towns; Treutlen; Turner; Twiggs; Upson; Walton; Washington; Wayne; Wilcox

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Sample ID Cards for PFFS Plans

Non-Network PFFS Partial Network PFFS Full Network PFFS

A Network PFFS, Partial Network PFFS and Non-network PFFS plan would not be marketed in the same county.

Medicare Preauthorization Summary

HMO and PPO

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Medicare Advantage Preauthorization SummaryHumana Gold Plus HMO and Medicare PPO

Inpatient Admissions (Acute Hospital; Acute Rehab; LTAC; SNF; MH-partial/residential) Before Admission/Next Business Date Website (Humana.com) or IVR 800-523-0023 Authorization

Plastic Surgery/Cosmetic Surgery Authorization

Hi-Tech Imaging (MRI, MRA, CT, CTA, SPECT, PET, Nuclear Test & Cardiac Caths) HealthHelp Authorization

Radiation Therapy HealthHelp Authorization

Outpatient Therapy Services (PT; OT; ST) Authorization

Durable Medical Equipment (DME over $750 ) Authorization

Pain Management Procedures OrthoNet Authorization

Cardiac Devices HealthHelp Authorization

Facility-Based Sleep Studies (PSG) Authorization

Full list is at www.humana.com/providers/referral/pre_authorization.aspx

Humana Gold Choice PFFS plans are “notification” only

• National Vendors• Utilization Programs

Diagnostic imaging Radiation therapySpecific cardiac services–Call 1-866-825-1550 for Humana radiology services authorizations –Or go online at www.healthhelp.com/humana and use the outpatient radiology authorization and referral link

Pain management –Online - Log into the Provider Self-Service Center (Humana.com or Availity.com)–Call OrthoNet at 1-888-605-5344–Fax OrthoNet at 1-888-605-5345

National Vendors:Utilization Management Vendors

LifeSynch - Behavioral Health Network

• Primary care physician (PCP) calls number on back of Humana member ID card

• PCP tells customer service representative the level of care for authorization

• PCP coordinates care with appropriate LifeSynch associate. LifeSynch locates in-network provider

• LifeSynch coordinates referrals and precertifications for covered services

• Provider lookup at Humana.com in Physician Finder, Lifesynch.com or 1-800-777-6330

http://www.lifesynch.com/

Apria and Edgepark – Medical Supply Companies

Apria - National Home Medical Equipment •Includes:– Home oxygen services– CPAP/BiPAP equipment and supplies– Home tube feeding – Outpatient negative pressure wound therapy

•Providers can contact their local Apria branch for referrals or call 1-800-962-7742•Local alternatives to national contract – refer to the Provider Directory•Edgepark Medical Supplies•Insulin pumps•https://www.edgepark.com or 1-888-394-5375

https://www.edgepark.com/

https://www.edgepark.com/

RightSource DME / Coram / Rotech / CCS

Right Source (Preferred Provider -Diabetic Monitoring Supplies)

• $0 copay• Free shipping to members•www.rightsourcerx.com or 1-800-379-0092 TTY: 711

Coram –Home Infusion Therapy

•Apria-affiliated company•www.coram.com or 1-800-423-1411

Rotech –DME•Mobility needs –wheelchairs and assist-devices•www.rotech.com

CCS Medical Supplies•www.ccsmed.com or 1-800-260-8193

http://www.rightsourcerx.com/

http://www.coram.com/

http://www.rotech.com/

http://www.ccsmed.com/

Golden Living –Nursing Centers / Hanger Prosthetics

Golden Living – Skilled Nursing Facilities•www.goldenliving.com

•Locations throughout Humana markets

Hanger Prosthetic and Orthotics•www.hanger.com or 1-877-442-6437

http://www.goldenliving.com/

http://www.hanger.com/

Laboratory and Prescription Home Delivery ServiceLaboratory

•LabCorp•Quest Diagnostics•Local alternative to national contract (this is where you list special local contracts with hospital systems; check with Contracting to be sure you are sharing current information)

RightSourceRx Mail-Order Pharmacy

•Significant saving to Humana members•Discounts for Brands•$0 copay for 90-day supply for many generics •To submit a new prescription:

o Transmit directly to RightSourceRx .como Call 1-800-379-0092 o Fax prescription fax form 1-800-379-7616 (online fax form at RightSourceRx.com)

•Drugs with quantity limits or that require prior authorization must be approved by Humana Clinical Pharmacy Review (HCPR) at 1-800-555-2546•Pharmacies and technicians available for member questions•Refill reminders via phone or email

• Medicare Programs • Medicare Contacts

• Medicare Health Risk Assessment (HRA)• Episodic Case Management• Renal Disease Management (VillageHealth at (800) 767-0063 or www.villagehealthdm.com)• HumanaCares – Complex Care Management (1-800-622-9529)• SeniorBridge• Health Achieve • Field Case Management• Disease Management• Humana Clinical Programs

– Bariatric management program – Medication therapy management (MTM) – Transplant management– HumanaFirst ® Nurse Advice Line

• Utilization Management (UM)- Post-Acute Care & Onsite Review Nurse (OSRN)• Transition of Care• Visit: www.humana.com/providers/clinical/health/

Clinical Management Programs

– Promote healthy living

– Provide guidance to members with complex conditions

http://www.villagehealthdm.com/

• Members complete five eligible health care activities during a calendar year– Eligible to receive five $10 gift cards from restaurants, gas stations, movie theaters

and retailers. Gift-card suppliers include Cracker Barrel Old Country Store®, Applebee’s®, AMC Theatres®, Shell®, BP®, ExxonMobil® and Chevron®

• Eligible Health Care Activities– For 2012, the following screenings and tests qualify for rewards:– Adult Wellness Visit (new for 2012) - Cardiovascular Disease Screening– Flu Shot - Routine Screening Mammogram– Pneumonia Vaccine - Routine Pap Smear and Pelvic Exam– Hepatitis B Vaccine - Colorectal Cancer Screening– Welcome to Medicare Visit - Prostate Cancer Screening– Glaucoma Eye Exam - Glucose Diabetes Screening– Bone Mass Osteoporosis Test

• Encourage your Humana Medicare Advantage patients to call 800-968-2281 if they have questions

Humana Medicare Rewards Program

Contacts You Need to Know

Medicare customer service: See back of member’s ID card

Authorization/IVR: 1-800-523-0023

Provider relations:(fee schedule requests, demographic changes, credentialing status)

1-800-626-2741

Medicare case management & Concurrent review 1-800-322-2758

Disease management program information: 1-800-620-9529

RightSourceRx pharmacy: 1-800-379-0092

Provider Consulting Team

Brenda Rose (North Georgia Market)

Karen Andrews (East Georgia Market)

423-531-6707 [email protected]


Kimberly Bryant (West Georgia Market)

Iris Johnson (Georgia Frontline Leader)



Tools for ProvidersAvaility.com and Humana Members

Overview of eTools

Jilliann Billingsley and Marchelle Sumpter– eBusiness Consultant

Introduction

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• Availity.com Multi-Payer Web Portal• HIPAA compliant health plan transactions in real-time on the web and in batch via Electronic Data Interchange (EDI) at no cost to

health care professionals

– Eligibility and Benefits Inquiry

– CareRead

– Referral and Authorization Submission

– Referral and Authorization Inquiry

– Claim Status Inquiry

– Claim Reconciliation Tool*

– Claim Correction

– Claim Attachment

– Remittance Information

– Fee Schedules*

– Medical Records Management*

– Service Fund HMO Reports*

ERA/EFT

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• Electronic Remit Advice (ERA)– HIPAA Transaction 835

• Electronic Fund Transfer (EFT)– HIPAA Transaction 837

Questions & Answers

Providing our members and providers Perfect Experience

Brenda Rose Provider Network Consultant October 30, 2012 2013 Medicare Advantage Prescription Plans...

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