FreedomBlue

A Medicare Advantage PPO From Highmark Blue Shield in Association with Blue Cross of Northeastern Pennsylvania

April 26, 2006

FreedomBlue

• What is Medicare Advantage?

• Who is eligible ?

• Number of enrolled Members

• Radiology Management Program

• Cost-sharing

• Overview of BCNEPA Provider Center

What is Medicare Advantage?

• Program administered by The Centers for Medicare and Medicaid Services (CMS)

• Formerly Medicare +Choice

• Provides all the same benefits of Medicare plus supplemental benefits (i.e. Dental, Vision, RX, etc.)

FreedomBlue Member ID Cards

Sample Medical ID Card

FreedomBlue Member ID Cards Cont.

Sample Prescription Drug ID Card

Who is Eligible?

• Permanent county residence: NEPA - Luzerne and Lackawanna counties

• Eligible for Part A and enrolled in Part B

• Can not be medically determined to have End Stage Renal Disease (ESRD)

FreedomBlue Membership

• The current membership in Luzerne and Lackawanna counties is:– Luzerne – 349– Lackawanna – 254

Radiology Management Program

• Privileging – Effective January 1, 2006 any Medicare Advantage

provider who wants to perform radiology services must be privileged by Highmark Blue Shield in order to bill and be reimbursed for services.

– Imaging providers must submit privileging applications and be approved to offer certain advanced imaging procedures to FreedomBlue members.

Radiology Management Cont.

• Prior Authorization– Effective with dates of service beginning April 1,

2006, and beyond. For selected CT scans, MRI and MRA scans and PET scans.

– Must be obtained by the ordering physician– Must utilize Highmark-Sponsored NaviNet

application (if available). If not available can call NIA via their toll-free number – 1-866-731-2045, option 5.

Radiology Management Cont.

– Intended to ensure quality and proper use of diagnostic imaging

– Clinical guidelines available at www.RadMD.com– Prior authorization only applies to FreedomBlue

Members in 13 county BCNEPA region, not for any Highmark commercial members.

Cost-Sharing

• FreedomBlue Value Option incorporated cost-sharing effective January 1, 2006, for outpatient diagnostic services.

• What services will this impact?– Advanced Imaging – including but not limited to,

CT and CTA scans, MRIs, MRAs, PET scans, PET/CT scans

– Standard Imaging Services- i.e. skeletal x-rays and ultrasound

Cost-Sharing Cont.

• Diagnostic Medical Services – procedures such as electrocardiograms (ECG), electroencephalograms (EEG), echocardiograms, pulmonary studies, stress tests, audiology tests.

• Laboratory and Pathology Services – procedures such as non-routine PAP smears, blood tests, urinalysis, biopsies and cultures.

• Allergy Testing Services – allergy testing procedures such as percutaneous tests, intracutaneous tests and patch tests

Cost-Sharing Cont.

• How will cost-sharing be applied?– If the member has coinsurance, cost-sharing will

apply to the total, technical and professional component, and to services associated with the actual diagnostic procedure, including any drugs and/or contrast media.

– If the member has co-pays, they will apply only to the total and the technical components, (not to the professional component).

Cost-Sharing Cont.

• Could Multiple Copays or Coinsurance and Copays be applied on the same date of service?– YES

• Ex: Member goes to a provider in the morning and receives a bone density test, then later that afternoon goes to a different provider for an X-ray. This member will be required to pay two separate copays if both procedures codes are identified as cost-sharing services.

Cost-Sharing Cont.

• Can I use NaviNet to Confirm Benefits, Including Diagnostic Cost-Sharing?– YES

• What if the Copay Amount is Greater Than the Allowance? – In the rare instance the allowance for the service is

less than the members copay, the provider would have to reimburse the member the difference.

• Ex: Provider collected $20 copay, reimbursement was $15, the member would be due a $5 refund from the provider.

BCNEPA Provider Center

• Medicare Advantage PPO Building– Bulletins and Articles– Reference Materials– Administrative Guides– Medical Policy– Radiology Management Program– Forms– Pharmacy Information

BCNEPA Provider Center Cont.

– Electronic Tools– Provider Directory

BCNEPA Provider Center Cont.

QUESTIONS???