Akamai Advantage Annual Provider Training - 10/11/2017€¦ · Akamai Advantage Annual Provider Training October 11, ... Member cannot have end-stage renal disease (ESRD) ... (NCP).

Akamai Advantage Annual Provider Training

October 11, 2017

Your Presenters Today

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Leslie Sylva Wendell Oumaye Valerie Sonoda Peter Wong

Agenda

Akamai Advantage Plans for 2018 Akamai Advantage Drug Plans for 2018 Medicare Plan Enrollment Periods Essential Advantage (HMO) Plan

Member Eligibility Referrals Prior Authorization

Dual Special Needs (DSNP) Plan Model of Care CMS Rules For Providers

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2018 Akamai Advantage Plans

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OAHU NEIGHBOR ISLANDS

• Complete (706-735) • Standard (708-725)

• Complete Plus (707-740) • Standard Plus (709-730)

• Essential Advantage (HMO:T-C-885)

Akamai Advantage Dual Care (D-SNP – 696-785) – All Islands All plans are comprehensive and include Part D prescription

drug coverage

Why will consumers choose Akamai Advantage?

Large statewide provider network Comprehensive benefits – all Original Medicare

benefits, drug coverage, and more Financial protection – Maximum Out-of-Pocket limit Predictable costs

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CY 2018 Akamai Advantage Plans - OAHU In-Network Complete Complete Plus Essential

Advantage Premium $57 $147 $20 MOOP $6,700 $3,400 $5,000 Combined MOOP $10,000 $5,100 Not a Benefit

PCP Visit $30 $10 $20 Specialist Visit $50 $30 $50 Fitness Silver&Fit Silver&Fit Silver&Fit

Inpatient Hospital

Days 1-6: $300/day Days 7-60: $44/day Days 61-90: $0/day No additional days.

Days 1-7: $280/day Days 8-90: $0/day $0 for additional

days

Days 1-6: $300/day Days 7-60: $44/day Days 61-90: $0/day No additional days.

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CY 2018 Akamai Advantage Plans - OAHU

In-Network Complete Complete Plus Essential Advantage

Annual Wellness Visit $0 $0 $0

Outpatient Services/Surgery

$150 deductible, then 20% 20% $150 deductible,

then 20%

Ambulance $250 $225 $250

Routine Eye Exams

$30 (1 per year)

$10 (1 per year)

$20 (1 per year)

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CY 2018 Akamai Advantage Plans - NI

In-Network Standard Standard Plus

Premium $92 $192

MOOP $6,700 $3,400

Combined MOOP $10,000 $5,100

PCP Visit $30 $10

Specialist Visit $50 $40

Inpatient Hospital Days 1-6: $300/day Days 7-60: $44/day Days 61-90: $0/day No additional days

Days 1-7: $300/day Days 8-90: $0/day

$0 for additional days

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CY 2018 Akamai Advantage Plans - NI

In-Network Standard Standard Plus

Annual Wellness Visit $0 $0

Outpatient Services/Surgery

$150 deductible, then 20% 20%

Ambulance $250 $225

Routine Eye Exams $30 (1 per year)

$10 (1 per year)

Fitness Silver&Fit Silver&Fit

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2018 Akamai Advantage Dual Care All Islands

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Co-pay/Deductible/Max Premium $0 MOOP $6,700 Medical Benefits (Medicare –covered)

$0

Part D No Deductible Cost-sharing depends on LIS Level

Fitness None Routine Vision/Eyewear (Non-Medicare required)

None

2018 Akamai Advantage Dual Care All Islands

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Benefit Dental (non-Medicare-covered)

$0/2 Exams/1 year $0/2 Cleanings/1 year

$0/1 Set Bitewing X-Rays/1 year $0/1 Full Mouth or Panoramic X-Rays/5 years

$0/2 Denture Adjustments/1 year $0/1 Denture Repair per Arch/1 year $0/1 Filling per Tooth Surface/1 year

$0/1 Root Canal per Tooth/1 year $0/1 Periodontal Scaling & Root Planing Procedure

per Quadrant/1 year

Annual Maximum Benefit Plan pays up to $1,500

Enhanced Dental Care Effective January 1, 2018 - Not a benefit

Part D Drug Benefits – OAHU Mail Order

90-day supply from HMSA’s network mail-order pharmacy

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Tier Complete Complete Plus Essential Advantage

Tier 1 - Preferred Generic $4.50 $4.00 $4.50

Tier 2 –Generic $12.00

$11.00

$12.00

Tier 3 – Preferred Brand $94.00 $90.00

$94.00

Tier 4 – Non-Preferred Drug $200.00 $190.00 $200.00

Tier 5 – Specialty Drugs 25% 33% 25%

• Mail order is fast and convenient • Members can save money on maintenance medications

New prescriptions sent from the doctor’s office • Patient will receive a call to confirm consent to ship the medication, verify • It is important that the patient responds to these calls to get the

medication shipped

Call 1 (855) 479-3659

Part D Drug Benefits – NI Mail Order

90-day supply from HMSA’s network mail-order pharmacy

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• Mail order is fast and convenient • Members can save money on maintenance medications

New prescriptions sent from the doctor’s office • Patient will receive a call to confirm consent to ship the medication, verify • It is important that the patient responds to these calls to get the

medication shipped

Tier Standard Standard Plus

Tier 1 – Preferred Generic $5 $4 Tier 2 –Generic $20 $11 Tier 3 – Preferred Brand $94 $90 Tier 4 – Non-Preferred Drug $200 $190 Tier 5 – Specialty Drugs 25% 33%

Call 1 (855) 479 - 3659

2018 Part D Copayments/Cost Shares Retail

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Essential Advantage

Complete Complete Plus

Standard Standard Plus

Tier 1 Preferred Generic

$4.50 $4.50 $4.00 $5.00 $4.00

Tier 2 Generic $12.00 $12.00 $11.00 $20.00 $11.00

Tier 3 Preferred Brand

$47.00 $47.00 $45.00 $47.00 $45.00

Tier 4 Non-Preferred Drugs

$100.00 $100.00 $95.00 $100.00 $95.00

Tier 5 Specialty 25% 25% 33% 25% 33%

Internal Use Only

2018 Non-Formulary Drugs

DRUG ALTERNATIVES EFFIENT* BRILINTA, clopidogrel

EMEND caps use generic

INVEGA use generic

LANTUS BASAGLAR

NASONEX fluticasone, flunisolide, OTC

NEORAL use generic

PULMICORT neb soln use generic Generic VYTORIN use simvastatin + ezetimibe

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2018 Drug Changes – Tier 3 to Tier 4 DRUG ALTERNATIVES

DEXILANT esomeprazole, omeprazole, pantoprazole, OTC

PRADAXA ELIQUIS, XARELTO

RELPAX* sumatriptan, rizatriptan, naratriptan, zolmitriptan

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2018 Positive Tier Changes DRUG TIER CHANGE

Cetirizine syrup Tier 2 → Tier 1

Escitalopram Tier 2 → Tier 1

Isosorbide mononitrate Tier 2 → Tier 1

ELIQUIS Tier 4 → Tier 3

TRULICITY Tier 4 → Tier 3

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Medicare Annual Enrollment Period

October 15, 2017 – December 7, 2017

Enrollment effective January 1, 2018

ANY Medicare beneficiary from any carrier can switch:

From MAPD to MAPD

From MAPD to PDP with Original Medicare

From MA-only to MAPD

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Essential Advantage (HMO) New!

Annual Akamai Advantage Provider Training October 11, 2017

Introducing Essential Advantage (HMO)

A new, HMO Medicare Advantage plan developed in partnership by HMSA and Hawaii Pacific Health. Offers an exclusive provider network that coordinates all care for Essential Advantage HMO members. Low monthly premium of $20.00 A plan that promotes good health and overall well-being for our Medicare members on Oahu. Coming soon! The plan becomes effective January 1, 2018. 11/27/2017 20

Essential Advantage (HMO) Plan - Eligibility

Same eligibility requirements as AA Complete and Complete Plus (Oahu) plans Member must have Medicare Part A & B Member cannot have end-stage renal disease (ESRD)

with some exceptions Member must reside in the City and County of

Honolulu Member must continue to pay their Part B premium in

addition to the Essential Advantage premium

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Essential Advantage (HMO) Plan Membership Card

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• Plan Name appears at the top right corner of the front of the card • Coverage Code: Medical T-C

HHIN – How to verify Essential Advantage Member Eligibility?

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Prior Authorizations

Essential Advantage has the same prior authorizations required for some services as the Akamai Advantage PPO plans. Reminder: A prior authorization is a process through which the

provider is required to obtain advance approval from HMSA to cover a service. Reminder: Submit a pre-service determination for services to

be provided by Non-Contracting Providers (NCP). Example: Non-Contracting Laboratory Referrals

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Referrals Referrals are required for most in-network services from a

Primary Care Provider (PCP). Hawaii Pacific Health will monitor these referrals with their systems. Referrals are required for most out-of-network services except

for urgent and emergency services. HMSA will monitor these referrals and claims will only process with an approved referral in HMSA’s systems. A referred provider can order lab services without another

referral. Other services must be referred by PCP. Reminder: A referral is a process through which the member’s

primary care provider (PCP) or other provider requires the member to obtain a service from another provider for the service to be covered.

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Services that do not require a Referral

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In-Network Emergency services Urgently needed services Ambulance DME Prosthetics Diabetic supplies and services Part B drugs Medicare-covered zero dollar preventive

services Medicare-covered diabetes self

management training Medicare diabetes prevention program Kidney dialysis services that you get at a

Medicare-certified dialysis facility

Out-of-Network Ambulance Emergency services Urgently needed services from providers

when network providers are temporarily unavailable or inaccessible

Kidney dialysis services that you get at a Medicare-certified dialysis facility when temporarily outside the plan’s service area

Essential Advantage (HMO) Plan Claims Filing/Billing Providers should bill HMSA Essential Advantage (HMO) Plan

members for coinsurance, copayments or deductibles for medical services File claims to HMSA Essential Advantage (HMO) Plan

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HMSA - CMS 1500 Claims (Professional) P.O. Box 44500 Honolulu, HI 96804-4500 HMSA - UB-04 Claims (Facility) P.O. Box 32700 Honolulu, HI 96803-2700

Akamai Advantage Dual Care (PPO SNP)

Annual Akamai Advantage Provider Training October 11, 2017

Akamai Advantage Dual Care Membership Card

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• Plan Name appears at the top right corner of the front of the card • No member premium (after Low Income Subsidy)

Akamai Advantage Dual Care Plan Claims Filing/Billing Providers should not bill HMSA Akamai Advantage Dual Care

Plan members for coinsurance, copayments or deductibles for medical services File claims to HMSA Akamai Advantage Dual Care Plan 1st ,

then bill HMSA QUEST Integration 2nd File claims to HMSA Akamai Advantage Dual Care Plan 1st, then

bill other QUEST Integration Plan 2nd Benefits covered by QUEST Integration that are not covered by

Original Medicare should only be billed to QUEST Integration

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HMSA - CMS 1500 Claims (Professional) P.O. Box 44500 Honolulu, HI 96804-4500 HMSA - UB-04 Claims (Facility) P.O. Box 32700 Honolulu, HI 96803-2700

Qualified Medicare Beneficiary (QMB) Balance Billing Law Effective 2016

QMB program is a Medicare Savings Program that exempts Medicare beneficiaries from Medicare cost-sharing liability

Ensure billing software and staff exempt QMB or QMB Plus patients from Medicare cost-share billing

Medicare Advantage providers are prohibited from discriminating against patients based on QMB status.

Identify QMB or QMB Plus individuals at: https://hiweb.statemedicaid.us/EligAndEnrollment/MemberVerificationHI.aspx

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Care Manager Support

Annual Akamai Advantage Provider Training October 11, 2017

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MEMBER

Health Risk Assessment

(HRA)

Individualized Care Plan

(ICP)

Interdisciplinary Care Team

(ICT)

Model of Care

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Akamai Advantage Dual Care member is at the center

Goals of Care Management Support Improve access to essential services such as medical &

behavioral health care and social services Improve access to:

Affordable care Preventive Health Services

Improve coordination of care through assignment of an HMSA Care Manager Improve seamless transitions of care across health care

settings, providers, and health services Ensure appropriate use of services Improve health outcomes

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Most Vulnerable

Somewhat Vulnerable

Least Vulnerable

Model of Care Support for your vulnerable patients

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Determined by HRAs and clinical

judgment

Examples of criteria for “most vulnerable” • 5 or more chronic comorbid

conditions (diabetes, congestive heart failure, hypertension, etc.)

• Terminal condition • 5 or more ER visits within

the past 6 months • Severe dementia

Health Risk Assessment and Care Plan

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Health Risk Assessment (HRA)*

1. Conducted by HMSA Care Manager or PCP

2. Frequency: a. Initial within 90 days b. Reassess at least annually c. Health events

3. Used to Risk Stratify 4. Methodology

a. In-person b. Telephonic c. Mail

5. Used to formulate ICP

Individualized Care Plan (ICP)*

1. Based on HRA results 2. Aerial algorithms and

clinical judgment 3. Developed with input from

ICT 4. Modified as needed 5. Communicated to

member, providers and ICT 6. Shared during care

transitions

* Must be evidence-based

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Interdisciplinary Care Team (ICT)

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Member

HMSA Medical Director

PCP

HMSA Service

Coordinator

“Core” team members

Examples of other team members

Family Members/Caregiver

Specialist

Dietician

Pharmacist

Gerontologist

Behavioral Health

The composition of the team is individualized according to the member’s needs and preference.

Provider Attestation for Model of Care Training

_____ I attest that my organization and its contracted providers have received the HMSA Akamai Dual Care Plan Model of Care training. CMS Regulation 42 CFR § 422.102 (f)(2)(ii).

_____ I attest that my organization has established a mechanism for compliance with the provider training requirement.

Your organization must establish a process for compliance, including but not limited to: dissemination to providers the HMSA Akamai Dual Care Plan MOC training, maintenance of all documentation including rosters, and a process for annual re-training

_____ I attest that within sixty (60) days receipt of this notice, my organization/practice will provide HMSA Akamai Dual Care Plan a roster of all providers/staff who received the training and a signed Attestation for HMSA Akamai Dual Care Plan Model of Care Training.

Providers that render services for members in the Dual-Special Needs Program (D-SNP) program are required to take the HMSA Akamai Dual Care Plan MOC training.

Signature:_______________ Printed Name:_______________ Date:___________________ Provider Name:______________

Email to: [email protected] 38

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• Notify HMSA of changes in your practice, such as: • Practice Location Address • Appointment Phone Number • Patient Acceptance Status • Email • Hours of operation

• Be sure to notify HMSA 30-days in advance of any practice changes by:

1. Calling (808) 952-7847 on Oahu or 1 (800) 603-4672 ext. 7847 toll free on the Neighbor Islands

2. Mail to: HMSA Provider Data Administration P.O. Box 860 Honolulu, HI 96808-0860

3. Email: [email protected] • Timely notification to HMSA will ensure:

• Payments and correspondence are sent to the correct address

• We market your practice using the correct address in our provider directory

HMSA Provider Reminders

HMSA Provider Resources

HMSA Provider E-Library: https://www.hmsa.com/portal/provider/ HMSA Care Managers:

HMSA Provider Services

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Phone Fax

948-6997 944-5604

Toll Free: 1-844-223-9856 Toll Free: 1-855-856-4176

Phone Fax

948-6330 948-6887

Toll Free: 1-800-790-4672 Toll Free: 1-800-540-1668

APPENDIX

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Acronyms

AEP Annual Election Period

CMS Centers for Medicare and Medicaid Services

C-SNP Chronic Condition Special Needs Plan

D-SNP Dual eligible Special Needs Plan

EOC Evidence of Coverage

ESRD End Stage Renal Disease

HRA Health Risk Assessment

ICP Individualized Care Plan

ICT Interdisciplinary Care Team

I-SNP Institutional Special Needs Plan

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LIS Low Income Subsidy

MAPD Medicare Advantage Part D

MOC Model of Care

MOOP Maximum Out of Pocket

NCP Non-Contracted Provider

NCQA National Committee for Quality Assurance

OOPM Out of pocket maximum

QI QUEST Integration

QMB Qualified Medicare Beneficiary

SB Summary of Benefits

SNP Special Needs Plan

CMS Rules Provider Practices Need to Know

Annual Akamai Advantage Provider Training October 11, 2017

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CMS Rules Provider Practices Need To Know

You are required to: Complete Medicare Fraud, Waste & Abuse Training annually at https://hmsa.com/portal/provider/zav_IN.Medicare-INDEX.htm

MMG Ch3., Section 70.5.1

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CMS Rules Provider Practices Need To Know

You may (but you aren’t required to): Provide the names of plan sponsors that you contract with or

participate. Help patients apply for the low-income subsidy. Make plan marketing materials available in common areas. If

you display marketing materials for some plans, you have to accept requests from all plans you participate with.

MMG Ch3., Section 70.5.1

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CMS Rules Provider Practices Need To Know

You may (but you aren’t required to): Refer patients to other sources of information such as the

State Health Insurance Assistance Program (SHIP), State Medicaid office, and Social Security office, or CMS’ website at http://www.medicare.gov/ or 1-800-MEDICARE

Share information with patients from CMS’ website, including

the “Medicare and You” Handbook or “Medicare Options Compare”, or other documents that were written by or previously approved by CMS

MMG Ch3., Section 70.5.1

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CMS Rules Provider Practices Need To Know

You may NOT: Offer anything of value to induce plan enrollees to select you

as their provider. Offer inducements to persuade beneficiaries to enroll in a

particular plan or organization. Conduct health screenings when distributing information to

patients.

MMG Ch3., Section 70.5.1

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CMS Rules Provider Practices Need To Know

You may NOT: Steer beneficiaries in any way to a limited number of plans. Mail marketing materials on behalf of plans. Offer sales/appointment forms. Accept enrollment applications. Make phone calls or direct, urge or attempt to persuade beneficiaries to enroll in a specific plan based on financial or any other interests of the provider MMG Ch3., Section 70.5.1

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Thank you!

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