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HMSA Medicare Advantage Plans for 2020
Annual Provider TrainingOctober 9, 2019
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Agenda
• Medicare Enrollment Periods
• HMSA Medicare Advantage Plans for 2020
• HMSA Essential Advantage
• HMSA Akamai Advantage Dual Care (PPO_SNP)
• Part D Updates for 2020
• CMS Rules & Provider Practices
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MA Enrollment PeriodsAnnual Enrollment
Period (AEP)Open Enrollment
Period (OEP)Special Enrollment
Periods (SEP)
October 15through
December 7
Plan effective1/1/2020
Jan. 1through
March 31
Plan effective 1st of following month
When losing healthplan coverage
LIS/Dual
Plan effective 1st offollowing month
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Oahu HMSA Medicare Advantage Plans
* Dual Care (PPO SNP) is statewide
Oahu PlansMonthly
Premium
Coverage
Codes
HMSA Essential Advantage (HMO) $0T-C
885
HMSA Akamai Advantage Complete
(PPO)$20 706 – 735
HMSA Akamai Advantage Complete
Plus (PPO)$145 707 – 740
HMSA Akamai Advantage Dual Care
(PPO SNP)*$0 696 - 785
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Neighbor Island Akamai Advantage Plans
* Dual Care (PPO SNP) is statewide
Neighbor Island PlansMonthly
Premium
Coverage
Codes
HMSA Akamai Advantage Standard
(PPO)$63 708 - 725
HMSA Akamai Advantage Standard
Plus (PPO)$190 709 - 730
HMSA Akamai Advantage Dual Care
(PPO SNP)*$0 696 - 785
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HMSA Medicare Advantage offers…
Prescriptiondrug coverage
Financial protection
Silver&Fit fitness centeror home fitness*
Vision exam and eyewear*
Coverage when traveling
Preventive care
Annual wellness visit at no cost
* Not a benefit of HMSA Akamai Advantage Dual Care (PPO SNP)
®
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• HMSA Online Care at $0
• HMSA365 discounts
• Dental discounts
• Health and well-being workshops
• Health coaching
• Island Scene magazine
• My Account on hmsa.com
Other HMSA Member Benefits
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HMSA Membership Card
Verify and photocopy member ID cards at each encounter formedical services and prescriptions
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Oahu Plan Benefit Highlights
In-NetworkHMSA Essential
Advantage
Akamai
Advantage
Complete
Akamai
Advantage
Complete Plus
Premium $0 $20 $145
MOOP $5,000 $6,700 $3,400
Combined MOOP Not a benefit $10,000 $5,100
PCP Visit $15 $30 $10
Specialist Visit $50 $50 $30
Inpatient Hospital
Days 1-6: $300/day
Days 7-60: $44/day
Days 61-90: $0/day
No additional days
Days 1-6: $300/day
Days 7-60: 44/day
Days 61-90: $0/day
No additional days
Days 1-7: $280/days
$0 for additional days
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Oahu Plan Benefit Highlights
In-NetworkHMSA Essential
Advantage
Akamai
Advantage
Complete
Akamai
Advantage
Complete Plus
Annual Wellness
Visit$0 $0 $0
Outpatient
Services/Surgery
$200 deductible,
then 20%
$200 deductible,
then 20%20%
Routine Eye Exams$15
(1 per year)
$30
(1 per year)
$10
(1 per year)
Vision Appliances $100 / 2 years $100 / 2 years $100 / 2 years
Silver&FitFitness Center program: $0 - $79
Home Fitness program: $0 for 2 kits/year10/9/2019 10
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Neighbor Island Plan Benefit Highlights
In-NetworkAkamai Advantage
Standard
Akamai Advantage
Standard Plus
Premium $63 $190
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
$0 for additional days
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Neighbor Island Plan Benefit Highlights
In-Network Standard Standard Plus
Annual Wellness Visit $0 $0
Outpatient
Services/Surgery
$150 deductible,
then 20%20%
Routine Eye Exams$30
(1 per year)
$10
(1 per year)
Vision Appliances $100 / 2 years $100 / 2 years
Silver&FitFitness Center program: $0 - $79
Home Fitness program: $0 for 2 kits/year
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Oahu HMO versus PPO plans
HMSA Essential Advantage
(HMO)
Complete
(PPO)
Complete Plus
(PPO)
$0 Premium $20 Premium $145 Premium
Essential Advantage
provider network
Larger PPO
provider network
PCP coordinates care and
provides referrals
Choose providers without
referrals
Emergency and urgent care
while traveling
Enhanced mainland travel
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• Referred to as the “HMSA Essential Advantage network”
• Most providers are with Hawai’i Health Partners, an affiliate of Hawai’i Pacific Health
• Additional specialists to meet CMS provider access requirements
• Increased our member education on their network
• HMSA Essential Advantage is only available on Oahu
HMSA Essential Advantage Network
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• (808) 643-4362
• Find a PCP in the HMSA Essential Advantage network
• Change to a different PCP
• Provide a clear explanation of facilities
• Offer “warm” transfer to a PCP office
Hawai’i Pacific Health “Find a Physician” Line
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Finding a Doctor
Step 1: Click Find a Doctor
Step 2: Check the box forplan name
Step 3: Search by doctorname, location,specialty, gender, language, etc.
Find your doctor on hmsa.com
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HMSA ESSENTIAL ADVANTAGE
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HMSA Essential Advantage
Prior Authorizations
• HMSA 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-Contracted Laboratory Referrals
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HMSA Essential Advantage Referrals
• Required for most in-network services from a Primary Care Provider (PCP). Hawai’i Health Partners will monitor these referrals with their systems.
• 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
• 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
• 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
In-Network Out-of-Network
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HHIN – Verifying Member Eligibility
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HMSA AKAMAI ADVANTAGE
DUAL CARE (PPO SNP)
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• Member must have Medicare and full Medicaid benefits
• Doubled plan membership since January 2019
• Continued year round marketing
• Claim coordination for HMSA QI members, other carriersremain separate submissions
Akamai Advantage Dual Care (PPO SNP)
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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)
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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, then HMSA will automatically cross over the claim to HMSA QUEST Integration
– Exceptions: claims denied for AI, claims paid at 100% member benefit, claims submitted by an FQHC
• 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) HMSA - UB-04 Claims (Facility)
P.O. Box 44500 P.O. Box 32700
Honolulu, HI 96804-4500 Honolulu, HI 96803-270010/9/2019
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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:
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https://hiweb.statemedicaid.us/EligAndEnrollment/MemberVerificationHI.aspx10/9/2019
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CARE MANAGER SUPPORT
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Model of Care
MEMBER
Health Risk Assessment
(HRA)
Individualized Care Plan
(ICP)
Interdisciplinary Care Team
(ICT)
Akamai Advantage Dual Care member is at the center
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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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Model of CareSupport for your vulnerable patients
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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
Health Risk Assessment and Care Plan
* Must be evidence-based
Individualized Care Plan
(ICP)*1. Based on HRA results
2. Aerial algorithms and clinical judgement
3. Developed with input from ICT
4. Modified as needed
5. Communicated to member, providers, and ICT
6. Shared during care transitions
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Interdisciplinary Care Team (ICT)The composition of the team is individualized according to the
member’s needs and preference.
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MEDICARE ADVANTAGE PART D
PRESCRIPTION DRUG UPDATES FOR 2020
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2020 Part D Cost Shares – Retail
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EssentialAdvantage
Complete Complete Plus
Standard Standard Plus
Tier 1Preferred Generic
$4.50 $4.50 $4.00 $5.00 $4.00
Tier 2Generic
$12.00 $12.00 $11.00 $20.00 $11.00
Tier 3Preferred Brand
$47.00 $47.00 $45.00 $47.00 $45.00
Tier 4Non-Preferred Drugs
$100.00 $100.00 $95.00 $100.00 $95.00
Tier 5Specialty
25% 25% 33% 25% 33%
30-day supply retail
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2020 Part D Cost Shares - Mail
TierEssential
AdvantageComplete
CompletePlus
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 – PreferredBrand
$94.00 $94.00 $90.00 $94.00 $90.00
Tier 4 – Non-Preferred Drug
$200.00 $200.00 $190.00 $200.00 $190.00
Tier 5 – Specialty Drugs
25% 25% 33% 25% 33%
90 day supply from HMSA’s network mail-order pharmacy
• Mail order is fast and convenient. Call 1 (855) 479 - 3659• Members can save money on maintenance medication
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2020 Non-formulary Drugs
REMOVED DRUG ALTERNATIVES
Febuxostat Allopurinol
LOTEMAX SUSP generic
Solifenacin Oxybutynin ER, Trospium, Toviaz, Myrbetriq
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2020 Drug Changes – Tier 3 to Tier 4
DRUG ALTERNATIVES
LINZESS Lactulose, AMITIZA
LYRICA generic
RESTASIS unit dose RESTASIS multidose
TRAVATAN Z Latanoprost, LUMIGAN, RHOPRESSA
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CMS RULES PROVIDER PRACTICES NEED TO KNOW
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CMS Rules Provider Practices Need To Know
You are required to: – Complete Medicare Fraud, Waste and Abuse
Training annually at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/CombMedCandDFWAdownload.pdf
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CMS Rules Provider Practices Need To Know
You may (but you aren’t required to):
• Distribute unaltered, printed materials created by CMS, such as reports from Medicare Plan Finder, the “Medicare & You” handbook, or “Medicare Options Compare” (from https://www.medicare.gov) including in areas where care is delivered;
• Provide the names of Plans/Part D sponsors with which they contract and/or participate;
• Answer questions or discuss the merits of a plan or plans, including cost sharing and benefit information (these discussions may occur in areas where care is delivered);
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You may (but you aren’t required to):
• Refer patients to other sources of information, such as State Health Insurance Assistance Program (SHIP) representatives, plan marketing representatives, State Medicaid Office, local Social Security Office, CMS’ website at https://www.medicare.gov, or 1-800-MEDICARE;
• Refer patients to Plan marketing materials available in common areas; and
• Provide information and assistance in applying for the LIS.
CMS Rules Provider Practices Need To Know
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CMS Rules Provider Practices Need To Know
You may NOT:• Accept/collect scope of appointment forms;
• Accept Medicare enrollment applications;
• Make phone calls or direct, urge, or attempt to persuade their patients to enroll in a specific plan based on financial or any other interests of the provider;
• Mail marketing materials on behalf of Plans/Part D sponsors;
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CMS Rules Provider Practices Need To Know
You may NOT:• Offer inducements to persuade their patients to enroll in a particular plan
or organization;
• Conduct health screenings as a marketing activity;
• Distribute marketing materials/applications in areas where care is being delivered;
• Offer anything of value to induce enrollees to select them as their provider; or
• Accept compensation from the plan for any marketing or enrollment activities.
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HMSA Provider Reminders
Notify HMSA of changes in your practice, such as:
• Be sure to notify HMSA 30 days in advance of any changes:
• Timely notification ensures:
✓ Payments and correspondence are sent to the correct address
✓ We market your practice using the correct address in our provider directory
✓ Practice Location Address ✓ Hours of Operation ✓ Email Address
✓ Appointment Phone Number ✓ Patient Acceptance Status
Call us:
OR
Oahu: (808) 952-7847
Neighbor Islands Toll Free:1 (800) 603-4672 ext. 7847
Email us: [email protected]
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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
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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
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
OEP Open Enrollment Period
OOPM Out of Pocket Maximum
QI QUEST Integration
QMB Qualified Medicare Beneficiary
SB Summary of Benefits
SNP Special Needs Plan
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MAHALO!HMSA
Medicare Advantage
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