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Maine Community Health Options 2015
AAHAM MeetingNovember, 14 2014
Warning: Content may leave you feeling like this!
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Nonprofit CO-OP
Lewiston, Maine & Concord, New
Hampshire
Member-Led
State-wide Broad Provider Network
Wrap Around National Network
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Your Provider Service TeamBill Schulz
Director, Provider & Network Operations
Debra McKinleyManager,
Credentialing
Matt Sanfacon
Credentialing
Coordinator
Karen GetchellManager, Provider
Contracting
Laura PrayContractin
g Specialist
Alyssa Rose, JD/MSW
Manager, Provider Relations
John WilsonPR
RepresentativeJessica Moore
PR Representative
Jennifer ByattNH PR
Representative
Lisa DionnePR
Representative
Stephanie Gordon
PR Representative
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MCHO PartnersValence Health –
TPA/Medical UM &Claims
Health Dialogue – Nurse Line and Health Coaching
Navitus – Pharmacy Manager
Behavioral Health Care
Plan (BHCP) – Behavioral
Health
Your Wellness Counts at MCHO
MCHO Outreach and Education6
Make informed decisions
with guidance
from skilled
coaches and get useful
information from
our online portal.
24/7 Access to Health Coaches
Healthy Options Online Health and Wellness Portal
Registered Nurses, Dieticians, Respiratory Therapists
May call you to talk about your condition
Provide information Help you make
important medical decisions
Over 6,000 health topics
Use decision support tools and videos
Complete your wellbeing assessment
Join challenges to earn points and get rewards.
Create personal goals and track progress
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To get an estimation of: Advance Premium Tax Credit Premium Cost
To find out if your doctor is In-Network
MCHO 2015 Plan Details
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Source: Huffingtonpost.com
Metal Level Plan DesignCategories are defined by the average share of total health spending on essential benefits paid for by the plan:
Gold: 80% of costs paid by insurance companyModerate premiums with low out of pocket expenses
Silver: 70% of costs paid by insurance companyModerate premiums with medium out of pocket expenses
Bronze: 60% of costs paid by insurance companyLow premiums with higher out of pocket expenses
NOTE: There are still catastrophic plans available
Silver
Plans
Bronze
Plan
GoldPlan
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• Plus plans include an Embedded Pediatric Dental Benefit
• *Please note that the above mentioned plans are pending approval by the Center for Medicare and Medicaid and may be subject to change.
Federal Poverty Guidelines for 2015 Plans
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*Please note that the above mentioned plans are pending approval by the Center for Medicare and Medicaid and may be subject to change.
Chronic Illness Support Program
Our Chronic Illness Support Program offers additional help for members with certain medical conditions that are ongoing and can be managed for better health. Benefits include reduced out-of-pocket costs (co-pays, deductible, and coinsurance) for:
disease management services; office visits;prescription medications; Certain lab services, and medical supplies – when performed by an MCHO in-network provider.
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Coronary Artery
Disease
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Prescription Drug Benefits• All specific medications used to treat Coronary
Artery Disease that are on our formulary and are approved by the FDA are available at $0 cost-sharing for generics (Tier 1)
• 50% reduction in cost-sharing for preferred brands (Tier 2).
• Deductible is waived for Tier 1 and Tier 2 medications.
• Non-preferred brand (Tier 3) and Specialty drugs (Tier 4) are subject to the co-pays and deductibles specific to your Plan.
Medical Care Benefits: The services listed below are covered with no Out-of-Pocket costs when performed by a Plan
Provider.
• PCP office visits for routine follow up for treatment of Coronary Artery Disease
• Cardiology visits for routine follow up for treatment of Coronary Artery Disease
• Electrocardiogram (ECG)• Cardiac rehabilitation (Deductible is waived and the Coinsurance is
reduced by half)• Laboratory services linked to a hyperlipidemia primary diagnosis code
Tobacco Cessation
Maine Community Health Options will cover:
FDA-approved tobacco cessation medications (including both prescription and over-the-counter medications) with no out-of-pocket costs when prescribed by a health care provider
Medications covered at no Out-Of-Pocket cost when prescribed by a Plan ProviderOver-the-counter and prescription medications such as:
Generic Nicotine Replacement Therapy (NRT): Gum, Patch, Lozenge
Chantix (up to two 90-day treatment regimens)
Tobacco cessation education and counseling
NOTE: MCHO does not use the new “tobacco rating band” or charge higher premiums for smokers
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Integrating Behavioral Health and Medical Health
Maine Community Health Options:
Provides enhanced access for behavioral health (BH) & substance abuse (SA) treatment at the same co-pay as primary care services
Waives costs for the first 3 outpatient behavioral health visits *not available on Community Safe Harbor and Community Options HSA plans
Allows BH/SA visits on the same day as medical visits, and facilitates immediate referrals without administrative roadblocks
Includes behavioral health and lifestyle modification support
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Termination Procedures (after receipt of binding payment)
Members receiving a tax creditMembers who receive a tax credit and have paid the first month’s
premium, but who fail to pay subsequent premiums will have a 90 day grace period to submit payment in full for outstanding premium due.
MCHO will pay appropriate claims for the first 30 days of the grace period. MCHO may hold claims during the remainder of the grace period or until
payment is received in full.If the outstanding balance is not paid in full by the end of the grace period,
MCHO will terminate coverage and the member will be responsible for paying any services received during the final 60 days of the grace period.
Members NOT receiving a tax creditIf a member does not make a premium payment in full they will have a 30
day grace period to pay the outstanding premium owed. Coverage does not lapse.
If the premium is not paid in full after the end of the grace period, MCHO may terminate their coverage. MCHO will not allow reinstatement after the grace period ends.
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MCHO Provider Operations Concerns
How to Access ResourcesVisit https://
www.maineoptions.org/Health-Care-Professionals/Online-Resources
Utilization & Care Management Prior Approval form on the MCHO websiteProviders can use the online Care Manager
System or fax in PA form for routine requestsUM phone line available 24/7 for urgent and
after hours requests2 Business Day turn-around time for Routine
Initial Requests48 hour turn-around time for Urgent RequestsAll Medical Necessity reviews go through our
Lewiston-based Chief Medical Officer, Dr. John Yindra
Claims CycleCritical importance of checking Member
eligibilityGrace PeriodClaims can be submitted by paper or
electronicallyMCHO moving to weekly check runsEFT payment available
Noteworthy for 2015
Expansion into NHUtilization management coming in house
New provider portalTransition to new behavioral health partner
Always looking to improve so please send us your feedback!
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Thank you for your time and interest in Maine Community Health Options.
Alyssa RoseMaine Community Health Options207-402-3347 (Provider Relations)
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