Annual Provider Training

October 10, 2018

Agenda

• Medicare Plan Enrollment Periods

• HMSA Medicare Advantage Plans for 2019

• HMSA Essential Advantage (HMO) Plan Highlights

Prior Authorizations & Referrals

• HMSA Akamai Advantage Dual Care (PPO SNP)

Model of Care

• HMSA Medicare Advantage Part D Updates for 2019

• Plan-Directed Care

• CMS Rules Provider Practices Need to Know

2

Why Will Your Patients Choose

HMSA?

• Choice of plans

• Access to care

• Convenience

• Nationally recognized 4-star CMS rating

• Extra benefits

HMSA Medicare Advantage Plans

Benefits Financial protection

Silver&Fit membership at no additional cost

Coverage while traveling

Vision exam and eyewear

Preventive care

No-cost annual wellness visits

Prescription drug coverage

What's New?

• CMS enrollment periods

• “Re-branding” of HMSA Medicare Advantage

..products

• Focus on Essential Advantage HMO

• Adjusted plan premiums

• Few benefit changes

Annual Election Period (AEP)

Enroll in an HMSA Medicare Advantage plan

Change your Medicare Advantage plan

Keep your plan:

No changes? No sweat! Auto renewal

Plan is effective 1/1/19

Medicare Annual Election Period

October 15 – December 7

New CMS Open Enrollment (OEP)

• MA-OEP, effective 1/1/19

• From January 1st through March 31st

• Annual; replaces MADP (Medicare Advantage

..Disenrollment Period)

• One time only during this window, plans are

..not permitted to solicit beneficiary changes

• Plan effective the 1st of the month

..following the election date

LIS/Dual Eligible SEP

(Special Enrollment Period)

• New in 2019

• For those with Medicare A+B and Medicaid; also

..LIS with or without Medicaid

• Only once per quarter, in the 1st 9 months of the

..calendar year

• Plan effective the 1st of the month following

..election date

HMSA Medicare Advantage Plans

O’ahu

* = Dual Care (PPO SNP) is statewide All plans include Part D Prescription Drug coverage

O’ahu Plans Coverage Codes

Essential Advantage (HMO)

$20 T-C - 885

HMSA Akamai Advantage Complete (PPO)

$56 706 – 735

HMSA Akamai Advantage Complete Plus (PPO)

$146 707 – 740

HMSA Akamai Advantage Dual Care (PPO SNP)*

$0 696 - 785

HMSA Medicare Advantage Plans

Neighbor Islands

* = Dual Care (PPO SNP) is statewide All plans include Part D Prescription Drug coverage

Neighbor Island Plans Coverage Codes

HMSA Akamai Advantage Standard (PPO)

$91 708 - 725

HMSA Akamai Advantage Standard Plus (PPO)

$208 709 - 730

HMSA Akamai Advantage Dual Care (PPO SNP)*

$0 696 - 785

Plan Benefit Changes

PPO and HMO

• Premium Changes

• Supportive Care $0 added to EOC

• Skilled Nursing Facility (SNF) after 20 days

• Emergency Room from $80 to $90

• Essential Advantage PCP and eye exam

..copays lowered to $15

CY2019 Oahu Plan Benefits

In-Network Complete Complete

Plus

Essential

Advantage

Premium $56 $146 $20

MOOP $6,700 $3,400 $5,000

Combined

MOOP $10,000 $5,100 Not a Benefit

PCP Visit $30 $10 $15

Specialist Visit $50 $30 $50

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

CY2019 Oahu Plan Benefits

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)

$15

(1 per year)

Vision Appliances $100 / 2 years $100 / 2 years $100 / 2 years

Fitness Silver&Fit Silver&Fit Silver&Fit

CY2019 Neighbor Island Plan Benefits

In-Network Standard Standard Plus

Premium $91 $208

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

CY2019 Neighbor Island Plan Benefits

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)

Vision Appliances $100 / 2 years $100 / 2 years

Fitness Silver&Fit Silver&Fit

O’ahu Plans:

How these plans differ

Essential Advantage (HMO) Complete

(PPO)

Complete Plus

(PPO)

One health center Larger provider network

O’ahu only benefit coverage Statewide benefit coverage

Coordinated care from a

primary care provider (PCP) Choose your own providers

Emergency and urgent care

while traveling Enhanced travel benefits

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HMSA Membership Card

Members will show this card when receiving

medical services and prescriptions.

HMSA Akamai Advantage (PPO)

Highlights

• Freedom to choose your doctors and facilities

..without physician referrals

• Large statewide network of providers

• Enhanced travel benefits

• Silver&Fit: Gym membership or at-home

..fitness kits (up to 2 per year) at no extra cost

CY2019 Dual Care (PPO-SNP)

• New SEP (Special Enrollment Period)

• Still requires QMB/QMB+ eligibility (Qualified

..Medicare Beneficiary)

• Supplemental Dental maximum raised to

..$2,500

• Members with certain chronic conditions

..have enhanced dental benefits (e.g.,

…stroke, oral cancer, diabetes)

Essential Advantage (HMO)

Highlights • $20 monthly premium

• Coordinated care

• Convenience

• Available to Oahu Residents

• Emergency and urgent care travel benefits,

..mainland and worldwide

• Silver&Fit: Gym membership or at-home

..fitness kits, up to 2 per year at no extra cost

Essential Advantage (HMO)

Network

• Hawaii Health Partners health center on O’ahu

• Includes Hawaii Pacific Health (HPH) facilities

• Includes additional specialists to meet CMS

..access requirements

• Referred to as “the Essential Advantage

..HMO Network”

HPH “Find a Physician” Line

(808) 643-4302

• Exclusively for Essential Advantage members

• Find a PCP in the Essential Advantage network

• Change to a different PCP in the Essential

Advantage network

• Provide clear explanation of facilities

• Warm transfer to a PCP office

Essential Advantage (HMO) Network

Find a doctor on hmsa.com

Step 1: Click on Find a Doctor

Step 2: Click Select your Plans, ..check the box for Essential …Advantage

Step 3: Click Save Changes

Start your search now by doctor name, location, specialty or ailment

Essential Advantage

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-Contracted Laboratory Referrals

24

Essential Advantage Referrals

• Required for most in-network services from a Primary Care Provider

..(PCP). Hawaii 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

26

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

HHIN – Verifying Member Eligibility

27

HMSA AKAMAI ADVANTAGE

DUAL CARE (PPO SNP)

Akamai Advantage Dual Care

Membership Card

29

• 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

30

HMSA - CMS 1500 Claims (Professional) HMSA - UB-04 Claims (Facility)

P.O. Box 44500 P.O. Box 32700

Honolulu, HI 96804-4500 Honolulu, HI 96803-2700

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:

31

https://hiweb.statemedicaid.us/EligAndEnrollment/MemberVerificationHI.aspx

CARE MANAGER SUPPORT

32

MEMBER

Health Risk Assessment

(HRA)

Individualized Care Plan

(ICP)

Interdisciplinary Care Team

(ICT)

Model of Care

33

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

34

Most

Vulnerable

Somewhat Vulnerable

Least Vulnerable

Model of Care Support for your vulnerable patients

35

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

36

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)

37

Member

HMSA Medical Director

PCP

HMSA Service

Coordinator

“Core” team

members:

Examples of other

team members:

Family

Members/Caregiver

Specialist

Dietitian

Pharmacist

Gerontologist

Behavioral Health

The composition of the team is individualized according to the

….member’s needs and preference.

38

Fax to: (808)948-6887 or Email to: AkamaiD-SNPAttestation@hmsa.com

MEDICARE ADVANTAGE PART D

PRESCRIPTION DRUG UPDATES

FOR 2019

39

2019 Part D Retail Cost Share Essential

Advantage

(O’ahu)

Complete

(O’ahu)

Complete Plus

(O’ahu)

Standard

(Neighbor

Islands)

Standard Plus

(Neighbor

Islands)

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 $100.00 $100.00 $95.00 $100.00 $95.00

Tier 5

Specialty 25% 25% 33% 25% 33%

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MA Plans – O’ahu 90-day supply from HMSA’s network mail-order pharmacy

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 $200.00 $190.00 $200.00

Tier 5 - Specialty 25% 33% 25%

• Mail order is fast and convenient. Call 1(855) 479-3659 • 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

41

MA Plans – Neighbor Islands 90-day supply from HMSA’s network mail-order pharmacy

Standard Standard Plus

Tier 1 - Preferred Generic $5.00 $4.00

Tier 2 – Generic $20.00 $11.00

Tier 3 - Preferred Brand $94.00 $90.00

Tier 4 - Non-Preferred $200.00 $190.00

Tier 5 - Specialty 25% 33%

• Mail order is fast and convenient. Call 1(855) 479-3659 • 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

42

2019 Non-Formulary Drugs

REMOVED DRUG ALTERNATIVES

ESTRACE vag cr use generic

INVOKANA JARDIANCE, FARXIGA

INVOKAMET XR SYNJARDY XR, XIGDUO XR

NAMENDA XR use generic

RELPAX use generic

RENVELA use generic

43

2019 Formulary Additions

Drug Name Tier

calcipotriene ointment (generic Dovonex) Tier 2

empagliflozin (JARDIANCE) Tier 3

empagliflozin/metformin (SYNJARDY) Tier 3

ibandronate (generic BONIVA) Tier 2

lansoprazole (generic Prevacid) Tier 2

memantine ER (generic Namenda ER) Tier 2

telmisartan (generic MICARDIS) Tier 1

44

High Risk Medication PA Removals

• Amitriptyline

• Doxepin

• Estradiol tablet/patch

• Imipramine

• Thioridazine

45

Opioid 7 Day Limit for Acute Pain

• 2019 CMS requires limit on initial fill for acute pain to

..reduce potential for chronic opioid use or misuse

• Exemptions for cancer pain, palliative care, hospice

..or long term care

• Does not apply if previous opioid claim within 90

..days

46

New DSNP Formulary –

Additional Drugs Therapeutic Class Drugs

Antidiabetics glyburide, glyburide/metformin

Antilipemics simvastatin/exemitibe (generic Vytorin)

ARB eprosartan (generic Teveten)

candesartan (generic Atacand)

Bisphosphonates risedronate (generic Actonel)

Fluoroquinolone moxifloxacin (generic Avelox)

Musculoskeletal carisoprodol (generic Soma)

methocarbamol (generic Robaxin)

PPI rabeprazole (generic Aciphex)

47

HMSA Akamai Advantage PPO Plans – Plan-Directed Care

The Centers for Medicare and Medicaid Services (CMS) has defined “plan-

directed care” as care the member believes they were instructed to obtain or

..authorized to receive by a health plan representative, including plan

…contracted physicians. CMS instructs that the MA organizations (MAO) are

…..responsible to ensure that contracting physicians and providers know

……whether specific items and services are covered in the MA plan. If the

contracting provider furnishes a service or refers the member to another

provider, and member believes is a covered service, member cannot be

held financially liable for more than the applicable cost-sharing for that

service. Additional information on this guideline is found in the

Medicare Managed Care Manual Chapter 4, section 160 on

Beneficiary Protections Related to Plan-Directed Care.

48

Plan-Directed Care (cont.) As an HMSA Akamai Advantage PPO provider, you’re responsible to ensure

that Medicare will cover services that you render, supply, or order and to

provide referrals to HMSA network providers whenever possible. Starting

January 1, 2019, you must do the following before referring a member to an

out-of-network provider:

- Submit an authorization to HMSA Medical Management for HMSA

..Akamai Advantage PPO plans. Refer to HMSA Provider

…Resource Center for more information on precertification process.

- Ensure that the providers who are being referred to are Medicare

enrolled providers and understand that they’re accepting the

patient under plan-directed care and that they must furnish,

supply, and order covered services. Once the referral is

approved, the services rendered by the non-contracting

provider will be subjected to the lesser of in-network and

out-of-network cost-sharing.

49

Plan-Directed Care (cont.)

The member will not be held financially liable for more than the appropriate

cost-sharing for that service received at the direction of his or her primary

care provider (PCP) or network specialist if prior authorization or

organizational determination guidelines aren’t followed.

The member will be held financially responsible for services only when

one of the following happens:

– Services aren’t covered by Medicare and/or are a clear

exclusion of the member’s Evidence of Coverage (EOC).

– Member is notified that service isn’t covered during the pre-

service organization determination and he/she still elected to

receive the service.

50

CMS RULES PROVIDER

PRACTICES NEED TO KNOW

51

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

52

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 plan sponsors that you contract with or

participate with

• Answer questions or discuss the merits of a Plan or Plans,

including cost sharing and benefits information. These

discussions may occur in areas where care is delivered.

MCMG Ch3., Section 60.1

53

CMS Rules Provider Practices Need To Know

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, their 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

• Provide information and assistance in applying for the LIS

54

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

• Offer inducements to persuade their patients to enroll

in a particular Plan or organization

55

CMS Rules Provider Practices Need To Know cont.

You may NOT:

• 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

• Accept compensation from the Plan for any marketing or

enrollment activities

56

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

O’ahu:

(808) 952-7847

Neighbor Islands Toll Free:

1 (800) 603-4672 ext. 7847

Email us: provider_data@hmsa.com

57

HMSA Provider Resources

• HMSA Provider E-Library:

https://www.hmsa.com/portal/provider/

• HMSA Care Managers

• HMSA Provider Services

58

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

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

59

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

Mahalo!