Johns Hopkins Advantage MD 2020 HMO and PPO Plans · MD Pharmacy network. Impacted members were mailed a letter starting in October about the pharmacy network change effective January

1/11/2019

Presented by: Johns Hopkins HealthCare Provider Relations Department

December 2019

Johns Hopkins Advantage MD2020 HMO and PPO Plans

HMO,PPO, PPO Plus, PPO Premier & Group

Advantage MD Product Overview

1/11/2019

Agenda• Our Mission• Advantage MD Overview• Advantage MD - Service Area, Medical Benefit Overview• Product Differentiation

-Advantage MD Product Overview – PPO, PPO Plus, PPO Premier, PPO Group-Advantage MD Product Overview – HMO

• Advantage MD Dental and Vision Coverage• Telemedicine• Requirements, Processes and Important Information for all

Advantage MD Plans• Health Care Performance Measures• JHHC Website and Contact Info

Our Mission• Our mission is to improve the health of our members

and provide them with high quality service and care.• Provider office staff and physicians play a critical role in

the member’s experience with our plan.• With our provider partners, we aim to deliver world-class

health care to our members while helping them to navigate the health care continuum.

• Additional details can be found in the Advantage MD Provider Manual at www.jhhc.com

Johns Hopkins Advantage MD Service AreaService Area is defined as a geographic area where a health plan can accept members.

– Anne Arundel County– Baltimore City– Baltimore County– Calvert County– Carroll County– Frederick County– Howard County– Montgomery County– Somerset County– Washington County– Wicomico County– Worcester CountyNOTE: Advantage MD Group is available

in Delaware, District of Columbia,

Florida, Georgia, Maryland, North Carolina,

Pennsylvania, South Carolina and Virginia

Medical Benefit Overview• Our plans cover all services covered under Original Medicare.• We also offer benefits beyond Original Medicare:

• Preventive dental, routine vision, routine podiatry, hearing exam and low-cost hearing aids

• Our PPO Plus, Premier and Group plans offer acupuncture coverage, fitness, routine chiropractic services, worldwide emergency and urgent coverage.

• Our HMO, PPO and PPO Plus plans have dental and fitness benefits.

• Our HMO plan offers post-discharge meal services to members who have been discharged from an inpatient or skilled nursing facility (SNF) stay, coordinated by Johns Hopkins Health Services.skilled nursing facility (SNF) stay, coordinated by Johns

Differences Between HMO & PPO Plans

HMO• Primary care physician (PCP) coordinates all care for the

member.• All care must be within the plan network (no out-of-

network coverage), unless in an emergency situation.• Lower out-of-pocket costs• Monthly premiums are lower than PPO plans.• Referrals are required for specialty care only; please provide

a copy to the patient and submit to JHHC.

Differences Between HMO & PPO Plans

PPO, PPO Plus, PPO Premier & Group• Flexibility in choosing physicians and specialists• Monthly premium higher than HMO plans• No referrals needed, but higher out-of-pocket costs than

HMOs• Coverage outside of the plan network (cost sharing may be

higher)• Robust supplemental benefits with premium products

Johns Hopkins Advantage MDNew for 2020

2020 New Member Benefits for All Johns Hopkins Advantage MD Plans

DECIDE is a literacy-adapted, online, self-paced program that helps adults learn how to change everyday behaviors to better manage their type 2 diabetes. This program is intended for patients who have struggles with the management of their diabetes.Act2 isDECIDE is a literacy-adapted, online, self-paced program that helps adults learn how to change everyday behaviors to better manage their type 2 diabetes. This program is intended for patients who have struggles with the management of their diabetes.Act2 is an online, interacted, year-long support and engagement program. This program is intended for patients at high risk of developing type 2 diabetes.If your patients would benefit from DECIDE or Act 2, both of which go into effect January 1, 2020, please refer them to us in one of the following ways:

• PHONE: 866-809-2073 • EMAIL: [email protected] all referrals, please include the following information:Patient’s name; address; home phone #; mobile phone #; email addressReferring provider’s name; NPI #; office address; office phone #; mobile phone #, email address.For more information on DECIDE or Act2, call 866-809-2073.

2020 Pharmacy Change

As of January 1, 2020, some pharmacies are not participating in the Advantage MD Pharmacy network. Impacted members were mailed a letter starting in October about the pharmacy network change effective January 1, 2020.

The impacted pharmacies are:• Martins Pharmacy • PillPack

If a member uses one of these pharmacies, they will need to start using an in-network pharmacy as of January 1, 2020. In-network pharmacies can be located on the Pharmacy Locator at www.hopkinsmedicare.com. Prescriptions can be transferred from the old pharmacy to the new pharmacy, or you can send in a new prescription to the new in-network pharmacy. Members can also sign up for mail-order prescriptions online at www.hopkinsmedicare.com or call Advantage MD Customer Service at 877-293-4998 for HMO or 877-293-5325 for PPO.

2020 New Product

PPO Premier – Montgomery County Only

Introducing Johns Hopkins Advantage MD Premier (PPO)

Exclusive PPO plan available only to residents of Montgomery County, Maryland

Starting January 1, 2020 residents in Montgomery County, Maryland in the Advantage MD PPO and PPO Plus will be dis-enrolled.

Members were notified via letters and calls in early October to select a different type of Medicare coverage (Advantage MD HMO, Advantage MD PPO Premier, another MAPD plan, Original Medicare with or without a Medicare Supplemental plan and/or a PDP plan, etc.)Additional information will be provided to providers to assist any affected members.

PPO Premier Highlights• Simple design with member cost sharing the same in-network and out-of-

network*• Members have flexibility and can see any doctor in-network or out-of-

network.• Members can visit any doctor in the United States for the same in-network

cost sharing (great for snowbirds!).• Many benefits beyond original Medicare, including coverage of

• Acupuncture• Chiropractic • Preventive and Comprehensive Dental • Vision Exams and Eyewear • Hearing Exams and Aids• Worldwide Emergent and Urgent Services • Fitness Center or At-Home Fitness Kits

*NOTE: “In-network” refers to providers and facilities contracted and credentialed to be part of the Johns Hopkins Advantage MD provider Network. “Out-of-network” refers to providers and facilities that do not participate in the Johns Hopkins Advantage MD provider network.

network” refers to providers and facilities that do not participate Johns

PPO Premier OverviewBenefits Member Cost-Sharing

PremiumMOOP

$350 $1500 IN / $5000 OON

Inpatient Hospital $200 per admit / stay

Emergency CareUrgent Care

$50 $20

PCP Specialist

$0$10

Outpatient – HospitalOutpatient – ASC

$100$50

RX (Part D) $3 / $10 / $40 / $90 / 33%

Preventive and Comprehensive Dental $0 to $400

Routine Chiropractic $10 copayment (12 visits a year)

Routine Podiatry $10 copayment (12 visits a year)

Acupuncture $300 allowance

Fitness (Silver&Fit) $0

Health Education (DECIDE) $0

Vision Eyewear - $300 every two years

Hearing Hearing Aids - $399 / $699 copay

Visitor / Traveler Benefit IN cost-sharing nationwide

Available in Montgomery County only

Same cost sharing in-network and out-of-network

Easy to understand plan design

Attractive all-in-one design with rich supplemental benefits

Low pharmacy copayments and robust formulary

No deductibles

2020 Advantage MD Product Overview

PPO, PPO Plus, PPO Premier & Group

Advantage MD PPO Member ID Cards

Front Back

Note: The circled section will vary depending on selected plan.

2020 Advantage MD PPO Benefits Comparison Chart

*NOTE: Advantage MD PPO Premier is available only in Montgomery County, Maryland.

2020 Advantage MD PPO Benefits ComparisonChart (cont.)

Advantage MD PPO Advantage MD PPO Plus

Advantage MD PPO Premier*

Urgent Care Visits $40 copay $40 copayCoverage available in the United States and worldwide.

$20 copayCoverage available in the United States and worldwide.

Emergency Room Visits $90 copay;waived if admitted to the hospital.

$90 copay; waived if admitted to the hospital. Coverage available in the United States and worldwide.

$50 copay; waived if admitted to the hospital. Coverage available in the United States and worldwide.

Medicare- covered Diagnostic Radiology Services

$30 copay (diagnostic x-rays- mammogram, ultrasound)$250copayfordiagnostic radiology (MRI andCT)

$30 copay (diagnostic x-rays- mammogram, ultrasound)$250copayfordiagnostic radiology (MRI andCT)

$10 copay (diagnosticx-rays- mammogram,ultrasound)$100copayfordiagnostic radiology (MRI andCT)

Ambulance Services

$240 copay per one-way emergency and non-emergency; copay not waived if admitted to the hospital

$240 copay per one-way emergency and non-emergency; copay not waived if admitted to the hospital

$100 copay (ground)$225 copay (air)

Ambulatory Surgical Centers $240 copay $240 copay $50 copay

Diabetic Supplies 0% coinsurance 0% coinsurance 0% coinsurance

KidneyDiseaseEducation $15 copay $10 copay $10 copay

Acupuncture Not covered $200 annual allowance $300 annual allowance

Routine Hearing Exams $0 copay for one routine hearing exam per year

$0 copay for one routine hearing exam per year

$0 copay for one routine hearing exam per year

Hearing Aids Through TruHearing,$699 or $999 (depending onmodel)

Through TruHearing,$699 or $999 (depending onmodel)

Through TruHearing,$399 or $699 (depending onmodel)

Eyewear(Non- Medicare covered) Not Covered

$150 allowance every two years to beusedon eyewear, includinglenses,frames,and contact lenses.

$300 allowance every two years to beusedon eyewear, includinglenses,frames,and contact lenses

Advantage MD PPO Advantage MD PPO Plus

Advantage MD PPO Premier*

Comprehensive Dental (non-Medicare covered)

Not Covered Not Covered0% to 50% coinsurance

Routine Podiatry Services 20% coinsurance (6 per year) 20% coinsurance (6 per year)$0 copay (up to 12 visits per calendar year)

Routine Chiropractic Visits Not Covered $20 copay (12 per year) $10 copay (up to 12 visits

per calendar year)

2020 Advantage MD PPO Benefits Comparison Chart (cont.)

Advantage MD PPO 2020 Group BenefitsThe Group plan is available to eligible Johns Hopkins Health System retired employees and families who reside in Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, and Virginia.

• Plan Overview- Low monthly premium ($175)- Low in-network maximum out-of-pocket ($300)- Worldwide emergency and urgently needed services coverage ($50,000 combined limit annually)- Visitor/Traveler benefit (ability to reside outside of the service area less than 12 months, remain in plan and receive in-network cost sharing anywhere in the United States).- Comprehensive dental coverage- Routine podiatry and chiropractic services- Acupuncture allowance

2020 Advantage MD Product Overview

HMO

Front Back

Advantage MD HMO Member ID Cards

2020 Advantage MD HMO Benefits ChartBenefit Cost Sharing

Primary Care Visits $5 copay

Specialist Care Visits $50 copay

Retail Prescription Drugs: Five Tiers

30 days:$0/$10/$47/$100/33% 60 days:$0/$15/$94/$200/NA

Mail Order Benefit 90-day supply at two times retail copay, excluding

Specialty Drugs (Tier 5)

Acute Inpatient Hospital Services Days 1-5:$310 copay per day.

Outpatient Hospital Surgery $300 copay

Urgent Care $40 copay

Emergency Room Visits

$90 copay; waived if admitted to the hospital within 24 hours

Diagnostic/Radiology Services

$20 copay (Diagnostic X-ray – mammography, ultrasound, etc.) $175 copay (Diagnostic Radiology – MRI and CT) 20% coinsurance (Therapeutic Radiology and Nuclear Medicine, lab services)

2020 Advantage MD HMO Benefits Chart (cont.)

Routine Vision Exams $0 copay - one exam annually

Ambulance Services

$240 copay per one-way emergency and nonemergency, under certain conditions; copay not waived if admitted to the hospital

Ambulatory Surgical Centers $250 copay

Diabetic Supplies 0% coinsurance

Kidney Disease Education $0 copay

Routine Hearing Exams

$0 copay (one routine hearing exam per year)

Hearing Aid

Through TruHearing, $699 or $999 (depending on model) per hearing aid per year to include:

• Advanced or Premium hearing aids • Three provider visits within first year of hearing

aid purchase • 45 day trial period • Three year extended warranty • 48 batteries per aid (retail or online)

Eyewear Allowance (Non Medicare-covered) $150 allowance every two years

Post-Discharge Meals (Skilled Nursing and Inpatient discharges only) Three meals a day for five days (four times per year)

Routine Podiatry Services (Non Medicare-covered) 20% coinsurance ( eight per calendar year)

Routine Chiropractic Visits (Non Medicare-covered) Not covered

HMO Referral Requirements

• Referrals are required for specialty services only.• Referrals should be to in-network specialty providers only –

there is no out-of-network coverage for HMO.• Primary care physicians (PCPs) should complete referrals in

HealthLINK and provide the member with a copy or complete the Maryland Uniform Consultation Referral Form, provide member a copy, and fax to JHHC at 410-424-4036.

HMO Referral Process

HealthLINK Submitting a Referral• Log into HealthLINK• From the office management

menu selectReferrals/Authorization

• Select the Specialist tab• Enter the patients information

and provider information*(all required fields indicated by a box)

The Maryland Uniform Referral Form can be faxed

to 410-424-4036.

Maryland Uniform Referral Form

CY2020 Product Overview (Note: Please use the Evidence of Coverage (EOC) released in October for benefits and coverage.)

HMO PPO PPO Plus PPO Premier* PPO Group

Premium $0 or $25 $75 $105 $350 $175

MOOP $6,700 $6,700 / $10,000 $6700 / $10,000 $1,500 / $5,000 $3,000 / $10.000

Service Area HMO 001 – All, but Baltimore City

HMO 002 – Baltimore City Only

All, but Montgomery County

All, but Montgomery County

Montgomery County only DC, VA, GA, MD, NC, SC, PA, DE, FL

MedicalDeductible

None None None None $100

Inpatient $310 days 1-5 $310 days 1-6 $310 days 1-6 $200 per stay $250 days 1-7

PCP $5 $10 $5 $0 $5

Specialist $50 $50 $50 $10 $30

OutpatientHospital

$300 (Outpatient)$250 (ASC)





ER $90 $90 $90 $50 $75

Urgent Care $40 $40 $40 $20 $40

Supplemental Benefits (not all inclusive)

PodiatryPreventive Dental

Hearing Vision

Post-Discharge Meals

Podiatry Preventive Dental

Hearing Vision

PodiatryChiropracticAcupuncture

Preventive Dental Hearing Vision

Silver&Fit

PodiatryChiropracticAcupunctureFull Dental

Hearing Vision

Silver&FitVisitor / Traveler

PodiatryChiropracticAcupunctureFull Dental

Hearing Vision

Silver&FitVisitor / Traveler

RX $0/$10/$47/$100/33%No Deductible

$7/$15/$47/$100/26% $350 Deductible

$4/$12/$47/$100/26%$350 Deductible

$3/$10/$40/$90/33%No Deductible

$4/$12/$42/$92/33%No Deductible

OptionalSupplemental Benefits

Comp Dental / Fitness$30 monthly premium

No Waiting Period

Comp Dental / Fitness$30 monthly premium

No Waiting Period

Comp Dental $28 monthly premium

No Waiting Period

N/A N/A

Vision and Dental

Provider Education 2020 Benefits Overview

Vision PPO Coverage Overview 2020

• Advantage MD PPO covers additional vision benefits through Superior Vision.

• The in-network benefit is covered only if the member visits a Superior contracted provider.

• Providers who do not participate with Superior can still see Advantage MD PPO members when there is an out-of-network benefit under the PPO products.

• You may electronically submit claims via the Superior website (www.superiorvision.com) or in the ASC X12N 837 HIPAA standard format, either directly to the Superior or through its clearinghouse. You may also utilize the CMS 1500 form for submitting paper claims to Superior or mail them to:Claims Department

Superior Vision

939 Elkridge Landing Rd, Ste. 200

Linthicum, MD 21090

Please refer to the “Claim Submission Requirements” section of the Provider Manual for further details on submitting claims, as well as the Superior’s reimbursement policies.

VISION HMO and PPO Coverage Overview (2020)

Service Advantage MD HMO

Advantage MD PPO

Advantage MD PPO Plus

Advantage MD PPO Premier

Advantage MD Group

Routine Eye Exam IN: $0 member costOON: No coverage

IN: $0 member cost OON: 50% member coinsurance


IN: $0 member cost OON: $0 member cost


Eyewear $150 towards eyewear or contacts lenses every twoyears from any source

Not Covered $150 towards eyewear or contacts lenses every twoyears from any source

$300 towards eyewear or contacts lenses every twoyears from any source

$300 towards eyewear or contacts lenses every twoyears from any source

The routine eye exam and eyewear benefit is processed through Superior Vision. For questions related to the benefits and claims process, please contact Superior at 866-819-4298.

Dental HMO Coverage Overview 2020

• Advantage MD covers additional dental benefits through DentaQuest.

• The in-network benefit is covered only if the member visits a DentaQuest contracted provider .

• There is an optional supplemental package available to members in the Advantage MD HMO plan that offers comprehensive dental coverage (additional monthly premium) in- and out-of-network.

• For questions related to the benefits, prior authorizations, and claims, please contact DentaQuestat 800-471-7140.

Dental PPO Coverage Overview 2020

• Advantage MD covers additional dental benefits through DentaQuest.

• The in-network benefit is covered only if the member visits a DentaQuest contracted provider.

• There is an optional supplemental package available to members in the Advantage MD PPO plans that offer comprehensive dental coverage (additional monthly premium) in- and out-of-network.

• For questions related to the benefits, prior authorizations, and claims, please contact DentaQuestat 800-471-7140.

DENTAL Coverage Overview (CY2020)Service Advantage MD HMO Advantage MD PPO Advantage MD PPO Plus Advantage MD PPO

PremierAdvantage MD Group

Preventive Dental (In-networkcovered through DentaQuest network)

IN: Cleaning (1 per year) $15 copay Dental X-Ray (frequency depends on type of services) $25 copayOral Exam (frequency depends on type of services) $15 copay

OON: No Coverage


OON: 50% coinsurance



IN: Cleaning (2 per year) $0 copay Dental X-Ray (frequency depends on type of services) $0 copayOral Exam (frequency depends on type of services) $0 copayFluoride (2 per year) $0 copay

OON: $0 copay



Comprehensive Dental (In-network covered through DentaQuest network)

Additional $30 a month premium

IN: $50 to $400 copayOON: 50% to 70% coinsurance

Covers extractions, root canals, crowns, oral surgery, dentures, and more

Maximum plan coverage $1,200 annually









Included at no extra monthly premium

IN and OON: 0% to 50%

Same cost IN or OON

Covers extractions, root canals, crowns, oral surgery, dentures, palliative treatment, tissue conditioning, protective restoration, consultations, and more


Included at no extra monthly premium




For questions related to the benefits, prior authorizations, and claims, please contact DentaQuest at 800-471-7140.For questions related to the benefits, prior authorizations, and claims,

Johns Hopkins Advantage MD

Telehealth


Covered telehealth services:• Certain telehealth services including consultation, diagnoses

and treatment by a physician or practitioner in certain rural areas or other locations approved by Medicare.

• Telehealth services for monthly ESRD-related visits for home dialysis members in a hospital-based or critical access hospital-based renal dialysis center, renal dialysis facility or the member’s home.

Johns Hopkins Advantage MDCovered telehealth services (cont.):• Remote evaluation of pre-recorded video and/or images members

send to their provider, including the provider’s interpretation and follow-up within 24 hours—if the member is an established patient and the remote evaluation is not related to an office visit within the previous seven days nor leads to an office visit within the next 24 hours or soonest available appointment.

• Telehealth services for diagnosis, evaluation or treatment of symptoms of an acute stroke. Brief virtual check-ins with your doctor if member is an established patient and the evaluation is not related to an office visit within the previous seven days nor leads to an office visit within the next 24 hours or soonest available appointment.an office visit within the next 24 hours or soonest available

Johns Hopkins Advantage MDRequirements, Processes and

Important Information for All Plans

Prior Authorization

• Prior Authorization requirements apply uniformly to all • Johns Hopkins Advantage MD products.• Submit a request for Prior Authorization prior to

rendering services by calling:– Medical Management at 844-560-2856– Behavioral Health at 844-340-2217

• Submit clinical notes and treatment plan by fax:– Medical Management at 855-704-5296– Behavioral Health at 844-363-6772

Preauthorization Guidelines• Product lines supported: HMO,

PPO, PPO Plus, PPO Premier, and PPO Group

• Preauthorization requirements• Contact and resource

information• For a comprehensive list, please

refer to the Preauthorization Guidelines, at https://www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physicians/resources_guidelines/

Diabetic Supplies

• Advantage MD members will have 0% coinsurance for diabetic supplies (excluding insulin pumps)

• Diabetic supplies include:– Blood sugar (glucose) test strips– Blood sugar testing monitors– Lancet devices and lancets– Glucose control solutions

• Advantage MD members will have 0% coinsurance for diabetic supplies (excluding insulin pumps)

• In-network providers for diabetic supplies:– Better Living Now, Inc.

• 800-854-5729

– Participating network pharmacies• For a 2020 listing of participating pharmacies, please

visit www.hopkinsmedicare.com

Diabetic Supplies (cont.)

• Advantage MD offers a comprehensive prescription drug benefit with coverage in all therapeutic classes, as indicated by the Medicare Part D rules and regulations.– Drugs excluded by Medicare: drugs used for cosmetic

purposes, erectile dysfunction, cough and cold, vitamins (except prenatal vitamins) and over-the-counter medications.

• The lists of formulary drugs, coverage limit requirements, and prior authorization forms are available on the plan’s website www.hopkinsmedicare.com

Prescription Drug Benefit (Part D) Formulary Overview

• Drugs must be used for a “medically accepted indication,”either:

• Approved by the FDA for the diagnosis or condition for which it is being prescribed OR

• Supported by certain Medicare-recognized references

NOTE: For more details on prescription drug benefits, please see the pharmacy section of the Advantage MD website.

Prescription Drug Benefit (Part D) Formulary Overview

• CVS/caremark, our mail order pharmacy, sends a 3-month supply of maintenance medications in one fill, making it easier for the patient by only having to fill four times a year.

• In addition, a 3-month supply of maintenance medication is available through CVS/caremark mail order at a reduced copay.

• This means your patient can fill a 90-day supply for only 2 times the retail copay—saving them an equivalent of four retail copays per year.

• Doctors and staff can contact CVS/caremark at 877-293-5325 (option 2) for PPO or 877-293-4998 (option 2) for HMO, 24 hours a day, 7 days a week.

Prescription Drug Benefit – Mail Order

Three easy ways for your Advantage MD members to register for mail order:• Online. Members can information to register on caremark.com.• On smartphone or tablet. Download the CVS/caremark

mobile app from the App Store or Google play.• By phone. Members can call Customer Service (TTY: 711)

number on the back of their Member ID card and select option 2. Our Customer Service will get them started with a personalized registration email or text.

• The mail order form is available at https://www.hopkinsmedicare.com/wp-content/uploads/member-mail-service-order-form.pdf.

Prescription Drug Benefit – Mail Order

Added Advantages for Advantage MD Providers

Health System/Provider:• Care Management support through Johns Hopkins Advantage

MD• The Medicare Three-Day Rule for accessing post-acute care

does not apply to Advantage MD. Members can be admitted to a skilled nursing facility (SNF) when it is clinically appropriate.

Care ManagementJohns Hopkins Advantage MD is committed to becoming the leader in care management population health solutions.

Our care management model promotes prevention skills, performs health risk identification, and manages member compliance to avoid costly treatments. We not only outreach to the sickest members to stabilize and manage conditions, we guide healthy members further along the prevention path.

Through our four main service areas of Preventive, Transitional, Complex, and Maternal/Child, we catch members wherever they are on the health continuum.

• To contact Care Management please call: 800-557-6916.

• To submit a referral to Care Management, please send an email to [email protected].

Please include:

• Member Name

• Date of birth

• ID number

• Diagnosis

• Patient needs

• Responses will be provided within two business days.

Care Management

The Claims Process

Providers are encouraged to submit claims electronically:• Medicare Advantage Payer ID # 66003• For electronic remittance advices (835) and

electronic payments:– Enroll online at changehealthcare.com OR– Download the enrollment form at

changehealthcare.com/epayment/enrollment and fax completed form to 615-238-9615

• Timely filing – 180 days from date of service• Clean claims processed within 30 days

• Mailing address for medical claims:-Johns Hopkins Advantage MDP.O. Box 3537, Scranton, PA 18505

For details on Medicare Secondary Payer & COB, as well as the Provider Payment Dispute Process, please see the Advantage MD Provider Manual and use the Participating Provider Post-Service Payment Dispute Form.

The Claims Process (cont.)

Johns Hopkins Advantage MDHealthcare Performance Measures

Center for Medicare & Medicaid Services (CMS) Five-Star Quality Rating System

The Center for Medicare & Medicaid Services (CMS) developed the Five-Star Quality Rating System to evaluate the quality and performance of Medicare Advantage (MA) plans and Prescription Drug Plans (PDPs). The Star Ratings measures change annually and include measures from Healthcare Effectiveness Data and Information Set (HEDIS®), Consumer Assessment of Healthcare Providers and Systems (CAHPS®), and Health Outcomes Survey (HOS).

As health plans and providers collaborate to give our members the best quality care, we can all look to the plan’s Star Ratings to see how well we are achieving this goal. The annually-updated Quality Measures Tip Sheet can guide all of our efforts to improve.can guide all of our efforts to improve.

Healthcare Effectiveness Data and Information Set (HEDIS®)

HEDIS® is a widely used set of health care performance measures that is developed and maintained by the National Committee for Quality Assurance (NCQA). Examples of HEDIS® measures are Comprehensive Diabetes Care, Breast Cancer Screening, Controlling Blood Pressure, and Colorectal Cancer Screening.

For detailed information about HEDIS®, please go to the NCQA website or view our Quality Measures Tip Sheet.

Consumer Assessment of Healthcare Providers (CAHPS®)

CAHPS® is a member satisfaction survey in which the objective is to capture information about consumer-reported experiences with healthcare. The focus of the survey is to measure how well plans are meeting member expectations, determine which areas of service have the greatest effect on overall member satisfaction, and identify areas of opportunity for improvement.

Topics included in the survey are Getting Needed Care, Getting Care Quickly, How Well Doctors Communicate, Customer Service, Coordination of Care, Getting Needed Prescription Drugs, and the Ratings of: Health Care, Personal Doctor, Specialist, and Health/Drug Plan. The survey is conducted annually according to CMS protocol by a CMS certified vendor.

Health Outcomes Survey (HOS)HOS is a member survey that assesses the physical and mental health of a patient over a two-year period. Topics included in the survey are: improving or maintaining physical and mental health, reducing the risk of falling, and improving bladder control.

Health LiteracyThere are many reasons health plan members, patients and caregivers may struggle to understand health information. Johns Hopkins HealthCare (JHHC) has structured its goals to meet their mission to provide quality health care, develop new methods to improve the health of its patient community and set standards of excellence in patient care. By having an engaged patient and developing a better means of communication through health literacy initiatives, healthcare providers can treat their patients and achieve optimal health outcomes and favorable HEDIS® and CAHPS® results.


For more information on Advantage MD’s Healthcare Performance Measures,

please contact your designated Provider Engagement Liaison at 888-895-4998.

Recap: Important Information• PPO members can go in-network or out-of-network.• HMO members can only go to in-network providers.• The formularies for the PPO and HMO products are not the

same. Please review the applicable formulary prior to prescribing.

• Advantage MD members have a 0% coinsurance for in-network diabetic supplies.

• Members can save money on medications by getting a long-term supply at either a retail pharmacy or through mail order.

• Johns Hopkins Advantage MD offers Medication Therapy Management (MTM) services at no cost to members through CVS/caremark.

• Some services and supplies will require prior authorization.prior authorization.

Johns Hopkins HealthCare Website

Provider website includes:– Provider manuals– Forms– HealthLINK@Hopkins portal access– Online provider directory

• Find participating providers on http://www.hopkinsmedicare.com/

– Policies & procedures– Compliance guidance– Prior authorization updates

HealthLINK@Hopkins

Registered providers are able to access the following information using HealthLINK:

• Eligibility• Claims• Authorizations & referrals• PCP member rosters• Care coordination reports• Advantage MD HMO – referral submission

NOTE: Quick Reference Guide on HealthLINK@Hopkins at www.jhhc.com.

Updating Your InformationYou are required to notify JHHC’s Provider Relations department of any demographic changes to your practice.

Provider Relations (For demographic changes, contract status and fee schedule questions):

Email: [email protected]

CMS requires the Health Plan to validate provider information ona quarterly basis.

Important Contact Information

• Toll Free Compliance Hotline: 844-SPEAK2US (1-844-773-2528)

• Provider Website: www.jhhc.com• Advantage MD Website: www.hopkinsmedicare.com• CMS: www.cms.gov

• Provider Relations Department: 888-895-4998 (provider education, credentialing & contract inquiries)

• Customer Service, PPO: 877-293-5325 (benefits &claims inquiries)

• Customer Service, HMO: 877-293-4998 (benefits &claims inquiries)

• Care Management Referrals: [email protected] or 800-557-6916

*For additional information, please reference the JH Advantage MD Provider Manual.

Important Contact Information

THANK YOUfor participating

with Advantage MD.

Presented by:1/11/2019Presented by: Johns Hopkins HealthCare Provider Relations Department

QUESTIONS?

Documents

Johns Hopkins Advantage MD 2020 HMO and PPO Plans · MD Pharmacy network. Impacted members were mailed a letter starting in October about the pharmacy network change effective January