Johns Hopkins HealthCare LLC

Transcription

1 Johns Hopkins HealthCare LLC Overview and Changes to Health Plans in 2019 Presented by: by: Johns Hopkins HealthCare Provider Relations Department 11/16/2018

2 Agenda Welcome About JHHC Provider Website Review Product Updates Advantage MD USFHP EHP Priority Partners MCO Resources 2

3 Johns Hopkins HealthCare Welcome: Johns Hopkins HealthCare LLC (JHHC) provides health care services for four health plans: Priority Partners Managed Care Organization, Johns Hopkins Employer Health Programs (EHP), Johns Hopkins US Family Health Plan (USFHP) and Johns Hopkins Advantage MD & Advantage MD Plus. 11/16/ /16/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department

4 Johns Hopkins HealthCare Provider Website: -> For Providers Provider website includes: Provider Manuals Forms portal access Online Provider Directory Find participating providers on Policies & Procedures Compliance Guidance Communications Repository 11/16/ /16/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department

5 Johns Hopkins HealthCare Provider Website: -> For Providers 11/16/ /16/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department

6 Johns Hopkins HealthCare Provider Website: -> For Providers -> Resources & Guidelines 11/16/ /16/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department

7 Johns Hopkins HealthCare Provider Website: -> For Providers -> Resources & Guidelines -> Priority Partners -> Outpatient Referral Guidelines (2018) 11/16/ /16/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department

8 Advantage MD Product Overview PPO, PPO Plus,& Group

9 Advantage MD Medical Benefit Overview Our plans cover all services covered under Original Medicare. We also offer benefits beyond Original Medicare: The option to purchase additional optional supplemental benefits Vision and hearing benefits above and beyond what Medicare covers Additional preventative services On our PPO Plus product, we offer services such as acupuncture and fitness included in the plan:

10 Johns Hopkins Advantage MD Service Area Service 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 Montgomery County Somerset County Washington County Wicomico County Worcester County 11/16/ /16/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department

11 Member ID Cards Advantage MD PPO Advantage MD PPO Plus

12 Group Plan Cards Advantage MD PPO Group

13 Advantage MD 2019 Group Changes Advantage MD Group -The Group retiree plan for eligible Johns Hopkins and PRMC retired employees and families will be offered to residents of Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, and Virginia in 2019 Exciting Changes -Reduced monthly premium ($175) -Reduced in-network maximum out-of-pocket ($3000) -Worldwide emergency and urgently needed services coverage ($50,000 combined limit annually) -Visitor/Traveler benefit (ability to reside outside of the service area for less than 12 months, remain in plan and receive in-network cost sharing

14 2019 Advantage MD PPO Benefits Comparison Chart The chart below details the in-network benefits comparison between the three programs: Advantage MD, Advantage MD Plus, and Advantage MD Group.

15 2019 Advantage MD PPO Benefits Comparison Chart (cont.)

16 2019 Advantage MD PPO Benefits Comparison Chart (cont.)

17 Member ID Card HMO

18 2019 Advantage MD HMO Benefits Chart

19 2019 Advantage MD HMO Benefits Chart (cont.)

20 Differentiation HMO/PPO HMO Primary care physician coordinates all care for the member All care must be within the plan network (no out-of-network coverage) Lower out-of-pocket costs Monthly premiums are lower than PPO plans Referrals are required for specialty care; please provide a copy to the patient and submit to JHHC

21 Differentiation HMO/PPO PPO, PPO Plus & Group Flexibility in choosing physicians and specialists Monthly premiums higher than HMO plans No referrals needed, but higher out-of-pocket costs than HMOs Coverage outside of the plan network (with higher cost sharing) Robust supplemental benefits expected from premium products

22 USFHP Product Overview 11/16/ /16/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department

23 Johns Hopkins US Family Health Plan (USFHP) is a health care choice for eligible beneficiaries under the Department of Defense s TRICARE Prime program Health care is provided to active duty family members, activated National Guard and Reserve family members, and retirees and their family members, including certain grandfathered beneficiaries who are age 65 and older. 11/16/ /16/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department

24 For members who have coverage under both Johns Hopkins USFHP and Medicare: Medicare cannot be billed for services that are covered by USFHP Members filing Medicare claims or members that have claims filed on their behalf are in violation of the conditions of participation for USFHP and are subject to disenrollment. Members who have coverage under both USFHP and Medicare may only use Medicare benefits for non-covered USFHP services, such as chiropractic care or end-stage renal disease. Members utilizing Medicare for benefits covered under USFHP are subject to disenrollment. 11/16/ /16/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department

25 USFHP offers programs and services to help members better manage their health. As USFHP members, your patients can take advantage of the following: Prescription coverage: Johns Hopkins USFHP utilizes the TRICARE pharmacy formulary for prescription drug benefits. The USFHP pharmacy and formulary can be viewed here. Dental care: USFHP members take advantage of two free dental cleanings per year and dental discount benefits administered through United Concordia Companies, Inc. (UCCI) and its Concordia Advantage. Members can call UCCI customer service at /16/ /16/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department

26 One-on-one health coaching: This gives members the opportunity to work one-on-one with a personal health coach to help them meet their health goals. Members can call for more information. Care management program: This program offers tools and ongoing support that members need to better understand and manage their health. Members can call for more information. Healthy Living for USFHP: Health and wellness programs for members ages 45+ to help them and their loved ones develop a healthier lifestyle through health education and the guidance of medical experts. 11/16/ /16/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department

27 Pregnancy resources: Various programs for expectant moms including case management and the Partners with Moms program. For additional information about these programs, members should call customer service at hour nurse hotline: Members can speak to a real registered nurse 24 hours a day for general medical advice. Members should call pin #382. HealthLink@hopkins: This is the secure web portal for members' personal health information. Members can login and register at hopkinsmedicine.org/usfhp. 11/16/ /16/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department

28 Vision care discounts including lenses, frames, and LASIK eye surgery performed by Johns Hopkins doctors. Discounts on selected cosmetic procedures performed by Johns Hopkins doctors. Discounts on selected fertility treatment services performed by Johns Hopkins doctors. 11/16/ /16/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department

29 Member ID Cards 11/16/ /16/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department

30 New for 2019 Updates to breast pump policies Clarification of language regarding medically necessary foods Updates to ambulance services Expansion of behavioral health services 11/16/ /16/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department

31 Vision and Dental Care New for 2019 (cont.) Active duty members will have vision and dental care through TRICARE effective January 1, In 2019, retired USFHP members will be offered an annual routine eye exam and value-added 2 free dental cleanings per year. There will be an option for retirees to enroll into the FEDVIP plans to provide the added coverage for vision and dental services. Under the FEDVIP vision program, members will not only have a covered eye exam but, depending on their choice of coverage, they may be able to get glasses, contacts or both for free or a deep discount. 11/16/ /16/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department

32 2019 TRICARE PRIME and TRICARE Select Out-of-Pocket Expenses **When TRICARE Prime enrollees other than active duty members self-refer to specialty or non-emergent inpatient care without a referral from a network provider and/or authorization from a regional contractor, the TRICARE Point of Service deductible and copayment applies in lieu of TRICARE Prime copayments. 11/16/2018 Presented 11/16/2018 by: Johns Hopkins HealthCare Provider Relations Department

33 2019 TRICARE PRIME and TRICARE Select Out-of-Pocket Expenses (cont.) **When TRICARE Prime enrollees other than active duty members self-refer to specialty or non-emergent inpatient care without a referral from a network provider and/or authorization from a regional contractor, the TRICARE Point of Service deductible and copayment applies in lieu of TRICARE Prime copayments. 11/16/2018 Presented 11/16/2018 by: Johns Hopkins HealthCare Provider Relations Department

34 Johns Hopkins Employer Health Programs (EHP) Product Overview

35 Johns Hopkins Employer Health Programs (EHP) As a third-party administrator, Johns Hopkins Employer Health Programs (EHP) provides benefits administration to Johns Hopkins Medicine employers and other strategic partners, serving more than 60,000 members. With 20,000 health care providers and 30 hospitals in Maryland and Southern Pennsylvania, and a nationwide network of nearly 691,000 providers and 3,500 hospitals, EHP self-funded plans are designed to meet the needs of all its members.

36 EHP offers programs and services to help members better manage their health. EHP offers the EHP Benefits Explorer, an interactive tool designed to help EHP members quickly and easily find coverage information related to specific services. For detailed information on what each individual employer offers, visit benefits.ehp.org or see the schedule of benefits.

37 As EHP members, your patients can take advantage of the following: Prescription coverage: Prescription drug benefits vary among EHP employer groups. The EHP pharmacy and formulary can be viewed here. Dental care: The EHP dental benefit, offered by some EHP plans, is administered by Delta Dental. Members can call Delta Dental customer service at Visits to urgent care: Members can find urgent care centers by accessing the Provider directory or calling EHP customer service at

38 One-on-one health coaching: This gives members in most plans (excluding Broadway Services and Anne Arundel Medical Center) the opportunity to work one-on-one with a personal health coach and create an individualized action plan to help them meet their health goals. Members can call for more information. Care management program: Members are placed in one of three levels and, depending on their level, are given a variety of support, tools, and services that are specifically designed to help them better understand and manage their medical conditions. Members can call for more information.

39 Pregnancy resources: Various programs for expectant moms including Partners with Mom a high risk prenatal case management program, the BabySteps online rewards program and health coaching. Members can call Ext for more information. 24 hour nurse hotline: Members can speak to a real registered nurse 24 hours a day for general medical advice. Members should call pin #380.

40 This is the secure web portal for members' personal health information. Members can login and register at ehp.org. National medical coverage outside the state of Maryland through MultiPlan PHCS Healthy Directions Network: Members can visit for more information.

41 Member ID cards

42 New for 2019 Benefit and plan changes effective January 1, 2019 include: New Additions to the Preferred Provider Network for the PPO Benefit Plan Greater Baltimore Medical Center (GBMC) and Anne Arundel Medical Center (AAMC) facilities and providers joins the Johns Hopkins Preferred Provider Network on 1/1/2019. Applies to Johns Hopkins Health System/Johns Hopkins Hospital, Bayview Hospital Providers and Facilities (PPO and EPO) Howard County General Hospital, Suburban and Sibley Hospitals Facilities only (PPO and EPO)

43 New for 2019 (continued) Exclusive Provider Organization (EPO) Plan JHHC introduces a new EPO (Exclusive Provider Organization) on 1/1/2019. This plan will have only in-network benefits EHP network (including MultiPlan out-of-state network*) and Johns Hopkins Preferred Network (including GBMC and AAMC facilities and providers). Care outside the EHP network is not covered under the EPO, except for emergency care. Applies to Johns Hopkins Health System/Johns Hopkins Hospital and Bayview Hospital Howard County General Hospital (HCGH) and Suburban Hospital *MultiPlan is also available inside Maryland for Suburban (PPO and EPO) and Sibley (PPO) members.

44 New for 2019 (continued) New Benefit for 2019 Direct Primary Care By enrolling in Direct Primary Care (DHP) pilot program, EHP members and their adult dependents (18 years or older) can receive 24/7 access to select primary care providers through a combination of longer in-person appointment times, s, phone calls, texts and video visits. DHP members experience no additional costs to their insurance plan and do not incur copayments or out-of-pocket costs for the first eight visits of the calendar year. The program will be capped at 1,600 members.

45 Additional 2019 EHP Plan Changes HCGH 2019 Plan Changes Changes for the PPO Benefit Plan: Acupuncture. Adding medically necessary services for pain control, and therapeutic purposes. Removing the Anesthesia only restriction. Hospital Care. Removing $40 copay for Observation Care professional fees for ER visits. Urgent Care. Removing (Patient First locations only) for physicians visits. Changing the Urgent Care copay to $40 for all urgent care facilities.

46 Additional 2019 EHP Plan Changes Bayview 2019 Plan Changes Salary tiers that determine deductibles and out-of-pocket amounts have changed for The plan codes are listed on the member ID cards.

47 Additional 2019 EHP Plan Changes Suburban 2019 Plan Changes Changes for the PPO Benefit Plan: ER Copay. $125 copay, then 90% of allowed amount; deductible waived (copay waived if admitted) for EHP Network Provider, Hopkins Affiliated Facility Network, and out-of-network providers. 90% coverage for facility coverage at all Hopkins Preferred Facilities EXCEPT for infusion therapy services. (continued)

48 Additional 2019 EHP Plan Changes Suburban 2019 Plan Changes EHP Network Provider Hospital Inpatient Care (Facility Fees). $100 copay per admission, then 80% of the allowed amount; deductible waived (for a service that Suburban doesn t provide: $100 copay per admission, then 90% of allowed amount deductible waived). EHP Network Provider Reproductive Health Inpatient Maternity Care and Delivery (Facility Fees). $100 co-pay per admission, then 80% of the allowed amount; deductible waived (for a service that Suburban doesn t provide: $100 copay per admission, then 90% of allowed amount deductible waived).

49 Additional 2019 EHP Plan Changes Suburban 2019 Plan Changes Infertility.50% of allowed amount; deductible applies (preauthorization required for all services and prescriptions; all criteria must be met; $30,000 lifetime maximum combined including prescription drugs, lab work and x-rays; in vitro fertilization attempts limited to a maximum of three per lifetime within the $30,000 lifetime maximum. Hearing Aids. 90% of allowed amount; deductible applies (for dependent children up to age 26; up to $1,400 per aid. preauthorization required) replacement aids once every 36 months all networks combined. (continued)

50 Additional 2019 EHP Plan Changes Suburban 2019 Plan Changes Private Duty Nursing. Removed for PT/OT- Sixty (60) visits per year maximum added for all networks combined; PT/OT preauthorization required for visits 13-60).

51 Additional 2019 EHP Plan Changes Sibley 2019 Plan Changes (PPO Plan) Nutritional Counseling. Limited to 6 visits per plan year for all networks combined; additional visits must be preauthorized. Infertility.50% of allowed amount; deductible applies (preauthorization required for all services and prescriptions; all criteria must be met; $30,000 lifetime maximum combined including prescription drugs, lab work and x-rays; in vitro fertilization attempts limited to a maximum of three per lifetime within the $30,000 lifetime maximum. Chiropractic. The 12 years of age restriction has been eliminated.

52 Empl Priority Partners Product Overview

53 Empl Priority Partners HealthChoice is a health care program of the Maryland Department of Health and Mental Hygiene The HealthChoice plan provided through Priority Partners includes coverage for Medical Assistance for Families and the Maryland Children s Health Plan for pregnant women and children. Eligibility is based on family size, income levels, or special medical circumstances. Priority Partners offers special needs and outreach programs to assist provider s offices in improving no-show rates by helping members get into care and partnering with them to provide special programs for diabetics, pregnant women and members with chronic diseases.

54 Empl Priority Partners offers programs and services to help members better manage their health. As Priority Partners HealthChoice members, your patients can take advantage of no and low cost services that include: Low-cost prescription drugs and over-the-counter medication. See the Priority Partners pharmacy and formulary for more information. Visits to urgent care centers Emergency department facility services Dental care: Dental care for pregnant women and children is directly provided by the Maryland Healthy Smiles Dental Program. Members can contact DentaQuest directly at For adults 21 and over, dental care is provided by Priority Partners through DentaQuest. Members can contact DentaQuest at

55 Empl Vision care: Vision care is provided by Superior Vision. Members can contact Superior Vision at /7 secure online access to personal health information. Members can login or register at ppmco.org. Transportation to doctor and medical appointments: Members can call for transportation scheduling. Assistance in finding the appropriate health care services, as well as help with making doctor's appointments: Members can call for assistance and appointment scheduling.

56 Empl Care management: Members are placed in one of three levels, and depending on their level, are given a variety of support, tools and services that are specifically designed to help them better understand and manage their medical conditions. Health education: Priority Partners has a team of health educators that teach different programs to help members better manage their health. Members can call to sign up for a program or contact a health educator. Pregnancy Resources: Expectant moms have access to various programs including Partners with Mom a high risk prenatal case management program and health coaching. Members can call Ext for more information.

57 Empl Member ID Card

58 Empl New for 2019 Audiology Benefit Changes. Audiology services will be covered by Priority Partners for both adults and children. For individuals under age 21, bilateral hearing amplification devices are covered by Priority Partners. Bilateral hearing amplification devices are only covered for adults 21 and older when the individual has a documented history of using bilateral hearing aids before age 21. Priority Partners will provide medically necessary audiology services (regardless of age) including: -Hearing aids -Cochlear implants -Auditory osseointegrated devices -Related audiology services

59 Empl New for 2019 (cont.) Value Based Purchasing (VBP) Update. The number of VBP measures has been reduced from 13 measures to nine measures for CY Several measures were removed and two new measures have been added. Contraceptives. A 12 month-supply of contraceptives will be dispensed to a member at one time. Remote Patient Monitoring Benefit. Changes to Network Adequacy Regulations. Details pending from state. Reminder Members should also update their information(address, phone # etc.) in Maryland Health Connection if they provide updated information during their provider office visit.

60 Empl New for 2019 (cont.) REM Promotion. The MDH administers a Rare and Expensive Case Management (REM) program to address the special needs of waivereligible individuals diagnosed with rare and expensive medical conditions. The REM program, a part of the HealthChoice program, was developed to ensure that individuals who meet specific criteria receive high-quality, medically-necessary and timely access to health services. To qualify for the REM program, a member must have one or more of the diagnoses specified in the Rare and Expensive Disease List in the Priority Partners Provider Manual. The members may elect to enroll in the REM program, or to remain in Priority Partners if the department agrees that it is medically appropriate.

61 Empl New for 2019 (cont.) eprep Promotion. New federal rules require that MCO providers enroll with the state s Medicaid agency (42 CFR Part 438, Subpart H). To continue to provide Medicaid reimbursable services, you must enroll with the Maryland Medical Assistance Program (Medicaid), even if your practice will be providing services only to HealthChoice participants. Enrolling with Medicaid does not mean that you must provide services to Fee-for-Service (FFS) participants. The Maryland Department of Health (MDH) is the state agency for Medicaid, and the tool that providers use to enroll is a self-service, online portal called electronic Provider Revalidation and Enrollment Portal (eprep), which can be accessed here: eprep.health.maryland.gov

62 Empl New for 2019 eprep Promotion (cont.) As a valued provider, we urge you to complete the mandatory eprep enrollment as soon as possible, if you haven t already done so. Not only is it required by law, but your future claims payments may be impacted adversely by failing to comply with the eprep enrollment requirement. eprep Enrollment Instructions To enroll with Maryland Medicaid, please visit eprep.health.maryland.gov.

63 JHHC Customer Service Employer Health Programs (EHP) Customer Service or Priority Partners Customer Service or US Family Health Plan (USFHP) Customer Service or Advantage MD Customer Service/Benefits Toll free: (PPO) or (HMO) 11/16/ /16/2018 Presented by: Johns Hopkins HealthCare Provider Relations Department

64 Provider Relations: THANK YOU 11/16/2018 Presented 11/16/2018 by: Johns Hopkins HealthCare Provider Relations Department