Health Exchange ID Card Guide Georgia

Transcription

1 Health Exchange ID Card Guide 2015 Georgia

2 Table of Contents Introduction... 3 Suggested HIX Financial Class and Payor Codes Assurant Health... 8 Blue Cross Blue Shield Healthcare Plan of Georgia... 9 Cigna Health and Life Insurance Company Coventry Health Care of Georgia Humana Employers Health Plan of Georgia AmBetter by Time Insurance UnitedHealthcare of Georgia National Enrollment Highlights Regional Marketplace Enrollment Data HIX Payors by Georgia County HIX Plan by Payor/Network Georgia Counties by HIX Payor/Network

3 Introduction For 2015, Health Exchange (HIX) products and plans expanded considerably with the entrance of several new plans that previously did not offer HIX products. Small, sub-networks were created to limit provider participation in the HIX products, in urban markets especially, and some commercial payors discounting current commercial rates to achieve lower reimbursement for their HIX products. All in all, understanding the HIX market has been much like hitting a moving target. With our feet squarely in the HIX world, there is some new terminology to understand, member identification cards to recognize, and operational processes that must be followed to ensure financial stability. This guide is intended for educational purposes within your organization, so please share it with your business office, registration, surgical and procedure scheduling, and any other department that intake patients or assists with setting up post-discharge care. Operational processes that you likely already have in place are now even more important to follow (see outlined below). It is also important to know if your organization is in network or out-ofnetwork with the HIX plans. You cannot assume that if you participate in a payor s commercial plan that your organization is automatically in network with the HIX. Several of the payors have created narrow networks specially for their HIX members. For example, Pathway for BCBS, Compass for UHC, and x for Humana, require you to confirm your organization s participation. In many cases, dependent upon the plan, there are no out-of-network benefits. You ll want to know your network participation status prior to rendering services so that you may collect payment from the patient. Verification of benefits and coverage are essential. When a patient presents a health insurance ID card (which we know is not proof of insurance anyway), there are three essential steps to take prior to rendering services: 3

4 1. Verify eligibility by contacting the health plan using online verification services directly with the plan or other third party vendors, or via telephone. Be sure to either print the verification, if done online, or record the name, telephone number, date and time of the individual with whom you spoke, if done via telephone. It is important to note that HIX members have a grace period if they fail to pay their premiums, during which time the health plan will continue to indicate their eligibility for services. It is very likely you ll need to prove that you verified eligibility in order to receive payment. 2. Verify benefits via online or other third party vendors. HIX plans must offer essential health benefits, but in some cases may offer additional benefits. There is also a wide range of patient financial responsibility (deductibles, copayments, coinsurances), depending upon the specific plan chosen and even within the range of health care services to be received. You ll need to have the benefit details available as you move to step Collect the patient s liability PRIOR to rendering services (except in cases of emergency). All of the HIX plans have a deductible, with some of them as high as $6,000. If not collected up front, it is very likely you ll collect as little as 10% of what is due afterwards. Get your money now. Set up Health Exchange as a separate Financial Class. Although it is still somewhat difficult to determine the difference between typical commercial and HIX ID cards, we do still suggest that you do two things to be able to track, report, and analyze the impact of HIXes on your organization: 1. Set up Health Exchange as a separate Financial Class. You already have classes set us as Medicare, Medicaid and Commercial. Be sure to distinguish this one as well. Additionally, build the specific Payor Codes (we included a suggested listing in this document) in your patient accounting systems. 2. Train and retrain your staff to correctly select the Financial Class and Payor Code within your system. This is also an opportunity to re-emphasize verifying eligibility and benefits and collecting patient liability. For example, you need to be able to differentiate Humana National (a commercial product) from Humana x (a health exchange product), for which your organization may have differing participation status. 4

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6 New Terminology: o On Exchange: health insurance purchased with the assistance of a governmental subsidy. o Off Exchange: health insurance purchased without subsidy. o Narrow Network: a smaller version or subset of an existing payor network, typically with lower reimbursement. Suggested HIX Financial Class and Payor Codes Financial Class Health Exchange Health Exchange Health Exchange Health Exchange Health Exchange Health Exchange Health Exchange Health Exchange Health Exchange Payor Code Alliant HIX Assurant HIX BCBS HIX Cigna HIX Coventry HIX Humana HIX Kaiser HIX AmBetter HIX UHC HIX 6

7 (available in the following counties ONLY: Banks, Barrow, Bartow, Carroll, Catoosa, Chattooga, Cherokee, Dade, Dawson, Fannin, Floyd, Forsyth, Franklin, Gilmer, Gordon, Habersham, Hall, Haralson, hart, Heard, Jackson, Lumpkin, Murray, Pickens, Polk, Rabun, Stephens, Towns, Union, Walker, White, Whitfield) Network(s) Accessed: Payor's Provider Directory: 7

8 Assurant Health (available state-wide) Network(s) Accessed: Aetna Payor's Provider Directory: Note: Time Insurance issued under Assurant Health 8

9 Blue Cross Blue Shield Healthcare Plan of Georgia (available state-wide) Continued 9

10 Network(s) Accessed: BCBS, BCBS Payor's Provider Directory: searchcriteria?qs=*qwfs+r/6hjpykm79eloplg==&brand=bcbsga 10

11 Cigna Health and Life Insurance Company (available in the following counties ONLY: Barrow, Bibb, Chattooga, Cobb, Dekalb, Floyd, Fulton, Gordon, Gwinnett, Laurens, Rockdale, Twiggs, Walton) Network(s) Accessed: Cigna LocalPlus Payor's Provider Directory: 11

12 Coventry Health Care of Georgia (available in the following counties ONLY: Appling, Baker, Berrien, Bibb, Bryan, Chatham, Chattahoochee, Cherokee, Clinch, Coffee, Crawford, Dawson, DeKalb, Dougherty, Echols, Effingham, Emanuel, Forsyth, Fulton, Gwinnett, Hall, Harris, Houston, Jones, Lanier, Lee, Liberty, Lowndes, Marion, Monroe, Muscogee, Newton, Peach, Rockdale, Stewart, Sumter, Terrell, Twiggs, Wayne, Worth) Network(s) Accessed: Coventry Payor's Provider Directory: -and-resources/tools/find-a-doctor/index.htm 12

13 Humana Employers Health Plan of Georgia x: (available Atlanta, Columbus, Macon, Savannah ONLY) : (available state-wide) 9CDMNRU0AHLOU0CGIMNST0AELT 0CDINST0ADEMSTY 0EPQST02EMNQ 06BIKNU029DEMNU 03/02ASY0MR 039DP 013CL012AE 059R03:DR :08 Network(s) Accessed: Humana and ChoiceCare Payor's Provider Directory: =218190c361cc4a02b986ae9bc242c847 13

14 Kaiser Foundation Health Plan of Georgia (available in the following counties ONLY: Barrow, Bartow, Butts, Carroll, Cherokee, Clayton, Cobb, Coweta, Dawson, Dekalb, Douglas, Fayette, Forsyth, Fulton, Gwinnett, Hall, Haralson, Heard, Henry, Lamar, Meriwether, Newton, Paulding, Pickens, Pike, Rockdale, Spalding, Walton) Network(s) Accessed: Kaiser Payor's Provider Directory: os3g3r2b_jyddrwolugmxa89qzzdns0bpqwmda30v_aj0npwkompwk F68asHyBsaegWB59wAzAwNPC-8Q7zBLb2MDAyOoPA7gaKDv55Gfm 6pfkB0c5FHuqAgALrzoAg!!/dl3/d3/L2dJQSEvUUt3QS9ZQnZ3 LzZfRkpTT0JCMUEwMEZEOTBJNjdKQzBIMDMwMDU! /?_ga=

15 AmBetter by (available in the following counties ONLY: Barrow, butts, Chattahoochee, Cherokee, Clarke, Clayton, Dekalb, Elbert, Fayette, Forsyth, Fulton, Greene, Gwinnett, Harris, Henry, Jackson, Madison, Marion, Muscogee, Oconee, Spalding, Talbot, Walton) Network(s) Accessed: Payor's Provider Directory: 15

16 Time Insurance See Assurant 16

17 UnitedHealthcare of Georgia (Available state-wide) Network(s) Accessed: UHC and Payor's Provider Directory: 17

18 National Enrollment Highlights ASPE Issue Brief, December 30, Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation. 18

19 Regional Marketplace Enrollment Data Description GA SC AL FL US Total Number of Individuals Determined Eligible to Enroll through the Marketplace for ,766 96,032 88, ,380 4,376,414 Eligible to Enroll with Financial Assistance 200,426 77,154 68, ,666 3,562,522 Determined or Assessed Eligible for Medicaid/CHIP by the Marketplace 22,298 6,647 3,434 48, ,026 Total Number of Individuals Who Have Selected a 2015 Marketplace Plan 187,654 75,075 64, ,255 4,048,861 New Consumers (Percent of State TotalThat Selected Plan) Consumers Reenrolling (Percent of State Total That Selected Plan) 55% 57% 47% 49% 50% 45% 43% 53% 51% 50% ASPE Issue Brief, December 30, Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation. 19

20 HIX Payors by Georgia County County Payor/Network Plan Type Appling Atkinson Bacon Baker Baldwin Banks Cigna Health and Life Insurance Company Barrow Bartow Ben Hill 20

21 Berrien Bibb Bleckley Brantley Brooks Bryan Bulloch Burke Butts Calhoun Cigna Health and Life Insurance Company 21

22 Camden Candler Carroll Catoosa Charlton Chatham Chattahoochee Chattooga Cherokee Cigna Health and Life Insurance Company 22

23 Clarke Clay Clayton Clinch Cobb Coffee Colquitt Columbia Cook Cigna Health and Life Insurance Company 23

24 Coweta Crawford Crisp Dade Dawson Decatur Dekalb Dodge Dooly Cigna Health and Life Insurance Company 24

25 Dougherty Douglas Early Echols Effingham Elbert Emanuel Evans Fannin Fayette 25

26 Floyd Forsyth Franklin Fulton Gilmer Glascock Glynn Gordon Cigna Health and Life Insurance Company Cigna Health and Life Insurance Company Cigna Health and Life Insurance Company 26

27 Grady Greene Gwinnett Habersham Hall Hancock Haralson Harris Cigna Health and Life Insurance Company 27

28 Hart Heard Henry Houston Irwin Jackson Jasper Jeff Davis Jefferson 28

29 Jenkins Johnson Jones Lamar Lanier Laurens Lee Liberty Lincoln Long Cigna Health and Life Insurance Company 29

30 Lowndes Lumpkin Macon Madison Marion Mcduffie Mcintosh Meriwether Miller Mitchell Monroe 30

31 Montgomery Morgan Murray Muscogee Newton Oconee Oglethorpe Paulding Peach 31

32 Pickens Pierce Pike Polk Pulaski Putnam Quitman Rabun Randolph Richmond 32

33 Rockdale Schley Screven Seminole Spalding Stephens Stewart Sumter Talbot Taliaferro Cigna Health and Life Insurance Company 33

34 Tattnall Taylor Telfair Terrell Thomas Tift Toombs Towns Treutlen Troup Turner Twiggs Cigna Health and Life Insurance Company 34

35 Union Upson Walker Walton Ware Warren Washington Wayne Webster Wheeler Cigna Health and Life Insurance Company 35

36 White Whitfield Wilcox Wilkes Wilkinson 36

37 HIX Plan by Payor/Network Payor/Network Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Cigna Health and Life Insurance Company Plan Name SoloCare SoloCare SoloCare SoloCare SoloCare SoloCare SoloCare SoloCare SoloCare SoloCare SoloCare SoloCare SoloCare SoloCare SoloCare SoloCare SoloCare SoloCare SoloCare SoloCare BCBSHP Bronze Pathway X 0 for HSA BCBSHP Bronze Pathway X 20 for HSA BCBSHP Bronze Pathway X 30 for HSA BCBSHP Bronze Pathway X BCBSHP Bronze Pathway X BCBSHP Catastrophic Pathway X BCBSHP Silver Pathway X 10 for HSA BCBSHP Silver Pathway X BCBSHP Silver Pathway X BCBSHP Silver Pathway X BCBSHP Silver Pathway X Blue Cross and Blue Shield Healthcare Plan of Georgia Gold DirectAccess, a Multi-State Plan Blue Cross and Blue Shield Healthcare Plan of Georgia Silver DirectAccess, a Multi-State Plan mycigna Health Flex 1000 mycigna Health Flex 2000 mycigna Health Flex 3000 mycigna Health Flex 5000 Bronze 37

38 Coventry Health Care of Georgia, Inc. Humana Employers Health Plan mycigna Health Savings 3400 mycigna Health Savings 6000 Coventry Bronze $20 Copay Albany Coventry Bronze $20 Copay Atlanta Coventry Bronze $20 Copay Columbus Coventry Bronze $20 Copay Hall Coventry Bronze $20 Copay Macon Coventry Bronze $20 Copay Savannah Coventry Bronze $20 Copay SEGA Coventry Bronze $20 Copay Valdosta Coventry Bronze Ded Only HSA Eligible Albany Coventry Bronze Ded Only HSA Eligible Atlanta Coventry Bronze Ded Only HSA Eligible Columbus Coventry Bronze Ded Only HSA Eligible Hall Coventry Bronze Ded Only HSA Eligible Macon Coventry Bronze Ded Only HSA Eligible Savannah Coventry Bronze Ded Only HSA Eligible SEGA Coventry Bronze Ded Only HSA Eligible Valdosta Coventry Gold $5 Copay Albany Coventry Gold $5 Copay Atlanta Coventry Gold $5 Copay Columbus Coventry Gold $5 Copay Hall Coventry Gold $5 Copay Macon Coventry Gold $5 Copay Savannah Coventry Gold $5 Copay SEGA Coventry Gold $5 Copay Valdosta Coventry Silver $10 Copay Albany Coventry Silver $10 Copay Atlanta Coventry Silver $10 Copay Columbus Coventry Silver $10 Copay Hall Coventry Silver $10 Copay Macon Coventry Silver $10 Copay Savannah Coventry Silver $10 Copay SEGA Coventry Silver $10 Copay Valdosta Coventry Silver $5 Copay 2750 Albany Coventry Silver $5 Copay 2750 Atlanta Coventry Silver $5 Copay 2750 Columbus Coventry Silver $5 Copay 2750 Hall Coventry Silver $5 Copay 2750 Macon Coventry Silver $5 Copay 2750 Savannah Coventry Silver $5 Copay 2750 SEGA Coventry Silver $5 Copay 2750 Valdosta Humana Basic 6600/Atlanta x 38

39 of Georgia, Inc. Kaiser Foundation Health Plan of Georgia Humana Basic 6600/Columbus GA x Humana Basic 6600/Macon x Humana Basic 6600/National - OpenAccess Humana Basic 6600/Savannah x Humana Bronze 4850/Atlanta x Humana Bronze 4850/Columbus GA x Humana Bronze 6300/Atlanta x Humana Bronze 6300/Columbus GA x Humana Bronze 6300/Macon x Humana Bronze 6300/National - OpenAccess Humana Bronze 6300/Savannah x Humana Gold 2500/Atlanta x Humana Gold 2500/Columbus GA x Humana Gold 2500/Macon x Humana Gold 2500/National - OpenAccess Humana Gold 2500/Savannah x Humana Platinum 1000/Atlanta x Humana Platinum 1000/Columbus GA x Humana Platinum 1000/Macon x Humana Platinum 1000/National - OpenAccess Humana Platinum 1000/Savannah x Humana Silver 4250/National - OpenAccess Humana Silver 4600/Atlanta x Humana Silver 4600/Columbus GA x Humana Silver 4600/Macon x Humana Silver 4600/Savannah x KP GA Bronze 4500/50/HSA KP GA Bronze 5000/30%/HSA KP GA Bronze 5000/50 KP GA Catastrophic 6600/0 KP GA Gold 0/20 KP GA Gold 1000/20 KP GA Gold 1500/20 KP GA Silver 1500/30 KP GA Silver 1750/25%/HSA KP GA Silver 2500/30 Ambetter Balanced Care 1 Ambetter Balanced Care 1 + Vision Ambetter Balanced Care 1 + Vision + Adult Dental Ambetter Balanced Care 2 Ambetter Balanced Care 2 + Vision Ambetter Balanced Care 2 + Vision + Adult Dental Ambetter Balanced Care 3 39

40 Ambetter Balanced Care 3 + Vision Ambetter Balanced Care 3 + Vision + Adult Dental Ambetter Balanced Care 4 Ambetter Balanced Care 4 + Vision Ambetter Balanced Care 4 + Vision + Adult Dental Ambetter Balanced Care 5 Ambetter Balanced Care 5 + Vision Ambetter Balanced Care 5 + Vision + Adult Dental Ambetter Essential Care 1 Ambetter Essential Care 1 + Vision Ambetter Essential Care 1 + Vision + Adult Dental Ambetter Essential Care 2 Ambetter Essential Care 2 + Vision Ambetter Essential Care 2 + Vision + Adult Dental Ambetter Essential Care 3 with 3 Free PCP Visits Ambetter Essential Care 3 with 3 Free PCP Visits + Vision Ambetter Essential Care 3 with 3 Free PCP Visits + Vision + Adult Dental Ambetter Essential Care 4 with 3 Free PCP Visits Ambetter Essential Care 4 with 3 Free PCP Visits + Vision Ambetter Essential Care 4 with 3 Free PCP Visits + Vision + Adult Dental Ambetter Secure Care 1 with 3 Free PCP Visits Ambetter Secure Care 1 with 3 Free PCP Visits + Vision Assurant Health by Time Insurance (Aetna network) UnitedHealthcare of Georgia, Inc. Ambetter Secure Care 1 with 3 Free PCP Visits + Vision + Adult Dental Ambetter Secure Care 2 Ambetter Secure Care 2 + Vision Ambetter Secure Care 2 + Vision + Adult Dental Assurant Health Bronze Plan 001 Assurant Health Bronze Plan 002 Assurant Health Gold Plan 002 Assurant Health Platinum Plan 002 Assurant Health Silver Plan 001 Assurant Health Silver Plan 002 UnitedHealthcare Bronze Compass 4200 UnitedHealthcare Bronze Compass HSA 5000 UnitedHealthcare Bronze Compass HSA 6275 UnitedHealthcare Catastrophic Compass 6600 UnitedHealthcare Gold Compass 1000 UnitedHealthcare Gold Compass HSA 1300 UnitedHealthcare Platinum Compass 250 UnitedHealthcare Silver Compass

41 UnitedHealthcare Silver Compass 5000 UnitedHealthcare Silver Compass HSA

42 Georgia Counties by HIX Payor/Network Payor/Network Cigna Health and Life Insurance Company County Banks Barrow Bartow Carroll Catoosa Chattooga Cherokee Dade Dawson Fannin Floyd Forsyth Franklin Gilmer Gordon Habersham Hall Haralson Hart Heard Jackson Lumpkin Murray Pickens Polk Rabun Stephens Towns Union Walker White Whitfield All counties in Georgia Barrow Bibb Chattooga 42

43 Cobb Dekalb Floyd Fulton Gordon Gwinnett Laurens Rockdale Twiggs Walton Appling Baker Berrien Bibb Bryan Chatham Chattahoochee Cherokee Clinch Coffee Crawford Dawson Dekalb Dougherty Echols Effingham Emanuel Forsyth Fulton Gwinnett Hall Harris Houston Jones Lanier Lee Liberty Lowndes Marion Monroe Muscogee Newton Peach 43

44 Rockdale Stewart Sumter Terrell Twiggs Wayne Worth Banks Barrow Bartow Bibb Bleckley Brantley Bryan Bulloch Burke Butts Camden Candler Carroll Chatham Chattahoochee Cherokee Clarke Clayton Cobb Columbia Coweta Crawford Dawson Dekalb Douglas Effingham Emanuel Evans Fayette Floyd Forsyth Fulton Glascock Glynn Greene Gwinnett 44

45 45 Hall Hancock Haralson Harris Heard Henry Houston Jackson Jefferson Jenkins Johnson Jones Lamar Laurens Liberty Lincoln Long Madison Marion Mcduffie Mcintosh Monroe Morgan Muscogee Newton Oconee Oglethorpe Paulding Peach Pickens Polk Richmond Rockdale Screven Spalding Stewart Talbot Taliaferro Tattnall Troup Twiggs Walton Warren

46 Washington Wayne Webster Wilkes Wilkinson Barrow Bartow Butts Carroll Cherokee Clayton Cobb Coweta Dawson Dekalb Douglas Fayette Forsyth Fulton Gwinnett Hall Haralson Heard Henry Lamar Meriwether Newton Paulding Pickens Pike Rockdale Spalding Walton Barrow Butts Chattahoochee Cherokee Clarke Clayton Dekalb Elbert Fayette Forsyth 46

47 Assurant Health by Time Insurance (Aetna network) Fulton Greene Gwinnett Harris Henry Jackson Madison Marion Muscogee Oconee Spalding Talbot Walton All counties in Georgia All counties in Georgia *** 47