2017 Frequently Asked Questions

Transcription

1 2017 Frequently Asked Questions NETWORK Q: Will I still have access to UPMC doctors and hospitals? A: At this time, UPMC providers are in our Security Blue HMO and Freedom Blue PPO networks. UPMC providers will remain in our Security Blue HMO and Freedom Blue PPO networks through June Members in Community Blue Medicare HMO will not have access to UPMC providers except in an emergency. Q: Do Highmark members have access to Cleveland Clinic? A: Cleveland Clinic is participating with Highmark s Freedom Blue PPO plan. Access to Cleveland Clinic is limited to urgent and emergent situations for Security Blue HMO and Community Blue Medicare HMO. Q: What are some examples of other out-of-area facilities that are included in the Freedom Blue PPO network? A: Memorial Sloan Kettering Cancer Center (New York City), Massachusetts General Hospital and Brigham and Women s Hospital (Boston). Q: Are Mayo Clinic and Johns Hopkins participating with Freedom Blue PPO? A: Because there is no Blue Cross Blue Shield Medicare Advantage network in the area, Highmark Members will not have access to these facilities at an in-network level. However, Highmark Members would have access through the Freedom Blue PPO out-of-network benefit. PLAN SPECIFICS Q: What are the main differences between Security Blue HMO ValueRx and Freedom Blue PPO ValueRx? A: The major difference (other than some slight copay differences) is the access to out of network care and the travel benefit. The travel benefit allows those enrolled in Freedom Blue PPO to utilize the Blue Cross Blue Shield Medicare Advantage network in 35 states plus Puerto Rico and receive routine care at the innetwork level. In areas where the network sharing is not available, the member can still receive routine care but will have higher cost sharing. As with all plans, urgent and emergent care received anywhere is covered at the in-network level. For those who are travelling and only need coverage for urgent and emergent care outside of the service area, Security Blue HMO or Community Blue Medicare HMO, if available, would fit their needs.

2 Q: How can a Highmark Medicare Advantage member submit out of country claims? A: There are some approved BCBSA hospitals in other countries (can be found on BCBSA website) that will file a claim to Highmark on the member s behalf. In most cases, the member will need to pay for the services up front and submit the claim to Highmark for reimbursement. Q: Can a Member enroll in a MA only (no PDP) and then enroll in a stand-alone prescription drug plan? A: No, both the MA only and the stand-alone PDP are considered Medicare Advantage plans and a Member can only be enrolled in one Medicare Advantage plan at a time. Please note that if a Member s Medicare Advantage Plan includes prescription drug coverage and the Member joins a Medicare Prescription Drug Plan, they will be disenrolled from their Medicare Advantage Plan and returned to Original Medicare. Some Veterans only use their VA drug coverage to get their medications, since VA drug coverage may offer more generous prescription drug coverage than Medicare Part D. Since VA drug coverage is considered creditable, meaning it is as good as or better than the Medicare prescription drug benefit, the VA Member can delay enrolling into Medicare Part D without penalty. If the VA Member loses VA drug coverage, they will need to enroll into a Part D plan within 63 days of losing their VA benefits. Note that although the VA Member can have both Medicare Part D and VA drug coverage, the two do not work together. VA benefits only cover the drugs the Veteran gets from VA pharmacies and Part D plans usually only cover drugs they get from pharmacies that are within the plan s network. Q: Can a Member with Veterans Affairs (VA) benefits enroll in a Medicare Advantage plan? A: Yes, VA Members can have both Medicare and Veterans Affairs (VA) benefits. However, Medicare and VA benefits do not work together. Medicare does not pay for any care a VA Member receives at a VA facility. In order for Medicare to cover a VA Member s care, they must receive care at a Medicare-certified facility that works with their Medicare coverage. In order for a VA Member s VA coverage to cover their care, the VA Member must generally receive health care services at a VA facility. VA Members are also able to enroll in a Medicare drug plan but the VA Member can t use both types of coverage for the same prescription at the same time. Q: Should agents submit a Medicare Supplement (Medigap) application if the beneficiary will be denied based on Highmark s medical underwriting guidelines? A: If the agent is sure the application will not be approved, it does not make sense to submit a Medigap application. This would be a good opportunity for the agent to sell a Highmark Medicare Advantage product instead. Please note that underwriting can take a few weeks and if they are waiting to hear back, the member might miss the end of AEP to enroll in a Highmark Medicare Advantage product.

3 Q: Does Highmark s Medicare Supplement (Medigap) plans include international travel benefits? A: Some of Highmark s Medigap plans include limited coverage outside US (see below for an example). Not all of Highmark s Medigap plans include this benefit. Since international travel is not covered by Medicare, the member would need to pay for the services up front and submit the claim to Highmark for reimbursement. Highmark Medigap Plans C, F and N ONLY: Highmark Medigap Plan F(HD) ONLY: PHYSICIAN AND FACILITY SERVICES Q: If a member is admitted to the hospital during an emergency room visit, will an emergency room copay be billed? A: If a member is admitted to the hospital during an emergency room visit for the same condition, they will not be charged the ER copay. The member will be charged the applicable inpatient hospital copay instead. Q: How much does a Skilled Nursing facility cost in 2017? A: The coverage for days 1-20 is $0 and coverage from days is $ a day. After 100 days, the member has exhausted their benefit period and has no additional coverage for the facility. If therapy and other services are medically necessary and authorized while in the facility, the member may still have coverage for those items.

4 Q: If a member has blood drawn at a PCP office, but the blood is analyzed at a hospital or an outside lab, what does the member pay? A: If the blood is drawn at the doctor's office or a free standing lab (like Quest), the member will pay the office/lab copay for the service. If the member goes to the hospital to have the blood work done, they will pay the outpatient copayment for labs. Q: If a member is seen by a non-participating physician at a participating hospital, how will the member be charged? A: If receiving care at a participating hospital, the member would be charged in-network rates. In this case the member is "held harmless" and the claim should process as in-network. If a member asks what to do in the event of an OON provider providing a service and it is out of the member s control (ER visit, Inpatient stay with an OON on duty physician, OON lab testing, etc.) the agent should advise the member to call member services and state they were not aware these services were being provided by an OON provider. Q: If a member is kept in the hospital overnight but not admitted to the hospital, how will the member be charged? A: Observation care will follow outpatient benefits for services completed (diagnostic testing, X-Rays, Advanced Imaging, etc.). There is coverage for these services, during this time the hospital doesn t have enough clinical proof of needing to admit the patient. This process is followed when a member needs an explanation on why they have been kept overnight in the hospital but their inpatient benefits have not been applied. BASIC PLAN COSTS Q: How is out-of-pocket maximum calculated? A: An out-of-pocket maximum is the most a member will pay in a calendar year (January to December) for Medicare covered health care services. Once the member reaches their out-of-pocket maximum, Highmark will begin to pay 100 percent of the allowed amount for covered services. This amount does not include the monthly premium, prescription drug costs, and services that are not covered by Medicare like vision and dental services. A very small percentage of members even meet Highmark s maximum out-of-pocket of $6,700. A Freedom Blue PPO ValueRx member in Pennsylvania would need to be hospitalized for 5 or more days ($1,500 per admit at $300 a day for days 1-5) more than 4 different times to come close to the out-of-pocket maximum of $6,700. Highmark s out-of-pocket maximum is put in place to help protect our Members from rising costs and to set a limit on their yearly spending should a catastrophic situation occur. Only Members with Part B drugs and/or an extended stay at a skilled nursing facility are likely to come close to Highmark s out-ofpocket maximum.

5 ADDITIONAL BENEFITS Q: How do I find more information about Highmark s dental and vision plans? A: The network of providers for dental is through UCCI. The network of providers for vision must participate with Davis Vision. You will not see stars to differentiate CB providers in the directory, all plans have the same network so if they are included the directory, they participate with all Highmark plans. United Concordia Dental Benefits are provided on an annual basis o Oral exam, cleaning and bitewing x-rays are covered with applicable copayment every 12 months To find a participating dentist, contact Highmark s Member Services. The number is located on the back of a member s ID card. Davis Vision Care Benefits are provided on an annual basis and are NOT reimbursement based o $0 Copay for routine eye exam o Standard Eyeglass lenses and frames or contact lenses are covered in full o A $100 benefit maximum applies to nonstandard frames and a $100 benefit maximum for specialty contact lenses o $200 benefit maximum for post cataract eyewear To find a participating provider, contact Highmark s Member Services. The number is located on the back of a member s ID card. Q: What does Highmark s Routine Transportation benefit include? A: Highmark will be providing an enhanced non-emergent transportation benefit that will include up-to 24 one-way routine trips for non-emergency, medical-related purposes such as doctor visits; appointments for dental, vision, hearing, and behavioral health services; and visits to pharmacies to pick up prescription drugs within a 50 mile limit. The destination must always be plan-approved. Special circumstances may be accommodated at discretion of the plan. The mode of transportation could include taxi, bus/subway, van, medical transport, wheelchair van, or car. If a member pays out of pocket for these modes of transportation, reimbursement may be provided in special circumstances at the discretion of the plan; however, personal vehicle expenses will not be considered for reimbursement. Plan authorization and scheduling rules apply. Members are responsible for obtaining prior authorization from the plan or a delegate. Any routine transportation services not scheduled through the plan or priorauthorized will not be covered. To obtain prior authorization and schedule a pickup, please call Member Services at the number on the back of the member s Highmark ID card.

6 FORMULARY CHANGES Q: Why does Highmark change its drug list (formulary) each year? A: There are several reasons for changes to the formulary year over year. Aside from making changes to the formulary to limit the number of covered drugs to keep costs down, there may be changes to what Medicare says should be covered, generic medications may become available (add the generic and remove the brand name), or drugs are found to be unsafe for the senior population. Any time drugs are removed from the formulary, there are always alternatives in the same drug class that are still covered. Q: What changes were made to the formulary from 2016? A: Highmark transitioned to one formulary in Highmark will continue to utilize the Closed formulary in Highmark will be piloting a new Preferred Pharmacy Network across the Community Blue Medicare HMO Signature (Western PA only), Security Blue HMO Value Rx, Blue Rx PDP Plus and Blue Rx PDP Complete plans in Members can continue to go to any in-network pharmacy but their costs for some drugs may be less at the pharmacies which offer preferred cost-sharing. In most cases, members who choose to use a standard network pharmacy will continue to pay the prescription drug copays they are accustomed to. Some of the preferred network pharmacies include: Walgreens Rite Aid Walmart (includes Sam s Club) K-Mart Costco Express Scripts PACE/LIS Q: What are the guidelines for PACE and Low Income Subsidy (LIS)? A: In 2016, for PACE, a single person cannot have countable income of more than $14,500. For a married couple, the combined income limit is $17,700. For PACENET, the income limit is between $14,500-$23,500 for a single person and $17,700-$31,500 for couples. In 2016, for LIS, income after exclusions, whether earned and unearned, must be less than 150% of the Federal Poverty Level (FPL) (based on size of the household) for subsidy eligibility. For a single person, their income cannot exceed $17,820. For a married couple, the combined income limit is $24,030. To be eligible for a full (100%) premium subsidy, the individual must have countable income less than, or equal to 135% of the FPL.