Important 2016 Changes

Transcription

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2 Important 2016 Changes SmartHealth Website Two Medical Benefit Plans PPO 500 and HDHP 1300 Fee Schedule Eligibility and Verification Claims Submission Authorization Process Pharmacy Benefit Manager (PBM) Wellness Plan/Preventative Plan Care Management

3 SmartHealth Website Local Ascension Network (Tier 1) Provider Search 0

4 2016 Medical Plans PPO 500 & HDHP 1300 Tier 1: Providers currently contracted directly with Seton Health Plan (SmartHealth) and Ascension Health Ministries physicians, Ancillary providers and facilities Tier 2 National Network: Providers Cigna PPO (Seton Associates) Blue Cross Blue Shield (Ascension Associates) Tier 3: Out-of-Network Providers who are not in the Tier 1 or 2

5 Two Medical Plans Option 500 / 15% HDHP 1300 / 0% Medical Plans Plan Sponsor: SmartHealth Plan Administrator: Seton Health Plan Tier 1: Seton Health Plan and Ascension Health Network contracted providers Tier 2: Cigna/BCBS National Network Lower Deductible / Out-of-Pocket Flat $ Co-pays across all tiers (e.g. Generic, Formulary, Specialty) Flexible Spending Account (FSA) Higher Deductible / Out-of-Pocket Pharmacy Plan Seton Central Outpatient Pharmacy (SCOP) Pharmacy Benefit Manager (PBM): Cigna Associate pays full $ contracted rates up to annual deductible Health Savings Account (HSA)

6 Schedule of Benefits PPO 500 Tier 1 (Seton Health Plan contracted providers) Individual Deductible: $500; Max: $2,200 Family Deductible: $1,000; Max: $4,400 Coinsurance: 15% after deductible

7 Schedule of Benefits PPO 500

8 Schedule of Benefits HDHP 1300 Tier 1 (Seton Health Plan contracted providers) Individual Deductible: $1,300; Max: $2,000 Family Deductible: $2,600; Max: $4,000

9 Schedule of Benefits HDHP 1300

10 Clinical Pathology Laboratories and Austin Radiological Associates Beginning January 1, 2016 SHP is contracted with CPL and ARA for Seton Associates What this means to you: Seton Health Plan employees are no longer required to have lab and imaging done at a Seton facility No more sending healthy patients to the hospital No more hassle remembering where to send lab specimen No more inconvenient trips to the hospital for the patient Current listing of locations is available on

11 Fee Schedule Jurisdiction H Part B: Physicians & other health care professionals

12 Novitas Solutions Search & Download Procedure Code: DOS: State: Texas Locality: Austin

13 Sample ID Cards

14 Eligibility & Verification In 2016 eligibility and verification is found in the Physician Self Service Center. We encourage providers to verify eligibility and benefits before each service is rendered. Log on to our Physician Self-Service Center to look-up claims status, eligibility, or authorizations Website: You must use the new member IDs that will be assigned January 2016 The member ID for 2016 will be a 9 digit number with a 2 digit suffix You must be a registered user to access this site.

15 Claims Submission Claims Address for SmartHealth Employee Plan ONLY Paper and Electronic Submission PO Box Chattanooga, TN Electronic Payer ID: 62308

16 Chiropractor, Physical & Occupational Therapy Claims Submission Chiropractors, and non-facility Physical and Occupational Therapist directly contracted with ASHN Claims for SmartHealth Members will be submitted directly to ASHN Send paper claims to the address below: American Specialty Health Network P.O. Box San Diego, CA Send electronic claims to: Payer ID ASH01 Payment for services will be issued by ASH network according to the contracted reimbursement outlined in your agreement with ASH For general inquiries, call ASH Provider Services Department at

17 Chiropractor, Physical & Occupational Therapy Claims Submission If you are a contracted Seton Health Plan Provider and not contracted through ASH Network Send paper claims to the address below: P.O. Box Chattanooga, TN Electronic Payer ID: Payer ID 62308

18 Authorization Process Medical Management Department 4515 Seton Center Parkway, Ste 310 Austin, Texas Phone: (512) Fax: (512) To inquire about an authorization please refer the PSS portal or contact the Medical Management Department Authorization/referral request forms and Authorization Grids are available on-line at

19 Seton Central Outpatient Pharmacy SCOP This program offers the lowest pharmacy costs for employees. The copays are lower than the retail pharmacies (HEB, Walgreens, CVS, etc.). Prescriptions are delivered to the inpatient pharmacy nearest to the associate Urgent medication requests should be filled at a retail pharmacy

20 Pharmacy Benefit Manager

21 Women s Health Services The ACA requires group health plans to provide coverage for women s health services as part of an array of women s preventive services. These services must be included in health plans without cost sharing to covered participants. Cigna manages this plan The Seton Healthcare Network Employee Health Plan will not provide coverage for contraceptive benefits that are in conflict with our Catholic Identity and the Ethical and Religious Directives for Catholic Health Care Services.

22 2016 SmartHealth Wellness Program Available to associates enrolled in the medical plan Health Risk Questionnaire Rewards for completion of wellness activities Wellness activities include five categories: Clinical Fitness Education Lifestyle Spirituality Stay tuned for more information!!

23 Seton s Care Coordination Program What is the Care Management Program? Helps ensure associates and their dependents receive medically necessary and appropriate health care. Current Programs Offered Complex/high risk medical conditions Chronic Disease Management, such as: Diabetes Asthma Stroke Heart Failure End Stage Renal Disease Spinal cord injury High Risk Pregnancy Transplants Catastrophic conditions Care Management is a benefit. This will not affect your cost or coverage! Enrollment Options Contact the Seton Health Plan at (512) option 6 for Disease Management your request to disease-mngt@seton.org Seton Health Plan Care Coordinators may contact associates and their dependents to enroll in the program

24 Provider Engagement Seton Health Plan Provider Staff are here to assist and guide you through any concerns or issues from 8:00 am to 5:00 pm, Monday through Friday. Please visit our website for more information: & Susan Fowler, MHA Misty Arayata Senior Provider Engagement Liaison Senior Provider Engagement Liaison Office: (512) x Office: (512) x SHPProviderservices@seton.org Seton Health Plan 4515 Seton Center Pkwy, Suite 310 Austin, Texas 78759

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