2014 Medicare Advantage HMO Product Training

Transcription

1 2014 Medicare Advantage HMO Product Training TexanPlus HMO-POS (Houston) & Kelsey-Seybold Training Update Y0067_AGT-KSCUpdate_0913 IA 09/27/2013

2 How TexanPlus HMO Plan Works Members enrolled in a TexanPlus plan: Must use TexanPlus contracted providers. Must select a Primary Care Physician (PCP) at the time of enrollment. Agents must: Select the provider using the online provider search tool on AgentLink as the source of truth. The online provider search tool allows agents to select providers in network, see who is accepting new patients, and confirm which providers are in an open panel. Because specialists are referred within the Local Physician Organization (LPO), a review of LPO doctors will identify which PCP and Specialists are available for services. Specialists in other LPO groups contracted with Texan Plus are not considered in network if not in the same LPO with the PCP. Should identify ALL providers the prospect is utilizing and ensure they are available. UPDATE - Kelsey-Seybold in the Houston Network: Members in TexanPlus in Houston may now select Kelsey-Seybold physicians in select counties with certain restrictions. Must use In-network hospitals to ensure lower hospital copays

3 HMO Network Overview Local Physician Organization (LPO) Investing In Member s Health Not Their Sickness. LPO also known as Physician Organized Delivery Systems (PODS) designed and directed by physicians leaders based on quality of care and clinical outcomes. Physician leaders work with the health plan to identify and recruit providers that are fully engaged in the model and deliver quality-driven results. Coordinated care with quality outcomes = cost-effective medicine. Because specialists are referred within the LPO, a review of LPO doctors will identify which PCP and Specialists are available for services. Specialists in other LPO groups contracted with Texan Plus are not considered in network if not in the same LPO with the PCP.

4 2014 Kelsey-Seybold Enrollment Update Kelsey-Seybold Clinic is in the Network Enrollees are able to select Kelsey-Seybold physicians in the following counties and zip codes only Harris Northern Brazoria (zip codes 77581, 77584, 77588) Fort Bend Northern Galveston (zip codes 77546, 77549, 77565) Montgomery All counties and zip codes not listed above Agents may not enroll members into a TexanPlus plan using Kelsey-Seybold physicians. NOTE: Network limitations or restrictions may apply to Northern Brazoria and Northern Galveston. Please contact the plan for more details.

5 2014 Kelsey-Seybold Enrollment Update Kelsey-Seybold Clinics are a significant addition to the Houston area. In the past, the TexanPlus and Kelsey- Seybold relationship has caused enrollment and exception challenges resulting in complaints and disenrollments. For the 2014 year the following Kelsey-Seybold policy has been simplified and will have no exceptions. Exceptions will not be considered for: Waller, Liberty, Chambers, Galveston Island, South Brazoria Counties Enrollees with Existing Kelsey-Seybold Spouses Recently approved exceptions will be honored No further exceptions will be considered as of September 1 st, 2013 NOTE: Network limitations or restrictions may apply to Northern Brazoria and Northern Galveston. Please contact the plan for more details.

6 Houston Area approved County Map accepting and not accepting Kelsey-Seybold Harris County Northern Brazoria County Pearland Pearland Pearland Fort Bend County Northern Galveston County Friendswood Friendswood Kemah X X Pearland X X X X Montgomery County NOTE: Network limitations or restrictions may apply to Northern Brazoria and Northern Galveston. Please contact plan for additional details.

7 2014 Medicare Advantage HMO-POS Product Training TexanPlus Choice (HMO-POS)

8 TexanPlus HMO-POS Plan The Key Differences TexanPlus Classic (HMO) Network-based product No out-of-network benefit Transportation benefit TexanPlus Choice (HMO-POS) Network-based product with Out-of-Network options Higher copayments and cost sharing apply No Transportation benefit Members may obtain care while traveling outside of the Houston / Beaumont area.

9 TexanPlus Choice - Point of Service (HMO-POS) All the value of TexanPlus HMO: local, engaged doctors providing personalized, connected care to keep members healthy, plus: Must use TexanPlus Network Providers for In-Network benefits. Flexibility to receive services from doctors or hospitals outside the plan network and Local Physician Organization (LPO) at a higher copay or coinsurance Because specialists are referred within the Local Physician Organization (LPO), a review of LPO doctors will identify which PCP and Specialists are available for services. Specialists in other LPO groups contracted with Texan Plus are not considered in network if not in the same LPO with the PCP.

10 HMO-POS In Network vs. Out-of-Network Members may choose to receive care from providers outside the plan LPO network, who participate in Medicare. Care received from an out-of-network provider will generally cause the member s cost share to be higher. Care received from an out-of-network provider who doesn t participate in Medicare will be responsible for the full cost of administered services (Except in emergency situations). * Out-of-network providers must choose to accept TexanPlus HMO-POS members as patients

11 In Network vs. Out-of-Network How Do the Provider Networks Work (continued)? If it is determined that services received from an out-of-network provider were not medically necessary, the plan may deny coverage and the member will be responsible for the entire cost. If a member uses an out-of-network provider for emergency care, urgently needed care or out-of-area dialysis, the member generally may not have to pay a higher out-of-network cost-sharing amount. Kelsey-Seybold will not allow members to utilize their providers as an outof-network provider Out-of-network providers must choose to accept TexanPlus HMO-POS members as patients. NOTE: Network limitations or restrictions may apply to Northern Brazoria and Northern Galveston. Please contact the plan for more details.

12 Out-of-Network services not covered The following are NOT covered under the POS out-of-network coverage: Durable Medical Equipment (DME) Except Prosthetics or Medical Supplies Skilled Nursing Facility (SNF) Home Health Transportation (Not covered In-Network or Out-of-Network)

13 TexanPlus Choice (HMO-POS) The following benefits are specific to the POS component of the plan The POS component is utilized when receiving services from an out-of-network provider, or when using contracted providers in the service area but outside of the LPO. The plan utilizes the HMO component when using contracted LPO providers.* HMO-POS members can see any Out-Of-Network, non-lpo contracted provider who participates in Medicare (except for Kelsey-Seybold providers)*. The POS out of network geographical area is defined as the United States but not within the LPO when using LPO-contracted providers. POS services do not need to be authorized by the plan and do not require any referrals however out-of-network providers must choose to accept TexanPlus HMO-POS members as patients. * Out-of-network providers must choose to accept TexanPlus HMO-POS members as patients

14 TexanPlus Choice (HMO-POS) The member s choice of a contracted PCP determines the specialists that are available to them as In-Network and when the POS would not be available to the member. When seeing an In-Network Contracted provider, the HMO component of the plan is being accessed. The member is responsible for the lower In-Network cost share. Authorizations and referrals are generally required; see EOC for full detail. Services provided by an In-Network contracted provider are not eligible to be covered under the POS component of the plan, but rather only under the innetwork HMO and the related in-network HMO cost-sharing. When seeing an Out-of-Network provider, the POS component of the plan is being accessed. The member is responsible for the higher Out-of-Network cost share. Authorizations and referrals are not required.

15 TexanPlus Plans and Kelsey-Seybold Enrolled members who will be utilizing Kelsey-Seybold Physicians: Must select a Primary Care Physician (PCP) at the time of enrollment. Agents should identify ALL providers the prospect is utilizing and ensure they are available within the network, LPO, and are accepting patients. Must insure members reside in an approved county or zip Kelsey-Seybold Restrictions Kelsey-Seybold (or any out-of-network provider) reserves the right to refuse outof-network coverage. Kelsey-Seybold physicians may only be chosen in the counties and zip codes authorized. No Exceptions. Specialists in other LPO groups contracted with Texan Plus are not considered in network if not in the same LPO as the PCP. NOTE: Network limitations or restrictions may apply to Northern Brazoria and Northern Galveston. Please contact the plan for more details.

16 Key Benefit Overview (HMO-POS) Benefit TexanPlus Choice (HMO-POS) In-Network Out-of-Network Service Area Houston/Beaumont United States Maximum Out Of Pocket $3,400 $10,000 Inpatient Hospital Copay $135 per day for days 1-6; $0 for days % PCP Copay $0 $35 Specialist Copay $30 $50 Urgently Needed Care $30 $30

17 Questions Regarding Kelsey-Seybold? UAM Sales Support Telephone: or Toll-Free: Available Monday to Friday, 8:30 a.m. to 5p.m. Eastern Time