Medicare Advantage Outreach and Education Bulletin

Transcription

1 Medicare Advantage Outreach and Education Bulletin Anthem BlueCross BlueShield 2014 Coverage Changes for Diabetic Supplies for DME Effective January 1, 2014, all of our individual Medicare Advantage plans will only cover LifeScan, Inc., OneTouch or Roche Diagnostics, ACCU-CHEK diabetic glucometers and blood test strips. This benefit change is meant to help control outof-pocket expenses while not compromising on quality. Covered glucometers and blood test strips in 2014: LifeScan, Inc., OneTouch Roche Diagnostics, ACCU-CHEK A limit of 100 blood test strips per month We will not cover other brands and manufacturers, or more than 100 test strips per month unless an exception is received from the member s provider stating it s medically necessary. Members impacted by this change were notified in October through their Annual Notice of Change and Evidence of Coverage plan benefit materials. Additionally, an outbound call campaign was launched. What will you need to do? If your customers are currently using OneTouch or ACCU-CHEK blood test strips or glucometer products, no action is required on your part. Customers not using OneTouch or ACCU-CHEK blood test strips and glucometer products, will need to obtain a new prescription or an exception from their doctor for their supplies by January 1 st in order for these claims to be covered. If the customer has questions, direct the customer to call the health plan s customer service number found on the back of their ID card. Physicians may call the following numbers to request an exception to the quantity limits or continue coverage of non Lifescan, Inc., or Roche Diagnostics products: Phone numbers for Precert: Transition Period: 1. NY & CT Plans All other Plans FAX number for Precert: 3. NY & CT Plans All other Plans

2 Our top priority is to ensure minimal disruption to our members who are impacted by these coverage changes. A transition period has been implemented to allow the member time to adjust to these changes. During the transition period, we will continue to cover the current brands for up to two fills during the first 90 days of the year (or the first 90 days of coverage for a new member). During this period, the member should talk with their doctor to decide what brand is medically appropriate for them. If a DME provider bills for non-covered brands or exceeds the quantity limit without having an exception on file once the transition period has expired, the DME provider will be liable for the charges, not the member, DME Providers will not be allowed to charge the member for those products unless they have a written agreement on file notifying the member that the product they chose is not covered and that they are 100% responsible for those charges. We recommend contacting the Precert number on the back of the member s ID card to confirm an exception is in place for plan permission to continue using the non LifeScan, Inc., and/or Roche Diagnostics blood test strips and glucometers once the transition period has expired. Diabetic Blood Test Strip Quantity Limits: Once the member has exceeded 1200/year blood test strips, provider claims will be rejected. Please refer back to page 1 What will you need to do? section and follow the instructions for the 4 th bullet. The member EOB will communicate a $0 member liability and no payment will be made to the DME Provider with the following reason: The plan allows for coverage of up to 100 Diabetic Test Strips per 30 days (1200/year) unless your doctor feels it is medically necessary for you to test more frequently. Your doctor must call the plan and order more. It is important that the DME provider work with the customer and/or physician to ensure that an exception be filed if needed. Once an exception is on file any charges that were denied can be resubmitted back to the health plan. HCFA Claim Form 1500/0805 Requirement: To ensure that members are using one of the two covered brands we request that DME Providers identify the National Drug Code (NDC) of the brand being used in section 24D on the claim form. As always, we reserve the right to conduct random audits to ensure compliance with the plan s benefit administration. Including the NDC on the claim form helps streamline the audit process, reducing the likelihood of requesting additional information from a DME Provider.

3 If a DME Provider does not include the NDC on the claim form, and we are unable to confirm an exception was given, allowing coverage for a non-covered brand during an audit, the DME Provider may be required to reimburse the health plan back for the benefits that were not covered. Medicare Advantage Plans included in this coverage change: CONTRACT # PBP PLAN NAME PLAN TYPE H Blue Cross Senior Secure Plan I (HMO) CA-HMO H Blue Cross Senior Secure Plan I (HMO) CA-HMO H Blue Cross Senior Secure Plan II (HMO) CA-HMO H Blue Cross Senior Secure Plan II (HMO) CA-HMO H Anthem Medicare Preferred Core (PPO) MO-LPPO H Anthem Medicare Preferred Core (PPO) MO-LPPO H Anthem Medicare Preferred Standard (PPO) IN-LPPO H Anthem Senior Advantage Value (HMO) KY-HMO H Anthem MediBlue Preferred Standard (PPO) CT-LPPO H Empire MediBlue Freedom III (PPO) NY-LPPO H Empire MediBlue Freedom I (PPO) NY-LPPO H Empire MediBlue Freedom II (PPO) NY-LPPO H Empire MediBlue Freedom II (PPO) NY-LPPO H Empire MediBlue Plus (HMO) NY-HMO H Empire MediBlue Select (HMO) NY-HMO H Empire MediBlue Plus (HMO) NY-HMO H Empire MediBlue Plus (HMO) NY-HMO H Empire MediBlue Plus (HMO) NY-HMO H Empire MediBlue Essential (HMO) NY-HMO H Anthem MediBlue Select (HMO) NH-HMO H Anthem Senior Advantage Basic (HMO) OH-HMO H Anthem Senior Advantage Plus (HMO) OH-HMO H Anthem Medicare Preferred Core (PPO) WI-LPPO H Anthem Medicare Preferred Standard (PPO) WI-LPPO H Anthem Medicare Preferred Standard (PPO) WI-LPPO H Anthem Medicare Preferred Core (PPO) VA-LPPO H Anthem Medicare Preferred Core (PPO) VA-LPPO H BlueValue Secure (HMO) GA-HMO H BlueValue Basic (HMO) GA-HMO H Anthem Medicare Preferred Standard (PPO) OH-LPPO H Anthem Medicare Preferred Select (PPO) OH-LPPO H Anthem Medicare Preferred Standard (PPO) KY-LPPO H Anthem MediBlue Value (HMO) CT-HMO H Anthem Medicare Preferred Premier (PPO) ME-LPPO H Anthem Medicare Preferred Premier (PPO) NH - LPPO H Anthem MediBlue Select (HMO) ME-HMO H Anthem Medicare Preferred Standard (PPO) CA-LPPO H Anthem Medicare Preferred Standard (PPO) CA-LPPO H Anthem Medicare Preferred Standard (PPO) CA-LPPO H Anthem Medicare Preferred Standard (PPO) CA-LPPO H Anthem Medicare Preferred Standard (PPO) CA-LPPO

4 H Anthem Medicare Preferred Standard (PPO) CA-LPPO H Anthem Medicare Preferred Standard (PPO) CA-LPPO H Anthem Medicare Preferred Standard (PPO) CA-LPPO H Anthem Medicare Preferred Standard (PPO) CA-LPPO H Anthem Medicare Preferred Standard (PPO) CA-LPPO H Anthem MediBlue Select (HMO) WI-HMO H Anthem MediBlue Select (HMO) WI-HMO H Anthem MediBlue Select (HMO) MO-HMO H Medicare Preferred Core (PPO) GA-LPPO H Anthem MediBlue Select (HMO) IN-HMO R Blue Medicare Access Classic (Regional PPO) OH-RPPO R Blue Medicare Access Value (Regional PPO) OH-RPPO R Blue Medicare Access Value (Regional PPO) IN&KY-RPPO To determine whether or not your customer is enrolled in one of our Individual Medicare Advantage plans versus an Employer or Union Sponsored plan, check the lower right front of the ID card which reflects the contract and PBP number (example: H ) and/or plan name. Note: If the PBP (the last three digits of the contract-pbp number) is in the 800 series, that member is in an Employer or Union Sponsored plan and these changes do not apply to their plans. Please contact the plan s Provider Service Department listed on the back of the member s ID card if you have any questions about these coverage changes.

5 The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. For more information about the exception process, or the appeals policy, please see the plan s 2014 Evidence of Coverage located at Y0071_14_19281_I_001 01/30/ MUPENMUB_001 Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia (serving Virginia excluding the city of Fairfax, the town of Vienna and the area east of State Route 123): Anthem Health Plans of Virginia, Inc. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi") underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") underwrites or administers the HMO policies; and Compcare and BCBSWi collectively underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.