Medicare Advantage Outreach and Education Bulletin

Transcription

1 Medicare Advantage Outreach and Educatin Bulletin Anthem Blue Crss and Blue Shield Changing 2013 Medicare Advantage Plan Update Dear Healthcare Prvider, Annual benefits changes fr Medicare Advantage plan members will be effective January 1, The changes apply t members enrlled in Anthem Medicare Preferred Cre (PPO). A new Anthem Medicare Advantage plan will als be available t beneficiaries in select Missuri cunties effective January 1, Yu can help members manage their health care csts by being aware f these changes. In additin, it is imprtant t check the Medical ID card at the beginning f each calendar year as the member may have changed plans. Each year, we renew ur cntract with the Centers fr Medicare and Medicaid Services (CMS). CMS re-evaluates and apprves the benefits we ll ffer t ur Medicare Advantage members fr the upcming year. Ntable 2013 benefit changes and highlights by plan type. Anthem Medicare Preferred Cre (PPO) plan changes Changes applicable t members in the existing cre plan in the fllwing cunties: Barry, Bartn, Cedar, Christian, Dade, Dallas, Duglas, Greene, Jasper, Lawrence, Newtn, Plk, St. Charles, St. Luis, St. Luis City, Stne, Taney, and Webster The maximum-ut-f-pcket fr Anthem Medicare Preferred Cre (PPO) will be increasing fr 2013 frm $4,500 t $5,400. Medicare Preferred Cre members will see a premium increase frm $0 t $34 in Outpatient Hspital and Ambulatry Surgical Centers cst shares will be mving frm a cpayment t a cinsurance. Member cst shares are changing fr certain utpatient labs, diagnstic tests, X-rays and radilgy prcedures fr Anthem Medicare Preferred Cre. In 2013, we will be ffering a new PPO plan. Anthem Medicare Preferred Cre (PPO) will be available in the fllwing cunties: Ozark, Warren, and Wright. Please check the member ID card fr any identificatin and/r grup number changes that may affect claim submissins. Anthem Medicare Preferred Cre (PPO) plan highlights fr Barry, Bartn, Cedar, Christian, Dade, Dallas, Duglas, Greene, Jasper, Lawrence, Newtn, Plk, St. Charles, St. Luis, St. Luis City, Stne, Taney and Webster cunties $34 plan premium. $5 cpay fr Primary care physician (PCP) visits and $35 cpay fr specialist visits. Medicare Preferred Cre participates in reciprcal netwrk sharing. This netwrk sharing allws all Blue MA PPO members t btain netwrk-level benefits when traveling r living in the service area f any ther Blue MA PPO

2 Plan as lng as the member sees a cntracted MA PPO prvider. Yu can recgnize a MA PPO member when their Blue Crss Blue Shield Member ID card has the MA in the suitcase, which indicates the member is cvered under the MA PPO netwrk sharing prgram. In 2013, the states f New Jersey and Texas have been added t the service area. $0 cpay fr Medicare-cvered Preventive Care. Anthem Medicare Preferred Cre (PPO) plan highlights fr Ozark, Warren, and Wright cunties $33 plan premium. $10 cpay fr Primary care physician (PCP) visits and $45 cpay fr specialist visits. Medicare Preferred Cre participates in reciprcal netwrk sharing. This netwrk sharing allws all Blue MA PPO members t btain netwrk-level benefits when traveling r living in the service area f any ther Blue MA PPO Plan as lng as the member sees a cntracted MA PPO prvider. Yu can recgnize a MA PPO member when their Blue Crss Blue Shield Member ID card has the MA in the suitcase, which indicates the member is cvered under the MA PPO netwrk sharing prgram. In 2013, the states f New Jersey and Texas have been added t the service area. $0 cpay fr Medicare-cvered Preventive Care. Grup/Unin Spnsred Plans may nt be impacted by mst f the changes described abve fr PPO plans including reductins t the plans service areas. Our members in Grup/Unin Spnsred Medicare Advantage LPPO Plans will cntinue t enjy access t health plan services acrss the cuntry. Optinal Supplemental Benefits (OSB) Fr 2013, many f ur Medicare Advantage plans will be ffering three Optinal Supplemental Benefit (OSB) packages fr an additinal premium. These packages will allw the Medicare Advantage plan t be tailred t add additinal dental, visin, chirpractic and acupuncture cverage by enrlling in an OSB package. Anthem will ffer the fllwing Optinal Supplemental Benefit (OSB) packages n select plans in which members will have up t 90 days frm their plan effective date t enrll. New fr 2013 will be the remval f the 10 visit limit n chirpractic and acupuncture benefits, but the yearly dllar cap fr these services will still apply. 1.) Preventive Dental Package 2.) Cmprehensive Dental and Visin Package 3.) Cmbinatin Package (includes dental, visin, chirpractic, and acupuncture). Medicare Part D Prescriptin drug cverage changes Initial Cverage Limit (ICL) fr Medicare Part D will increase frm $2,930 t $2,970. TROOP amunt will increase frm $4,700 t $4,750. During the Catastrphic Cverage Phase: Members will pay 5% r $2.65 whichever is mre fr generic drugs, and members will pay 5% r $6.60 fr brand drugs.

3 Grup/Unin Spnsred Plans are nt impacted by the changes described abve fr Pharmacy plans. Deductible: In 2013, Anthem Medicare Preferred Cre (PPO) will have a Part D deductible amunt f $60 that will apply t its tier 3 Preferred Brand drugs and tier 4 Nn-Preferred Brand drugs. Anthem Medicare Preferred Cre (PPO) in Ozark, Warren, and Wright cunties will have a Part D deductible amunt f $91 that will apply t its tier 2 Nn-Preferred Generic drugs, tier 3 Preferred Brand drugs and tier 4 Nn-Preferred Brand drugs. This deductible will have t be met befre thse tier s regular cpays/cinsurance will apply. Free First Fill: Starting January 1, 2013, we will be discntinuing ur Free First Fill prgram fr Anthem Medicare Preferred Cre (PPO). This prgram was included t all members in 2012 as part f their enrllment in ur plan. Under this prgram, when a prvider prescribed a patient/member any (brand r generic) cvered steprsis drug, the patient/member wuld nt pay any cst sharing fr their first fill f that drug frm any netwrk pharmacy, regardless f which drug payment stage the patient/member is in (including if they are still in the deductible stage, if they have ne). Enhanced Gap Cverage Remval: Anthem Medicare Preferred Cre (PPO)will n lnger be ffering enhanced cverage fr it s generic drugs when the member reaches the gap. In previus years this plan allwed a member t cntinue t pay their pre-icl cpays during the gap fr generics. In 2013, when a member reaches the gap fr these plans, they will be expected t pay a 79% cinsurance fr all generics, r a 47.5% cinsurance (plus a prtin f the dispensing fee)fr their brand drugs until they reach the catastrphic phase. In 2013, when a member reaches the gap fr Anthem Medicare Preferred Cre (PPO), Anthem Medicare Preferred Standard (PPO) and tw Anthem MediBlue Select (HMO) they will be expected t pay a 79% cinsurance fr all generics, r a 47.5% cinsurance (plus a prtin f the dispensing fee)fr their brand drugs until they reach the catastrphic phase. Help yur patients get the best buy each year fr their health care needs Each year we evaluate ur benefits and frmulary and may make changes t update them. Frmulary changes in the upcming year include: actual frmulary change, tier name changes, the tier that a drug may sit n, drug remvals, and new Prir Authrizatin, Step Therapy and Quantity Limit requirements. Yur patients experiencing frmulary changes will likely want t discuss their ptins with yu. They will need yur help t ensure they get their needed treatments at the mst affrdable cst. Encurage yur patients t review the 2013 frmulary infrmatin within their Annual Ntice f Change (ANOC) mailing, r t view the infrmatin nline when it is available, beginning Octber 1, Ask them if the cverage fr any f their prescriptins has been changed, and cnsider alternative medicatins in a lwer cst-sharing tier that may meets their need.

4 Balance Billing Reminder: The Centers fr Medicare and Medicaid Services and ur plan des nt allw yu t balance bill Medicare Advantage HMO and PPO members fr Medicare cvered services. CMS prvides fr an imprtant prtectin fr Medicare beneficiaries and ur members such that, after ur members have met any plan deductibles, they nly have t pay the plan s cst-sharing amunt fr services cvered by ur plan. As a Medicare prvider and/r a plan prvider, yu are nt allwed t balance bill members fr an amunt greater than their cst share amunt. This includes situatins where we pay yu less than the charges yu bill fr a service and includes charges that are in dispute. Here is hw this prtectin wrks. If the member cst sharing is a cpayment (a set amunt f dllars, fr example, $15.00), then the member pays nly that amunt fr any services frm a netwrk prvider. Cpayments may be higher fr services perfrmed by an ut-fnetwrk prvider. If the member cst sharing is a cinsurance (a percentage f the ttal charges), then the member never pays mre than that percentage. Hwever, the cst depends n the type f prvider: If the member btains cvered services frm a netwrk prvider, the member pays the cinsurance percentage multiplied by the plan s reimbursement rate (as determined in the cntract between the prvider and the plan). If the member btained cvered services frm an ut-f-netwrk prvider wh participates with Medicare, then the member pays the cinsurance percentage multiplied by the Medicare payment rate fr participating prviders. If yu btain cvered services frm an ut-f-netwrk prvider wh des nt participate with Medicare, then yu pay the cinsurance amunt multiplied by the Medicare payment rate fr nn-participating prviders. If a member btains cvered services frm a prvider wh has pted ut f Medicare, then the plan will nt pay fr these services, and depending upn the circumstances, the member may be liable fr the entire amunt. Emplyer Grup Retiree changes Emplyer r Unin Spnsred Grup Medicare Advantage plans may nt be impacted by mst f the changes t services area and benefits described abve. Fr Emplyer r Unin Spnsred Grup members, please refer t the members Evidence f Cverage r call Prvider Services at the number n the back f the member ID card fr mre benefit details. Prviders shuld reference the member s ID card fr changes at every visit t help ensure prper billing. Yu can als assist yur patients by passing n any ID card prefix r benefit change infrmatin t any ancillary prviders wh will be asked t serve yur patient. Medicare Advantage: The Annual Wellness Visit

5 What Prviders Shuld Knw The Annual Wellness Visit (AWV) was a new benefit effective n all plans January 1, Beneficiaries new t Medicare will cntinue t be cvered under the nce in a lifetime Welcme t Medicare exam. Hwever, nw all beneficiaries are cvered fr the AWV every 12 mnths. What cdes are billed fr the AWV? Fr the first visit, prviders shuld bill G0438 fr the AWV which includes the Persnalized Preventin Plan Service. Thereafter, prviders shuld bill G0439 fr the AWV and Persnalized Preventin Plan Service, subsequent visit. Rutine Physical Exams and the Annual Wellness Visit Medicare Advantage plans may ffer extra supplement benefits that culd include a rutine physical exam. Prviders shuld check with the plan t cnfirm if this is an extra benefit n the member s plan befre billing. The cdes fr the rutine physical (under preventive services) include: CPT cde range thrugh These cdes are nt cvered by riginal Medicare and may nt be an extra benefit n the member s plan. Hwever, all Medicare Advantage plans cver the AWV. Members are encuraged t use this annual benefit as ne way t help assess current health status and future needs. What if additinal services are prvided at the same time as the AWV? If ther evaluatin and management services are prvided in cnjunctin with the AWV, use CPT Mdifier 25 (Significant, separately identifiable evaluatin and management service by the same physician n the same day f the prcedure r ther service) as apprpriate. Prir authrizatin updates fr Medicare Advantage Plans. A list f the 2013 prir authrizatin requirements will be psted in December t the Medicare Advantage Prvider Prtals. Please reference the dcument: Medicare Advantage 2013 Precertificatin Requirements; fr the list f precertificatin requirements. The mst current list f Precertificatin Requirements can be fund at Please visit ur website at fr mre detailed prduct infrmatin r cntact Prvider Services at the number n the back f the member s ID card. Yu can find imprtant Medicare Advantage updates in the Plan & Administrative Changes/Update sectin. Cntact yur prvider representative fr participatin details fr ur cntracted plans. In Missuri (excluding 30 cunties in the Kansas City area): Anthem Blue Crss and Blue Shield is the trade name fr RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Cmpany (HALIC), and HMO Missuri, Inc. RIT and certain affiliates administer nn-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missuri, Inc. RIT and certain affiliates nly prvide administrative services fr self-funded plans and d nt underwrite benefits. Independent licensees f the Blue Crss and Blue Shield Assciatin. ANTHEM is a registered trademark f Anthem Insurance Cmpanies, Inc. The Blue Crss and Blue Shield names and symbls are registered marks f the Blue Crss and Blue Shield Assciatin. Y0071_12_16177_I_004