Medicare Advantage Outreach and Education Bulletin

Transcription

1 Medicare Advantage Outreach and Educatin Bulletin Anthem BlueCrss BlueShield 2014 Maine Medicare Advantage Plan Changes Dear Healthcare Prvider, Annual benefits changes fr Medicare Advantage plan members will be effective January 1, Each year, we renew ur cntract with the Centers fr Medicare and Medicaid Services (CMS) and CMS re-evaluates and apprves the benefits we ll ffer t ur Medicare Advantage members fr the upcming year. There are changes in the Individual Medicare Advantage fferings frm Anthem Blue Crss and Blue Shield. Yu can help members manage their health care csts by being aware f these changes. In additin, remember t check the MemberID card at the beginning f each calendar year, as the member may have changed plans. Anthem Medicare Preferred Premier (PPO) Plan Changes The Anthem Medicare Preferred Premier (PPO) service area is expanding t the fllwing cunties: Yrk. Anthem Medicare Preferred Premier (PPO) members will see a premium increase frm $95 t $96 in Diabetic shes and inserts will be cvered at $0 cpay in netwrk. If a member is admitted t the hspital within 72 hurs fr the same cnditin the emergency care cpay will nt be waived in Member cst shares are changing fr surgical prcedures fr Anthem Medicare Preferred Premier (PPO). Members will have access t additinal dental benefits in 2014 with ne cleaning and ne exam at $0 cpay when services are in-netwrk. The member ID card will indicate whether the member has preventive dental benefits cvered n their plan. The Visitr Travel Prgram nw includes Mntana, New Mexic and Oklahma. Please check the member ID card fr any identificatin and/r grup number changes that may affect claim submissins. Anthem Medicare Preferred Premier (PPO) Plan Highlights Maintaining the member in-netwrk and cmbined maximum-ut-f-pcket limits fr Individual Medicare Advantage plans in which all Medicare cvered expenses apply. Primary care physician (PCP) cpays range frm $10 t $40 and specialist cpays range frm $45 t $65. Anthem Medicare Preferred Premier (PPO) plan 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. $0 cpay fr Medicare-cvered preventive care in netwrk. Grup Spnsred Medicare Advantage Health Benefit Plans are nt impacted by the changes described abve fr PPO plans. Our members in Grup Spnsred Plans will cntinue t be cvered thrugh a natinal service area.

2 Anthem MediBlue Select (HMO) Plan Changes In 2014 we will be ffering a new HMO plan. Anthem MediBlue Select (HMO) will be available in the fllwing cunties: Cumberland, Kennebec, Penbsct, and Yrk. Anthem MediBlue Select (HMO) Plan Highlights Lw plan premiums at $9 with Anthem MediBlue Select (HMO). A cmbined maximum-ut-f-pcket f $3,800 Primary care physician (PCP) cpays at $5 and specialist cpays at $40. $0 cpay fr Medicare-cvered preventive care. Grup Spnsred Medicare Advantage Health Benefit Plans are nt impacted by the changes described abve fr HMO plans. Our members in Grup Spnsred Plans will cntinue t be cvered thrugh the same cunties in the 2013 service area. Optinal Supplemental Benefits (OSB) Fr 2014, many f ur Medicare Advantage plans will ffer three Optinal Supplemental Benefit (OSB) packages fr an additinal premium. OSB packages allw the Medicare Advantage plan t be tailred fr additinal dental, and visin cverage. Please nte, in 2014 OSB s will n lnger cver chirpractic and acupuncture benefits. We will ffer the belw Optinal Supplemental Benefit (OSB) packages n select plans. Members will have up t 90 days frm their plan effective date t enrll in ne f the belw packages: 1.) Preventive Dental Package 2.) Dental and Visin Package 3.) Enhanced Dental and Visin Package New Year! New Frmulary Changes! Each year we evaluate ur benefits and frmulary and may make changes t update them. Frmulary changes in the upcming year include: tier changes, drug remvals, and new Prir Authrizatin and Quantity Limit requirements. Yur patients will have frmulary changes and will need yur help t ensure they get their needed treatments at the mst affrdable cst. Encurage yur patients t review the 2014 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. Initial Cverage Limit (ICL) fr Medicare Part D will decrease frm $2,970 t $2,850. TROOP amunt will decrease frm $4,750 t $4,550. In 2014 we will ffer daily fills fr all MAPD plans. Daily fills give members an pprtunity t try a high-priced drug fr adverse reactins befre purchasing an entire prescriptin. The pharmacy netwrk includes preferred and ther netwrk retail pharmacies. Yu save mre by paying a lwer cst-sharing amunt at preferred retail pharmacies. Our preferred retail pharmacies include Krger Pharmacy, Rite Aid Pharmacy and Walmart. Krger C. participating preferred pharmacies include Krger, FredMeyer, King Spers, City Market, Fry s, Smith s, Dillns, Ralphs, QFC, Baker s, Sctt s, Owen s, Pay Less, Gerbes and JayC. Walmart participating preferred pharmacies include Walmart, Neighbrhd Market and Sam s Club.

3 Members can fill a prescriptin at a netwrk retail pharmacy, but their cst-sharing amunt may be higher. During the Catastrphic Cverage Phase: Members will pay 5% r $2.55 whichever is mre fr generic drugs, and members will pay 5% r $6.35 fr brand drugs. Grup/Unin Spnsred Plans are nt impacted by the changes described abve fr Pharmacy plans. Diabetic Supplies Beginning January 1, 2014, ur Individual Medicare Advantage Members will nly cver LifeScan, Inc, OneTuch r Rche Diagnstics, ACCU-CHEK diabetic bld glucmeters and bld glucse test strips fr ur Individual Medicare Advantage members. T be cvered fr a $0 cpay, the members must purchase these supplies at an in-netwrk: retail r mail-rder pharmacy, r Durable Medical Equipment supplier. Cvered bld glucmeters and bld glucse test strips in 2014: LifeScan, Inc., OneTuch Rche Diagnstics, ACCU-CHEK A limit f 100 bld glucse test strips per mnth Other bld glucmeter r bld glucse test strip brands r quantities f mre than 100 test strips per mnth are nt cvered unless yu as the dctr r prvider tell us anther brand r a larger quantity is medically necessary fr the member s treatment, n ther brand r larger quantity limit will be cvered. If ur member is currently using LifeScan, Inc, OneTuch r Rche Diagnstics, ACCU-CHEK bld test strips r glucmeter prducts, yu dn t need t d anything! If ur member is nt using LifeScan, Inc, OneTuch r Rche Diagnstics, ACCU-CHEK bld test strips r glucmeter prducts, then ur member will need t get new prescriptins fr the supplies by January 1 st fr these claims t be cvered by us. Yu shuld discuss these cverage changes and pssible new prescriptins with ur member/yur patient. If it is medically necessary fr them t cntinue using a different brand f bld test strips r glucmeter and/r mre than 100 bld test strips per mnth, yu will need t cmmunicate this t us by requesting an exceptin. If yur patient purchases their supplies thrugh the pharmacy r the ESI mail-rder service exceptins may be requested after December 1, 2013 by calling If yur patient purchases their supplies thrugh a Durable Medical Equipment supplier, yu will need t call the health plan. The benefit and brand limitatins described abve generally d nt apply t ur Grup Spnsred Medicare Advantage Health Benefit Plans. Please cntact prvider services fr benefit infrmatin. Insulin Exclusivity Effective January 1, 2014, select Individual MAPD plans will establish an insulin exclusivity cntract with Eli Lilly, the manufacturer f Humulin and Humalg human insulins. Other insulin s are cnsidered nnfrmulary and are nt eligible fr cverage beginning January 1, The fllwing plans will be impacted by an insulin change: Anthem Medicare Preferred Premier (PPO). Please have members check their plan name n the left hand crner f their member ID card t see if they were impacted by this change. If members were impacted by this change the belw frmulary changes will apply:

4 The fllwing chart prvides the frmulary cvered insulin medicatins in 2014: Insulin Medicatin Humalg pens Tier 3 Humalg vials Tier 3 Humulin 3 ml vials Tier 3 Humulin pens Tier 3 Humulin R u500 vials Tier 3 Humulin vials Tier 3 Relin vials / pens Tier 3 Tier Nte: Nvlin and Nvlg vials and pens and all ther insulins are cnsidered nn-frmulary and nt eligible fr cverage. The benefit and brand limitatins described abve generally d nt apply t ur Grup Spnsred Medicare Advantage Health Benefit plans. Please cntact prvider services fr benefit infrmatin. 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. This als includes charges that are in dispute. Fr the Anthem Medicare Preferred Premier (PPO) Plan - 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-f-netwrk 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 the member btains cvered services frm an ut-f-netwrk prvider wh des nt participate with Medicare, then the member pays the cinsurance amunt multiplied by the Medicare payment rate fr nn-participating prviders. If the 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. Fr the Anthem MediBlue Select (HMO) Plan - Here is hw this prtectin wrks:

5 If a members cst sharing is a cpayment (a set amunt f dllars, fr example, $15.00), then the member pays nly that amunt fr any cvered services frm a netwrk prvider. If a members cst sharing is a cinsurance (a percentage f the ttal charges), then the member never pays mre than that percentage. Hwever, a members cst depends n which type f prvider the member sees. If a member receives the cvered services frm a netwrk prvider, members pay the cinsurance percentage multiplied by the plan s reimbursement rate (as determined in the cntract between the prvider and the plan). If a member receives the cvered services frm an ut-f-netwrk prvider wh participates with Medicare, the member pays the cinsurance percentage multiplied by the Medicare payment rate by the participating prviders. Emplyer r Unin Grup Retiree Changes Grup Spnsred Medicare Advantage Benefit Plan benefits vary frm the Anthem Medicare Preferred Premier (PPO) r Anthem MediBlue Select (HMO) plans mentined here. Emplyer r Unin Grup Plan names and benefit changes may be different than what is described abve. Fr Grup Spnsred Medicare Advantage Health Benefit Plan members, please refer t the member s Evidence f Cverage r call Prvider Services at the number n the member ID card fr mre benefit detail. Medicare Advantage member ID cards cntain a CMS identifier in the lwer right crner f the card. The number will be five characters (XXXXX) fllwed by three characters (XXX). The member is in a Grup Spnsred Medicare Advantage Health Benefit Plan when the last three digits start with an eight (8XX). 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. What Des the Annual Wellness Visit Cver All f ur 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. 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. Annual Wellness Visit 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. Prviders are required t peridically review and cmply with the latest Medicare Advantage Prir Authrizatin requirements fund at n the dcument named: Medicare Advantage Precertificatin Requirements (updated 10/01/2013)

6 Referral Prcess Updates fr Anthem MediBlue Select (HMO) In mst situatins, ur members may need t receive a referral frm their PCP befre they can use specialists in the Plan s netwrk. Examples f specialists include Cardilgists, Dermatlgists, Orthpedic surgens, Onclgists and Urlgists. Hwever, referrals frm a PCP are nt required fr emergency care r urgently needed care. There are als ther kinds f care members can btain withut having apprval in advance frm their PCP. Prviders are required t peridically review and cmply with the latest Medicare Advantage Referral requirements fund at n the dcument named: Medicare Advantage Referral Requirements (available 11/01/2013). 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. Anthem Blue Crss and Blue Shield is the trade name f Anthem Health Plans f Maine, Inc. Independent licensee 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_13_18397_I