Medicare Advantage Outreach and Education Bulletin
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- Loreen Stewart
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1 Medicare Advantage Outreach and Educatin Bulletin Empire Blue Crss Blue Shield 2013 Medicare Advantage Plan Updates Dear Healthcare Prvider, Annual benefits changes fr Medicare Advantage plan members will be effective January 1, The changes apply t members enrlled in Empire MediBlue Freedm I (PPO), Empire MediBlue Freedm II (PPO), and Empire MediBlue Freedm III (PPO), and Empire MediBlue Essential (HMO), Empire MediBlue Plus (HMO), and Empire MediBlue Select (HMO) plans. 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. Empire MediBlue Freedm I, II and III (PPO) plan changes Instituting netwrk physician cpayment and hspital inpatient cpayment changes n sme plans. The member ID card will reflect the change, if any. The maximum-ut-f-pcket fr Empire MediBlue Freedm II will be increasing fr 2013 frm $3,400 t $3,900. The maximum-ut-f-pcket fr Empire MediBlue Freedm III will be increasing fr 2013 frm $2,800 t $3,000. Empire MediBlue Freedm I, II, and III members (except in Greene cunty) will see a premium increase in Outpatient Hspital and Ambulatry Surgical Centers cst shares will be mving frm a cpayment t a cinsurance fr the fllwing plans: Empire MediBlue Freedm I, II and III (PPO). Member cst shares are changing fr certain diagnstic tests, X-rays and radilgy prcedures fr Empire MediBlue Freedm I, II, and III. In 2013, Empire MediBlue Freedm I, II and III (PPO) will be remving the additinal cverage f pap and pelvic exams that have been ffered in previus years and will g back t the mandated Medicare-cverage guidelines fr these benefits. The fllwing cunties will n lnger have the Empire MediBlue Freedm I (PPO) available t them in 2013: Dutchess, New Yrk, Orange, Putnam, Queens, Sullivan, Ulster, and Westchester. Hwever, these cunties will still have access t ther Empire PPO and/r Empire HMO plans. Dutchess: Empire MediBlue Select (HMO), Empire MediBlue Essential (HMO) New Yrk: Empire MediBlue Plus (HMO), Empire MediBlue Essential (HMO) Orange: Empire MediBlue Select (HMO), Empire MediBlue Essential (HMO) Putnam: Empire MediBlue Select (HMO), Empire MediBlue Essential (HMO) Queens: Empire MediBlue Plus (HMO), Empire MediBlue Essential (HMO) Sullivan: Empire MediBlue Freedm II (PPO), Empire MediBlue Select (HMO), Empire MediBlue Essential (HMO) Ulster: Empire MediBlue Freedm II (PPO), Empire MediBlue Select (HMO) Westchester: Empire MediBlue Select (HMO), Empire MediBlue Essential (HMO)
2 The fllwing cunties will n lnger have the Empire MediBlue Freedm II (PPO) available t them in 2013: Delaware, Dutchess, Greene, Kings, Nassau, New Yrk, Orange, Putnam, Queens, Rckland, and Westchester. Hwever, these cunties will still have access t ther Empire PPO and/r Empire HMO plans. Delaware: Empire MediBlue Freedm I (PPO) Dutchess: Empire MediBlue Select (HMO), Empire MediBlue Essential (HMO) Greene: Empire MediBlue Freedm I (PPO), Empire MediBlue Freedm III (PPO) Kings: Empire MediBlue Freedm I (PPO), Empire MediBlue Freedm III (PPO), Empire MediBlue Plus (HMO), Empire MediBlue Essential (HMO) Nassau: Empire MediBlue Freedm I (PPO), Empire MediBlue Select (HMO), Empire MediBlue Plus (HMO) New Yrk: Empire MediBlue Plus (HMO), Empire MediBlue Essential (HMO) Orange: Empire MediBlue Select (HMO), Empire MediBlue Essential (HMO) Putnam: Empire MediBlue Select (HMO), Empire MediBlue Essential (HMO) Queens: Empire MediBlue Plus (HMO), Empire MediBlue Essential (HMO) Rckland: Empire MediBlue Freedm I (PPO), Empire MediBlue Select (HMO) Westchester: Empire MediBlue Select (HMO), Empire MediBlue Essential (HMO) The fllwing cunties will n lnger have the Empire MediBlue Freedm III (PPO) available t them in 2013: Clumbia, Delaware, Dutchess, Nassau, New Yrk, Orange, Putnam, Queens, Rckland, Sufflk, Sullivan, Ulster, and Westchester. Hwever, these cunties will still have access t ther Empire PPO and/r Empire HMO plans. Clumbia: Empire MediBlue Freedm I (PPO), Empire MediBlue Freedm II (PPO) Delaware: Empire MediBlue Freedm I (PPO) Dutchess: Empire MediBlue Select (HMO), Empire MediBlue Essential (HMO) Nassau: Empire MediBlue Freedm I (PPO), Empire MediBlue Select (HMO), Empire MediBlue Plus (HMO) New Yrk: Empire MediBlue Plus (HMO), Empire MediBlue Essential (HMO) Orange: Empire MediBlue Select (HMO), Empire MediBlue Essential (HMO) Putnam: Empire MediBlue Select (HMO), Empire MediBlue Essential (HMO) Queens: Empire MediBlue Plus (HMO), Empire MediBlue Essential (HMO) Rckland: Empire MediBlue Freedm I (PPO), Empire MediBlue Select (HMO) Sufflk: Empire MediBlue Freedm I (PPO), Empire MediBlue Freedm II (PPO), Empire MediBlue Plus (HMO Sullivan: Empire MediBlue Freedm II (PPO), Empire MediBlue Select (HMO), Empire MediBlue Essential (HMO) Ulster: Empire MediBlue Freedm II (PPO), Empire MediBlue Select (HMO) Westchester: Empire MediBlue Select (HMO), Empire MediBlue Essential (HMO) Please check the member ID card fr any identificatin and/r grup number changes that may affect claim submissins. Empire MediBlue Freedm I, II and III (PPO) plan highlights Primary care physician (PCP) cpays range frm $5 t $40 and specialist cpays range frm $25 t $65. Empire MediBlue Freedm I, II, and III plans participate 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. Maintaining the member maximum-ut-f-pcket limits fr Empire MediBlue Freedm I
3 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. Empire MediBlue Essential, Empire MediBlue Plus, and Empire MediBlue Select (HMO) plan changes Instituting netwrk physician cpayment and hspital inpatient cpayment changes n sme plans. The member ID card will reflect the change, if any. The maximum-ut-f-pcket fr Empire MediBlue Plus (HMO) in the NYC area will be increasing fr 2013 frm $2,800 t $3,400. The maximum-ut-f-pcket fr Empire MediBlue Plus (HMO) in Sufflk cunty will be increasing fr 2013 frm $3,400 t $4,000. The maximum-ut-f-pcket fr Empire MediBlue Select (HMO) in the Metr-Nrth area will be increasing fr 2013 frm $3,400 t $4,000. Essential (HMO) in the Metr-Nrth area will be increasing fr 2013 frm $3,400 t $4,000. In 2013 we will be ffering a new HMO plan. Empire MediBlue Select (HMO) will be available in the fllwing cunty: Dutchess. All plans Outpatient Hspital and Ambulatry Surgical Centers cst shares will be mving frm a cpayment t a cinsurance. The nly exceptin t this is Empire MediBlue Plus (HMO) in NYC, which will remain at a cpayment. Member cst shares are changing fr certain utpatient diagnstic tests, X-rays and radilgy prcedures fr Empire MediBlue Essential, Empire MediBlue Plus, and Empire MediBlue Select (HMO) plans. In 2013 Empire MediBlue Essential, Empire MediBlue Plus, and Empire MediBlue Select (HMO) plans will be remving the additinal cverage f pap and pelvic exams that have been ffered in previus years and will g back t the mandated Medicare-cverage guidelines fr these benefits. In 2013 the rutine eye glasses limit changed frm $200 every 24 mnths t $130 every 24 mnths fr the Empire MediBlue Plus (HMO) in the NYC area. Rutine hearing benefits were remved frm the Empire MediBlue Plus (HMO) in the NYC area fr Rutine hearing benefits were added t the Empire MediBlue Plus (HMO) and Empire MediBlue Select (HMO) plans in Nassau cunty fr The fllwing cunty will n lnger have the Empire MediBlue Select (HMO) available t them in 2013: Dutchess. Hwever, this cunty will still have access t the Empire MediBlue Select (HMO) and Empire MediBlue Essential (HMO) plans. The fllwing cunties will n lnger have the Empire MediBlue Essential (HMO) available t them in 2013: Nassau, Rckland, and Ulster. Hwever, these cunties will still have access t the ther Empire PPO and/r Empire HMO plans. Nassau: Empire MediBlue Freedm I (PPO), Empire MediBlue Select (HMO), Empire MediBlue Plus (HMO) Rckland: Empire MediBlue Freedm I (PPO), Empire MediBlue Select (HMO) Ulster: Empire MediBlue Freedm II (PPO), Empire MediBlue Select (HMO) Please check the member ID card fr any identificatin and/r grup number changes that may affect claim submissins. Empire MediBlue Essential, Empire MediBlue Plus, and Empire MediBlue Select (HMO) plan highlights Plan premiums as lw as $0 fr Empire MediBlue Plus (HMO) in the NYC area and the Empire MediBlue Essential (HMO). Primary care physician (PCP) cpays range frm $10 t $25 and specialist cpays range frm $20 t $45. $0 cpay fr Medicare-cvered Preventive Care. Maintaining the member maximum-ut-f-pcket limits fr Empire MediBlue Plus (HMO) in Nassau cunty.
4 Grup/Unin Spnsred Plans may nt be impacted by mst f the changes described abve fr the Medicare Advantage HMO plans. Our members in Grup/Unin Spnsred Plans will cntinue t have access t the same service area in New Medicare Advantage HMO and HMO based Special Needs Plans (SNP) New in 2013, Medicare beneficiaries in Brklyn will have access t three new plans that include exclusive access t the CareMre health delivery system and its neighbrhd Care Centers. Care Center services supprt primary care prviders and deliver individualized supprt t members thrugh preventative medicine, disease management and health educatin services. Plans include a MediBlue (HMO) plan ( Empire MediBlue Lcal ) and tw MediBlue (HMO-SNP) special needs plans designed t meet the needs f individuals wh have diabetes ( Empire MediBlue Diabetes ) and COPD ( Empire MediBlue COPD ). Featured benefits include: N mnthly plan premium $0 cpay fr PCP visit, lab test and rutine X-rays Generic drug cpays f $0 t $5, plus generic drug cverage in the cverage gap Optinal Supplemental dental care benefits (available fr an additinal fee). Preventative benefits and disease management prgrams Prviders cntracted with CareMre t prvide services t members in these plans will receive specific infrmatin abut plans, benefits, and prgrams. T learn mre abut the CareMre Health Delivery System, visit r call (888) Select Optin 3, then Optin 5. Optinal Supplemental Benefits (OSB) Fr 2013, the Empire MediBlue Select (HMO) (in Dutchess cunty nly) will be ffering tw Optinal Supplemental Benefit (OSB) packages fr an additinal premium. These packages will allw the Medicare Advantage plan t be tailred t add additinal dental and visin cverage by enrlling in an OSB package. Empire will ffer the fllwing Optinal Supplemental Benefit (OSB) packages n the Empire MediBlue Select (HMO) (in Dutchess cunty nly) plan in which members will have up t 90 days frm their plan effective date t enrll. 1.) Preventive Dental Package 2.) Cmprehensive Dental and Visin Package Medicare Part D Prescriptin drug cverage changes (applicable t plans with Part D cverage) Fr ALL MAPD Plans: 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.
5 Deductible: In 2013, Empire MediBlue Freedm I (PPO), Empire MediBlue Freedm II (PPO), and Empire MediBlue Plus (HMO) (Nassau cunty nly) will have a Part D deductible amunt f $75 that will apply t it s tier (it applies t tiers 3 & 4) 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. 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). Fr ALL MAPD Plans: 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. Grup/Unin Spnsred Plans are nt impacted by the changes described abve fr Pharmacy plans. 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. 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-f-netwrk prvider.
6 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 nnparticipating 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 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.
7 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. Services prvided by Empire HealthChice HMO, Inc. and/r Empire HealthChice Assurance, Inc., licensees f the Blue Crss and Blue Shield Assciatin, an assciatin f independent Blue Crss and Blue Shield plans. The Blue Crss and Blue Shield names and symbls are registered marks f the Blue Crss and Blue Shield Assciatin.
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