Medicare Advantage

Dual Care

Model of Care

STARs

March 20, 2019

Agenda

Medicare Advantage Plan Updates for 2019

Akamai Advantage Dual Care Plan

Eligibility – How to identify a Dual Care Member

Benefits – What is covered

Claims Filing and Billing

Model of Care – Service Coordination

HMSA’s Goals for Dual Care Members

Health Risk Assessment (HRA)

Individualized Care Plan (ICP)

Interdisciplinary Care Team (ICT)

DSNP Quality Metrics

HMSA Provider Resources

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Medicare Advantage - New in 2019

CMS enrollment periods

“Re-branding” of HMSA’s Medicare Advantage

products

Akamai Advantage – PPO (including Dual

Care)

Essential Advantage - HMO

HMSA Medicare Advantage Plans

Benefits

Financial protection

Silver&Fit membership at no additional cost

Coverage while traveling

Vision exam and eyewear

Preventive care

No-cost annual wellness visits

Prescription drug coverage

New CMS Open Enrollment (OEP)

• MA-OEP, effective 1/1/19

• From January 1st through March 31st

• Annual; replaces MADP (Medicare Advantage

..Disenrollment Period)

• One time only during this window, plans are not

permitted to solicit beneficiary changes

• Plan effective the 1st of the month following the

election date

LIS/Dual Eligible SEP

(Special Enrollment Period)

• New in 2019

• For those with Medicare A+B and Medicaid; also LIS

with or without Medicaid

• Only once per quarter, in the 1st 9 months of the

calendar year

• Plan effective the 1st of the month following election

date

Medicare Advantage Dual Care Plan

Eligibility

Must be eligible for Medicare and Medicaid

May be Qualified Medicare Beneficiary (QMB) Only or

have (QMB) Plus dual eligibility status

May have HMSA Akamai Advantage and HMSA

QUEST Integration

May have HMSA Akamai Advantage and QUEST

Integration with another health plan

Note: DSNP members are allowed to change MA D-SNP

anytime during the year as long as Medicaid eligibility is

maintained

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Medicare Advantage Dual Care Plan

“Continued Eligibility”

If a member loses Medicaid eligibility, the

member may have “deemed continued eligibility”

for the month HMSA is notified of the member’s

Medicaid ineligibility, plus one full calendar month

HMSA MA Dual Care members who are in a

“deemed continued eligibility” status will be

responsible for copayments, coinsurance and

deductibles under HMSA’s MA Dual Care Plan

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Medicare Advantage Dual Care Plan

Membership Card

• Plan Name appears at the top right corner of the

front of the card

• No member premium (after Low Income Subsidy)

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HHIN – Identifying Medicare Advantage Dual Care Members

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HHIN – Identifying Medicare

Advantage Dual Care Members

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Click on coverage code 696 to

view plan description for MA

Dual Care members

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https://hiweb.statemedicaid.us/EligAndEnrollment/MemberVerificationHI.aspx

Akamai Advantage Dual Care Plan - Benefits

1. Dual Care offers Original Medicare with some added benefits (after

QUEST Integration coordination)

a. $0 copay Annual Physical Exam

b. $0 copay health education and wellness

c. $0 copay for HMSA Online Care

2. Care Coordination and support services through a Care Manager

such as a Registered Nurse or Social Worker

3. Prior authorizations are the same as on individual Akamai Advantage

plans

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In general, Medicare pays primary and Medicaid is always the payer of last resort. For Original Medicare

benefits, Medicaid covers the Part A & B deductibles, Part B premium, and member cost shares:

Medicaid pays 20% Medicare pays 80% 100% coverage

Member pays $0

2019 Dual Care (PPO-SNP) Benefits

• New SEP (Special Enrollment Period)

• Still requires QMB/QMB+ eligibility (Qualified

..Medicare Beneficiary)

• Supplemental Dental maximum raised to

..$2,500

• Members with certain chronic conditions ..have

enhanced dental benefits (e.g., stroke, oral

cancer, diabetes)

2019 Akamai Advantage Dual Care Benefits

Dental Benefits: Effective January 1, 2018

Annual Max: Plan pays up to $2,500 for covered dental services

Enhanced Dental Care: Not a benefit effective 1/1/18

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Benefit In Network

Two Dental Exams per year $0

Two Cleanings per year $0

One set of Bitewing X-rays $0

One Full Mouth or Panoramic X-rays every 5 years $0

Two Denture Adjustments per year $0

One Denture Repair, per Arch, per year $0

One Filling per Tooth Surface, per year $0

One Root Canal per Tooth, per year $0

One Periodontal Scaling & Root Planing, per

quadrant, per year

$0

Max Out of Pocket (MOOP) Accumulation

Dual Care MOOP: $6,700 in-network

Medicaid will pay member cost shares for Original

Medicare benefits, for QMB and QMB Plus dual eligible.

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Akamai Advantage Dual Care Plan Claims Filing/Billing Tips

Providers should not bill HMSA Akamai Advantage Dual

Care Plan members for coinsurance, copayments or

deductibles for medical services

File claims to HMSA Akamai Advantage Dual Care Plan

1st , then bill HMSA QUEST Integration 2nd

File claims to HMSA Akamai Advantage Dual Care Plan

1st, then bill other QUEST Integration Plan 2nd

Benefits covered by QUEST Integration that are not

covered by Original Medicare should only be billed to

QUEST Integration

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Qualified Medicare Beneficiary (QMB)

Balance Billing Law Effective 2016

QMB program is a Medicare Savings Program that exempts

Medicare beneficiaries from Medicare cost-sharing liability

Ensure billing software and staff exempt QMB or QMB Plus

patients from Medicare cost-share billing

Medicare Advantage providers are prohibited from

discriminating against patients based on QMB status.

Identify QMB or QMB Plus individuals at: https://hiweb.statemedicaid.us/EligAndEnrollment/MemberVerificationHI.aspx

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Service Coordination Dual Eligible Special Needs Plan (D-SNP)

3/18/2019 DRAFT 19

Goals of Service Coordination

Improve access to essential services such as medical &

behavioral health care and social services

Improve access to:

Affordable care

Preventive Health Services

Improve coordination of care through assignment of an

HMSA Service Coordinator

Improve seamless transitions of care across health care

settings, providers, and health services

Ensure appropriate use of services

Improve health outcomes

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Model of Care

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MEMBER

Health Risk Assessment

(HRA)

Individualized Care Plan

(ICP)

Interdisciplinary Care Team

(ICT)

Akamai Advantage Dual Care

member is at the center

Model of Care

Support for your vulnerable patients

Most

Vulnerable

Somewhat Vulnerable

Least Vulnerable

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Determined by HRAs and clinical

judgment

Examples of criteria for

“most vulnerable”

• 5 or more chronic

comorbid conditions

(diabetes, congestive heart

failure, hypertension, etc.)

• Terminal condition

• 5 or more ER visits within

the past 6 months

• Severe dementia

Health Risk Assessment and Care Plan

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Health Risk

Assessment (HRA)* 1. Conducted by HMSA Care

Manager or PCP

2. Frequency:

a. Initial within 90 days

b. Reassess at least annually

c. Health events

3. Used to Risk Stratify

4. Methodology

a. In-person

b. Telephonic

c. Mail

d. Via PCP

5. Used to formulate

ICP

Individualized Care Plan

(ICP)*

1. Based on HRA results

2. Aerial algorithms and clinical judgment

3. Developed with input from ICT

4. Modified as needed

5. Communicated to member, providers and ICT

6. Shared during care transitions

* Must be evidence-based

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What is an Interdisciplinary Care Team?

The team consists of family members, health care

providers and others who can help the member achieve

their health and wellness goals.

The composition of the team is individualized according to

the member’s needs and preference.

The team meets intermittently to ensure that the ICP is on

track and is achieving the member’s goal.

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Interdisciplinary Care Team (ICT)

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Member

HMSA Medical Director

PCP

HMSA Service

Coordinator

“Core” team

members:

Examples of other

team members:

Family

Members/Caregiver

Specialist

Dietitian

Pharmacist

Gerontologist

Behavioral Health

The composition of the team is individualized according to the

….member’s needs and preference.

• Focusing on care gaps

• Collaborating with HMSA RNs to ensure accurate/timely HRA completion

• Providing medical records when requested

• Discussing Advanced Care Planning/POLST with DSNP patients

• Discussing COPD management information/plan for applicable patients

• Participating as a critical member on the Interdisciplinary Care Team

HMSA can partner with PCPs by:

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What can Providers expect?

PCPs can partner with HMSA by:

• Providing service coordination for challenging patients by:

o Focusing on care gaps

• Working with PCPs and their staff to provide:

o COPD management information/plan for applicable patients

o Collaborating with PCPs to accurately complete patient Health Risk

Assessment to ensure timely access to patient care

• Communicate updates to Interdisciplinary Care Team

DSNP Quality Metrics

DSNP includes all Medicare Metrics

Preventative Screenings Breast Cancer

Colorectal Cancer

Chronic Disease Monitoring and Control Diabetes

Hypertension

Rheumatoid Arthritis

Osteoporosis

Medication Oversight Medication Adherence

Medication Reconciliation Post Discharge

Medication Therapy Management

Four (4) Dual Care Specific Star Metrics

Health Risk Assessment

Care for Older Adults

• Medication Review

• Pain Assessment

• Functional Assessment

• Advance Care Planning

Care for Older Adults Star Metrics

Once per calendar year

DSNP members turning 66 this

year and older

Use your Coreo dashboard to

identify eligible patients

Four part assessment:

1. Medication Review

2. Functional Status

Assessment

3. Pain Assessment

4. Advance Care Planning

Care for Older Adults: Closing the Gap

Complete an Annual Wellness Visit using an HMSA Health Risk Assessment form

and Document current medication list and your medication review

• Requires two codes for full credit: 1159F and 1160F

• File a claim using CPT II codes

Medicare Stars Resources

Provider Resource Center / Medicare Star Ratings E-library https://hmsa.com/portal/provider/zav_pel.aa.MED.100.htm

Forms:

Dual Care Health Risk Assessment Form

Care for Older Adults Worksheets

Patient Medication Review Form

Medicare Star Ratings:

Measure Reference Guides – Code Set & Description

Annual Wellness Visit Toolkit

Coreo Medicare Star Measures dashboard

HMSA Provider Resources

HMSA Provider E-Library:

https://www.hmsa.com/portal/provider/

HMSA Service Coordinators: Monday – Friday 7:30 – 4:30

HMSA Provider Services

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Phone Fax

948-6997 944-5604

Toll Free: 1-844-223-9856 Toll Free: 1-855-856-4176

Phone Fax

948-6330 948-6887

Toll Free: 1-800-790-4672 Toll Free: 1-800-540-1668

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• Notify HMSA of changes in your practice, such as:

• Practice Location Address

• Appointment Phone Number

• Patient Acceptance Status

• Email

• Hours of operation

• Be sure to notify HMSA 30-days in advance of any

practice changes by:

1. Calling (808) 952-7847 on Oahu or 1 (800) 603-

4672 ext. 7847 toll free on the Neighbor Islands

2. Mail to:

HMSA

Provider Data Administration

P.O. Box 860

Honolulu, HI 96808-0860

3. Email: provider_data@hmsa.com

• Timely notification to HMSA will ensure:

• Payments and correspondence are sent to the

correct address

• We market your practice using the correct address

in our provider directory

HMSA Provider Reminders

Acronyms

AEP Annual Election Period

CMS Centers for Medicare and

Medicaid Services

C-

SNP

Chronic Condition Special Needs

Plan

D-

SNP

Dual eligible Special Needs Plan

EOC Evidence of Coverage

ESRD End Stage Renal Disease

HRA Health Risk Assessment

ICP Individualized Care Plan

ICT Interdisciplinary Care Team

I-SNP Institutional Special Needs Plan

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LIS Low Income Subsidy

MAPD Medicare Advantage Part D

MOC Model of Care

MOOP Maximum Out of Pocket

NCQA National Committee for Quality

Assurance

OOPM Out of pocket maximum

QI QUEST Integration

QMB Qualified Medicare Beneficiary

SB Summary of Benefits

SEP Special Election Period

SNP Special Needs Plan

Provider Attestation for Model of Care Training

_____ I attest that my organization and its contracted providers have received the HMSA

Akamai Dual Care Plan Model of Care training. CMS Regulation 42 CFR § 422.102 (f)(2)(ii).

_____ I attest that my organization has established a mechanism for compliance with the

provider training requirement. Your organization must establish a process for compliance, including but not limited to: dissemination to providers the

HMSA Akamai Dual Care Plan MOC training, maintenance of all documentation including rosters, and a process for annual re-training

_____ I attest that within sixty (60) days receipt of this notice, my organization/practice will

provide HMSA Akamai Dual Care Plan a roster of all providers/staff who received the training and a signed Attestation for HMSA Akamai Dual Care Plan Model of Care Training.

Providers that render services for members in the Dual-Special Needs Program (D-SNP) program are required to take the HMSA Akamai Dual Care Plan MOC training.

Signature:_______________ Printed Name:_______________

Date:___________________ Provider Name:______________

Email to: AkamaiD-SNPAttestation@hmsa.com

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Thank you!

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