VIEWS: 55 PAGES: 26 POSTED ON: 10/11/2011
Humana Inc. North Carolina Medical Society Alan Wheatley President – East Region Humana Inc. Humana Highlights Founded in 1961; headquartered in Louisville, KY Fortune 200 company 7 million health plan members – 2 million Medicare members Ranked number six among all U.S. companies in all sectors for technology leadership, according to Forrester Research Full spectrum of innovative products 20 + years working with the Medicare Advantage Program Humana’s Medicare Footprint WA ME MT ND VT NH MN OR WI NY MA ID SD CT MI RI Milwaukee WY PA NJ Chicago Cleveland IA OH Columbus Salt Lake City NE Dayton DE NV Boulder IL IN Cincinnati MD UT Indianapolis WV DC Denver Kansas City Louisville VA CO KS MO Lexington CA St. George KY Raleigh NC Nashville TN AZ OK Memphis SC NM AR Atlanta Phoenix Dallas AL GA MS Shreveport TX LA Jacksonville Austin Baton Rouge Daytona Beach San Antonio Houston New Orleans Orlando FL AK Tampa Treasure Coast Ft. Myers Corpus Christi HI PUERTO RICO PFFS & HMO Markets only Local Markets PDP States Medicare Advantage/PDP Feb 25, 2005 v3 Medicare’s History 1965 1972 1977 1997 2003 Medicare & Medicaid Eligibility extended to HCFA created BBA creates M+C MMA established people with disabilities program passed Medicare Beneficiary Coverage Options For a Medicare beneficiary, there are several different health plan options available today including: Original Medicare Original Medicare, plus a Medicare Supplement (or MediGap policy) A Medicare Advantage plan – choices include HMO, PPO and PFFS plan designs (depending on the service area) Prescription Drug Plan * No matter which option is chosen, the beneficiary is still in the Medicare program. Medicare Advantage Plan Options Private Fee-for-Service (PFFS) Preferred Provider Organization (PPO) Health Maintenance Organization (HMO) Prescription Drug Plans (PDP) What Is Medicare Private Fee-for-Service? Created by the Balanced Budget Act of 1997 Medicare Advantage design that works like Original Medicare, but with enhanced benefits Providers can accept members on a patient-by- patient basis Humana began offering PFFS plans in 2002 – Individual plans in 34 states and Puerto Rico – Group plans in 50 states and Puerto Rico What Is Medicare Private Fee-for-Service? Defined by the Centers for Medicare and Medicaid Services (CMS) as a plan that: Reimburses providers on a fee-for-service basis Does not place providers at risk Does not vary payment rates based on utilization Does not restrict provider selection among those who agree to accept the plan’s payment terms and conditions Private Fee-for-Service (PFFS) Members can seek care from any Medicare-approved provider that is willing to provide care and accepts the plans terms and conditions Plan benefits must include all services covered by Medicare Parts A and B Extra benefits may be offered by the plan A premium, in addition to the monthly Part B premium, may be required. Follows Medicare medical policies and guidelines Referrals and authorizations are not required Provider payments follow Medicare reimbursement methodologies Medical care is available outside of the plan’s service area Why Seniors Choose Humana’s Medicare Advantage Plans Original Medicare Medicare Advantage o A and B Coverage o A and B Coverage o Low or no deductibles o No A and B deductibles o 20% coinsurance o Co-payments o Limited coverage of o Outpatient drug coverage outpatient drugs o Worldwide urgent/emergent care o No coverage outside U.S. o Routine physicals o Limited preventive care o Routine hearing exams o Routine vision discounts o Silver Sneakers o Personal Nurse/Case Manager o Disease Management o New member services SilverSneakers® and Silver Steps SilverSneakers® – Reside within 15 miles of a metropolitan statistical area (MSA), free membership to a network of fitness centers at no additional cost – Staff trained in senior needs – Specialized classes for seniors – Motivational incentives SilverSneakers Steps – Reside more than 15 miles from a MSA, self-directed walking program – Online, telephone and mail support – Prize incentives Offers social, as well as health, benefits to seniors Member Cost Share Impact 20% Cost Share by DRG $8,000 $6,000 $4,000 $2,000 $0 DRG 9 DRG 76 DRG 531 DRG 106 MA Non-Par Understanding benefits- PFFS Sales associate are required to articulate the product specifics – Closely monitored. Constant reinforcement In bound and outbound verification calls – Expanded hours of operation – Expanded questionnaire Pre enrollment kits explaining benefits Welcome Calls – Describing Health Management Programs – Health Risk Assessment – Explaining Benefits Provider education Why Medicare PFFS? Medicare Advantage Plan Same patients Patient receive better benefits Same reimbursement Same medical policies and guidelines No additional credentialing – Medicare certified = Humana certified No authorizations or referrals required No secondary billing in many cases Less bad debt Primary Care Provider Original Medicare Humana Gold Choice Primary Care w/procedure Primary Care w/procedure (Office visit 99212 + procedures) (Office visit 99212 + procedures) Billed charges $ 532.00 Billed charges $ 532.00 Medicare allowable $ 332.12 Medicare allowable $ 332.12 Patient coinsurance (20%) $ 66.42 Patient copay $ 15.00 Medicare pays (80%) $265.70 Humana pays $ 317.12 Total to Provider $ 332.12 Total to Provider $ 332.12 Hospital Examples Emergency Room Inpatient DRG ER visit 99283 w/lab work 3 day length of stay, billed (ER allowed based on APC, lab charges - $19,540 allowed based on fee schedule) Billed charges . . . . . . $ 317.00 DRG….. . . . . . . . . . . . $3,908.98 APC rate . . . . . . . . . . 113.30 Add-ons . . . . . . . 984.55 Lab rate . . . . . . . . . . . 8.74 ________ Tot. Medicare allow . $ 122.04 Tot. Medicare allow . $ 4,893.53 Patient copay . . . . $ 24.41 Patient copay. . . . . $ 540.00 Humana pays . . . . . . $ 97.63 Humana pays . . . . . $ 4,353.53 Total to provider . . . . . .$ 122.04 Total to Provider . . . $ 4,893.53 Preferred Provider Organization (PPO) Most common and popular type health plan for Americans Available on both a regional and local level Members may seek care from any provider that accepts Medicare – Member out-of-pocket costs are lower when receiving care from network providers Referrals are not required for specialty care Plan benefits must include all services covered by Medicare Parts A and B Extra benefits may be offered by the plan CMS PPO Regions Health Maintenance Organization (HMO) Members choose a Primary Care Physician when they join the plan Referrals are required for specialty care or for certain services Members receive most care from network providers Only emergency and urgent care is covered outside of the service area Provider payments are based on their contract with the health plan Plan benefits must include all services covered by Medicare Parts A and B Extra benefits may be offered by the plan Prescription Drug Plans Part D is a voluntary program It is designed to provide coverage for outpatient prescription medications Part D will replace Medicare-approved drug discount cards, which will phase out by 5/15/06 Available as: – Stand-alone prescription drug plans (PDPs) – Medicare Advantage + prescription drug (MA-PD) plans If MA members enroll in a PDP, they will lose their MA membership PDP Regions WA ME MT ND VT NH MN OR WI NY MA ID SD CT MI RI WY PA NJ IA OH NE DE NV IL IN MD UT WV DC VA CO KS MO KY CA NC TN OK SC AZ NM AR AL GA MS TX LA AK FL HI Note: Each territory is its own PDP region. PDP Enrollment To receive Medicare prescription drug coverage, beneficiaries must: – Have Medicare Part A and/or be enrolled in Part B AND – Enroll in a Medicare-approved prescription drug plan offered by a Medicare-approved organization OR – Enroll in a Part D benefit offered by employers/unions responsible for retiree benefits OR – Enroll in a fully insured MA plan with PD coverage offered by a Medicare-approved health benefits company PDP Enrollment Members eligible for both Medicare and Medicaid: – Will be automatically enrolled in a PDP plan if they do not enroll on their own • If automatically enrolled in one plan, the member can switch to another plan at any time – Will no longer receive prescription drug coverage from Medicaid No new supplements with prescription drug coverage will be sold after January 1, 2006 Filling Prescriptions Humana members can have their prescriptions filled at more than 50,000 retail pharmacies nationwide – Including Wal-Mart, Sam’s Club and Neighborhood Store pharmacies Members may also use mail order program for maintenance medications HUMANA'S Prescription Drug Plans Humana Standard Plan Humana Enhanced Plan Humana Complete Plan For the first For the first $250 deductible $250 of total drug costs: $250 of total drug costs: ▪ $0 Generic ▪ $0 Generic STAGE MEMBER PAYS ▪ $30 Preferred ▪ $30 Preferred 1 ▪ $60 Non-preferred ▪ $60 Non-preferred ▪ 25% Specialty ▪ 25% Specialty Plan pays $0 Balance of costs Balance of costs For the next For the next For the next $2000 of total drug costs: $2000 of total drug costs: $2000 of total drug costs: 25% of costs ( = $500) ▪ $7 Generic ▪ $7 Generic STAGE MEMBER PAYS ▪ $30 Preferred ▪ $30 Preferred 2 ▪ $60 Non-preferred ▪ $60 Non-preferred ▪ 25% Specialty ▪ 25% Specialty Plan pays 75% of costs ( = $1500) Balance of costs Balance of costs The next The next For the next $2850 of total drug costs $2,850 of total drug costs $2850 of total drug costs: (This brings your total (This brings your total ▪ $7 Generic STAGE MEMBER PAYS out-of-pocket costs to $3600) out-of-pocket costs to $3600) ▪ $30 Preferred 3 ▪ $60 Non-preferred ▪ 25% Specialty This is the coverage gap This is the coverage gap NO COVERAGE GAP Plan pays $0 $0 Balance of costs 5% of total drug costs for 5% of total drug costs for 5% of total drug costs for STAGE MEMBER PAYS the rest of the year the rest of the year the rest of the year 4 95% of total drug costs for 95% of total drug costs for 95% of total drug costs for Plan pays the rest of the year the rest of the year the rest of the year Formulary for all Humana plans includes 97 of the top 100 drugs.
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