Humana - PowerPoint by xiangpeng


									            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
              Humana’s Medicare Footprint
                          WA                                                                                                                                                  ME
                                                     MT                      ND
                       OR                                                                                     WI                                               NY         MA

                                       ID                                    SD                                                                                          CT
                                                                                                                              MI                                                   RI
                                                        WY                                                                                           PA             NJ
                                                                                                                        Chicago             Cleveland
                                                                                                                                      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
                                        AZ                                              OK                               Memphis                    SC
                                                           NM                                           AR
                                        Phoenix                                   Dallas                                          AL        GA
                                                                                     TX                  LA                                              Jacksonville
                                                                               Austin                               Baton Rouge                             Daytona Beach
                                                                        San Antonio            Houston
                                                                                                                        New Orleans                           Orlando
                  AK                                                                                                                        Tampa
                                                                                                                                                               Treasure Coast
                                                                                                                                            Ft. Myers

                                                                                             Corpus Christi
                                                                                                                                                          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

     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
  Medical care is available outside of the plan’s service
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





           DRG 9   DRG 76   DRG 531   DRG 106

                     MA     Non-Par
Understanding benefits- PFFS
  Sales associate are required to articulate the product
    – 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
   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
  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
 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
PDP Regions
       WA                                                                                                               ME
                              MT                   ND
     OR                                                                 WI                               NY         MA

                  ID                               SD                                                              CT
                                                                                   MI                                        RI
                                WY                                                                  PA        NJ
                                                   NE                                                                   DE
          NV                                                                 IL   IN                                    MD
                       UT                                                                     WV                        DC
                                     CO                 KS        MO
                                                        OK                                         SC
                    AZ              NM                             AR
                                                                                   AL        GA

                                                        TX          LA



     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
 – Enroll in a Medicare-approved prescription drug plan
   offered by a Medicare-approved organization
 – Enroll in a Part D benefit offered by
   employers/unions responsible for retiree benefits
 – Enroll in a fully insured MA plan with PD coverage
   offered by a Medicare-approved health benefits
 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
 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
       – 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
        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
        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
        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
        MEMBER PAYS          the rest of the year                        the rest of the year                  the rest of the year
                      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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