ma annual provider training 2018
TRANSCRIPT
Annual Provider Training
October 10, 2018
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Agenda
• Medicare Plan Enrollment Periods
• HMSA Medicare Advantage Plans for 2019
• HMSA Essential Advantage (HMO) Plan Highlights
Prior Authorizations & Referrals
• HMSA Akamai Advantage Dual Care (PPO SNP)
Model of Care
• HMSA Medicare Advantage Part D Updates for 2019
• Plan-Directed Care
• CMS Rules Provider Practices Need to Know
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Why Will Your Patients Choose
HMSA?
• Choice of plans
• Access to care
• Convenience
• Nationally recognized 4-star CMS rating
• Extra benefits
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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
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What's New?
• CMS enrollment periods
• “Re-branding” of HMSA Medicare Advantage
..products
• Focus on Essential Advantage HMO
• Adjusted plan premiums
• Few benefit changes
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Annual Election Period (AEP)
Enroll in an HMSA Medicare Advantage plan
Change your Medicare Advantage plan
Keep your plan:
No changes? No sweat! Auto renewal
Plan is effective 1/1/19
Medicare Annual Election Period
October 15 – December 7
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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
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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
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HMSA Medicare Advantage Plans
O’ahu
* = Dual Care (PPO SNP) is statewide All plans include Part D Prescription Drug coverage
O’ahu Plans Coverage Codes
Essential Advantage (HMO)
$20 T-C - 885
HMSA Akamai Advantage Complete (PPO)
$56 706 – 735
HMSA Akamai Advantage Complete Plus (PPO)
$146 707 – 740
HMSA Akamai Advantage Dual Care (PPO SNP)*
$0 696 - 785
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HMSA Medicare Advantage Plans
Neighbor Islands
* = Dual Care (PPO SNP) is statewide All plans include Part D Prescription Drug coverage
Neighbor Island Plans Coverage Codes
HMSA Akamai Advantage Standard (PPO)
$91 708 - 725
HMSA Akamai Advantage Standard Plus (PPO)
$208 709 - 730
HMSA Akamai Advantage Dual Care (PPO SNP)*
$0 696 - 785
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Plan Benefit Changes
PPO and HMO
• Premium Changes
• Supportive Care $0 added to EOC
• Skilled Nursing Facility (SNF) after 20 days
• Emergency Room from $80 to $90
• Essential Advantage PCP and eye exam
..copays lowered to $15
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CY2019 Oahu Plan Benefits
In-Network Complete Complete
Plus
Essential
Advantage
Premium $56 $146 $20
MOOP $6,700 $3,400 $5,000
Combined
MOOP $10,000 $5,100 Not a Benefit
PCP Visit $30 $10 $15
Specialist Visit $50 $30 $50
Inpatient
Hospital
Days 1-6: $300/day
Days 7-60: $44/day
Days 61-90: $0/day
No additional days
Days 1-7: $280/day
Days 8-90: $0/day
$0 for additional days
Days 1-6: $300/day
Days 7-60: $44/day
Days 61-90: $0/day
No additional days
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CY2019 Oahu Plan Benefits
In-Network Complete Complete
Plus
Essential
Advantage
Annual Wellness
Visit $0 $0 $0
Outpatient
Services/Surgery
$150 deductible,
then 20% 20%
$150 deductible,
then 20%
Ambulance $250 $225 $250
Routine Eye Exams $30
(1 per year)
$10
(1 per year)
$15
(1 per year)
Vision Appliances $100 / 2 years $100 / 2 years $100 / 2 years
Fitness Silver&Fit Silver&Fit Silver&Fit
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CY2019 Neighbor Island Plan Benefits
In-Network Standard Standard Plus
Premium $91 $208
MOOP $6,700 $3,400
Combined MOOP $10,000 $5,100
PCP Visit $30 $10
Specialist Visit $50 $40
Inpatient Hospital
Days 1-6: $300/day
Days 7-60: $44/day
Days 61-90: $0/day
No additional days
Days 1-7: $300/day
Days 8-90: $0/day
$0 for additional days
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CY2019 Neighbor Island Plan Benefits
In-Network Standard Standard Plus
Annual Wellness Visit $0 $0
Outpatient
Services/Surgery
$150 deductible,
then 20% 20%
Ambulance $250 $225
Routine Eye Exams $30
(1 per year)
$10
(1 per year)
Vision Appliances $100 / 2 years $100 / 2 years
Fitness Silver&Fit Silver&Fit
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O’ahu Plans:
How these plans differ
Essential Advantage (HMO) Complete
(PPO)
Complete Plus
(PPO)
One health center Larger provider network
O’ahu only benefit coverage Statewide benefit coverage
Coordinated care from a
primary care provider (PCP) Choose your own providers
Emergency and urgent care
while traveling Enhanced travel benefits
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HMSA Membership Card
Members will show this card when receiving
medical services and prescriptions.
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HMSA Akamai Advantage (PPO)
Highlights
• Freedom to choose your doctors and facilities
..without physician referrals
• Large statewide network of providers
• Enhanced travel benefits
• Silver&Fit: Gym membership or at-home
..fitness kits (up to 2 per year) at no extra cost
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CY2019 Dual Care (PPO-SNP)
• 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)
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Essential Advantage (HMO)
Highlights • $20 monthly premium
• Coordinated care
• Convenience
• Available to Oahu Residents
• Emergency and urgent care travel benefits,
..mainland and worldwide
• Silver&Fit: Gym membership or at-home
..fitness kits, up to 2 per year at no extra cost
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Essential Advantage (HMO)
Network
• Hawaii Health Partners health center on O’ahu
• Includes Hawaii Pacific Health (HPH) facilities
• Includes additional specialists to meet CMS
..access requirements
• Referred to as “the Essential Advantage
..HMO Network”
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HPH “Find a Physician” Line
(808) 643-4302
• Exclusively for Essential Advantage members
• Find a PCP in the Essential Advantage network
• Change to a different PCP in the Essential
Advantage network
• Provide clear explanation of facilities
• Warm transfer to a PCP office
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Essential Advantage (HMO) Network
Find a doctor on hmsa.com
Step 1: Click on Find a Doctor
Step 2: Click Select your Plans, ..check the box for Essential …Advantage
Step 3: Click Save Changes
Start your search now by doctor name, location, specialty or ailment
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Essential Advantage
Prior Authorizations • Essential Advantage has the same prior authorizations
..required for some services as the Akamai Advantage
…PPO plans
• Reminder: A prior authorization is a process through
which the provider is required to obtain advance
approval from HMSA to cover a service
• Reminder: Submit a pre-service determination for
services to be provided by Non-Contracting
Providers (NCP).
Example: Non-Contracted Laboratory Referrals
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Essential Advantage Referrals
• Required for most in-network services from a Primary Care Provider
..(PCP). Hawaii Health Partners will monitor these referrals with their
…systems.
• Required for most out-of-network services except for urgent and
..emergency services. HMSA will monitor these referrals and
…claims will only process with an approved referral in HMSA’s
….systems.
• A referred provider can order lab services without another
..referral. Other services must be referred by PCP.
• Reminder: A referral is a process through which the
..member’s primary care provider (PCP) or other provider
…requires the member to obtain a service from another
….provider for the service to be covered.
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Services That DO NOT Require a
Referral
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In-Network • Emergency services
• Urgently needed services
• Ambulance
• DME
• Prosthetics
• Diabetic supplies and services
• Part B drugs
• Medicare-covered zero dollar preventive
services
• Medicare-covered diabetes self
management training
• Medicare diabetes prevention program
• Kidney dialysis services that you get at a
Medicare-certified dialysis facility
Out-of-Network • Ambulance
• Emergency services
• Urgently needed services from providers
when network providers are temporarily
unavailable or inaccessible
• Kidney dialysis services that you get at a
Medicare-certified dialysis facility when
temporarily outside the plan’s service area
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HHIN – Verifying Member Eligibility
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HMSA AKAMAI ADVANTAGE
DUAL CARE (PPO SNP)
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Akamai Advantage Dual Care
Membership Card
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• 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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Akamai Advantage Dual Care Plan
Claims Filing/Billing • 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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HMSA - CMS 1500 Claims (Professional) HMSA - UB-04 Claims (Facility)
P.O. Box 44500 P.O. Box 32700
Honolulu, HI 96804-4500 Honolulu, HI 96803-2700
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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:
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https://hiweb.statemedicaid.us/EligAndEnrollment/MemberVerificationHI.aspx
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CARE MANAGER SUPPORT
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MEMBER
Health Risk Assessment
(HRA)
Individualized Care Plan
(ICP)
Interdisciplinary Care Team
(ICT)
Model of Care
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Akamai Advantage Dual Care member is at the center
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Goals of Care Management Support
• 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
..Care Manager
• 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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Most
Vulnerable
Somewhat Vulnerable
Least Vulnerable
Model of Care Support for your vulnerable patients
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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
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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
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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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.
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MEDICARE ADVANTAGE PART D
PRESCRIPTION DRUG UPDATES
FOR 2019
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2019 Part D Retail Cost Share Essential
Advantage
(O’ahu)
Complete
(O’ahu)
Complete Plus
(O’ahu)
Standard
(Neighbor
Islands)
Standard Plus
(Neighbor
Islands)
Tier 1
Preferred
Generic
$4.50 $4.50 $4.00 $5.00 $4.00
Tier 2
Generic $12.00 $12.00 $11.00 $20.00 $11.00
Tier 3
Preferred
Brand
$47.00 $47.00 $45.00 $47.00 $45.00
Tier 4
Non-Preferred $100.00 $100.00 $95.00 $100.00 $95.00
Tier 5
Specialty 25% 25% 33% 25% 33%
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MA Plans – O’ahu 90-day supply from HMSA’s network mail-order pharmacy
Complete Complete
Plus
Essential
Advantage
Tier 1 - Preferred Generic $4.50 $4.00 $4.50
Tier 2 – Generic $12.00 $11.00 $12.00
Tier 3 - Preferred Brand $94.00 $90.00 $94.00
Tier 4 - Non-Preferred $200.00 $190.00 $200.00
Tier 5 - Specialty 25% 33% 25%
• Mail order is fast and convenient. Call 1(855) 479-3659 • Members can save money on maintenance medications
New prescriptions sent from the doctor’s office: • Patient will receive a call to confirm consent to ship the medication, verify • It is important that the patient responds to these calls to get the medication shipped
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MA Plans – Neighbor Islands 90-day supply from HMSA’s network mail-order pharmacy
Standard Standard Plus
Tier 1 - Preferred Generic $5.00 $4.00
Tier 2 – Generic $20.00 $11.00
Tier 3 - Preferred Brand $94.00 $90.00
Tier 4 - Non-Preferred $200.00 $190.00
Tier 5 - Specialty 25% 33%
• Mail order is fast and convenient. Call 1(855) 479-3659 • Members can save money on maintenance medications
New prescriptions sent from the doctor’s office: • Patient will receive a call to confirm consent to ship the medication, verify • It is important that the patient responds to these calls to get the medication shipped
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2019 Non-Formulary Drugs
REMOVED DRUG ALTERNATIVES
ESTRACE vag cr use generic
INVOKANA JARDIANCE, FARXIGA
INVOKAMET XR SYNJARDY XR, XIGDUO XR
NAMENDA XR use generic
RELPAX use generic
RENVELA use generic
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2019 Formulary Additions
Drug Name Tier
calcipotriene ointment (generic Dovonex) Tier 2
empagliflozin (JARDIANCE) Tier 3
empagliflozin/metformin (SYNJARDY) Tier 3
ibandronate (generic BONIVA) Tier 2
lansoprazole (generic Prevacid) Tier 2
memantine ER (generic Namenda ER) Tier 2
telmisartan (generic MICARDIS) Tier 1
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High Risk Medication PA Removals
• Amitriptyline
• Doxepin
• Estradiol tablet/patch
• Imipramine
• Thioridazine
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Opioid 7 Day Limit for Acute Pain
• 2019 CMS requires limit on initial fill for acute pain to
..reduce potential for chronic opioid use or misuse
• Exemptions for cancer pain, palliative care, hospice
..or long term care
• Does not apply if previous opioid claim within 90
..days
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New DSNP Formulary –
Additional Drugs Therapeutic Class Drugs
Antidiabetics glyburide, glyburide/metformin
Antilipemics simvastatin/exemitibe (generic Vytorin)
ARB eprosartan (generic Teveten)
candesartan (generic Atacand)
Bisphosphonates risedronate (generic Actonel)
Fluoroquinolone moxifloxacin (generic Avelox)
Musculoskeletal carisoprodol (generic Soma)
methocarbamol (generic Robaxin)
PPI rabeprazole (generic Aciphex)
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HMSA Akamai Advantage PPO Plans – Plan-Directed Care
The Centers for Medicare and Medicaid Services (CMS) has defined “plan-
directed care” as care the member believes they were instructed to obtain or
..authorized to receive by a health plan representative, including plan
…contracted physicians. CMS instructs that the MA organizations (MAO) are
…..responsible to ensure that contracting physicians and providers know
……whether specific items and services are covered in the MA plan. If the
contracting provider furnishes a service or refers the member to another
provider, and member believes is a covered service, member cannot be
held financially liable for more than the applicable cost-sharing for that
service. Additional information on this guideline is found in the
Medicare Managed Care Manual Chapter 4, section 160 on
Beneficiary Protections Related to Plan-Directed Care.
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Plan-Directed Care (cont.) As an HMSA Akamai Advantage PPO provider, you’re responsible to ensure
that Medicare will cover services that you render, supply, or order and to
provide referrals to HMSA network providers whenever possible. Starting
January 1, 2019, you must do the following before referring a member to an
out-of-network provider:
- Submit an authorization to HMSA Medical Management for HMSA
..Akamai Advantage PPO plans. Refer to HMSA Provider
…Resource Center for more information on precertification process.
- Ensure that the providers who are being referred to are Medicare
enrolled providers and understand that they’re accepting the
patient under plan-directed care and that they must furnish,
supply, and order covered services. Once the referral is
approved, the services rendered by the non-contracting
provider will be subjected to the lesser of in-network and
out-of-network cost-sharing.
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Plan-Directed Care (cont.)
The member will not be held financially liable for more than the appropriate
cost-sharing for that service received at the direction of his or her primary
care provider (PCP) or network specialist if prior authorization or
organizational determination guidelines aren’t followed.
The member will be held financially responsible for services only when
one of the following happens:
– Services aren’t covered by Medicare and/or are a clear
exclusion of the member’s Evidence of Coverage (EOC).
– Member is notified that service isn’t covered during the pre-
service organization determination and he/she still elected to
receive the service.
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CMS RULES PROVIDER
PRACTICES NEED TO KNOW
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CMS Rules Provider Practices Need To Know
You are required to: Complete Medicare Fraud, Waste & Abuse Training annually at:
https://hmsa.com/portal/provider/zav_IN.Medicare-INDEX.htm
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CMS Rules Provider Practices
Need To Know You may (but you aren’t required to): • Distribute unaltered, printed materials created by CMS, such as reports
from Medicare Plan Finder, the “Medicare & You” handbook, or
“Medicare Options Compare” (from https://www.medicare.gov) including
in areas where care is delivered
• Provide the names of plan sponsors that you contract with or
participate with
• Answer questions or discuss the merits of a Plan or Plans,
including cost sharing and benefits information. These
discussions may occur in areas where care is delivered.
MCMG Ch3., Section 60.1
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CMS Rules Provider Practices Need To Know
You may (but you aren’t required to):
• Refer patients to other sources of information, such as State Health
Insurance Assistance Program (SHIP) representatives, Plan
marketing representatives, their State Medicaid Office, local Social
Security Office, CMS’ website at:
https://www.medicare.gov or 1-800-MEDICARE
• Refer patients to Plan marketing materials available in
common areas
• Provide information and assistance in applying for the LIS
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CMS Rules Provider Practices Need To Know
You may NOT: • Accept/collect scope of appointment forms
• Accept Medicare enrollment applications
• Make phone calls or direct, urge, or attempt to persuade
their patients to enroll in a .specific Plan based on
financial or any other interests of the provider
• Mail marketing materials on behalf of Plans/Part D
sponsors
• Offer inducements to persuade their patients to enroll
in a particular Plan or organization
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CMS Rules Provider Practices Need To Know cont.
You may NOT:
• Conduct health screenings as a marketing activity
• Distribute marketing materials/applications in areas where
care is being delivered
• Offer anything of value to induce enrollees to select them as
their provider
• Accept compensation from the Plan for any marketing or
enrollment activities
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HMSA Provider Reminders • Notify HMSA of changes in your practice, such as:
• Be sure to notify HMSA 30 days in advance of any changes:
• Timely notification ensures:
Payments and correspondence are sent to the correct address
We market your practice using the correct address in our
provider directory
Practice Location Address Hours of Operation Email Address
Appointment Phone Number Patient Acceptance Status
Call us: OR
O’ahu:
(808) 952-7847
Neighbor Islands Toll Free:
1 (800) 603-4672 ext. 7847
Email us: [email protected]
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HMSA Provider Resources
• HMSA Provider E-Library:
https://www.hmsa.com/portal/provider/
• HMSA Care Managers
• 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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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
LIS Low Income Subsidy
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MAPD Medicare Advantage Part D
MOC Model of Care
MOOP Maximum Out of Pocket
NCP Non-Contracted Provider
NCQA National Committee for Quality
Assurance
OEP Open Enrollment Period
OOPM Out of Pocket Maximum
QI QUEST Integration
QMB Qualified Medicare Beneficiary
SB Summary of Benefits
SNP Special Needs Plan
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Mahalo!
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