sr hmos scripps access training and development. what is a sr hmo? n a medicare contracted hmo n...
TRANSCRIPT
SR HMOs
SCRIPPS
ACCESS TRAINING AND DEVELOPMENT
WHAT IS A SR HMO?
A Medicare contracted HMO
Uses approved network of providers
PCP directs care
WHO IS ELIGIBLE?
Must be enrolled in Medicare Parts A & B
Continue to pay Part B premiums
Not have ESRD
Not be receiving hospice care
Must live in plans’ service area
WHY CHOOSE A Sr HMO?
Same Medicare benefits Lower OOP expenses Most offer additional benefits:
Preventive care Prescription drugs Dental care Eyeglasses Hearing aids
AUTHORIZATIONS
PCP sends authorization request to UR for review
Required for: Inpatient visits Some outpatient services Specialists
OUT OF NETWORK SERVICES
No POS option Need auth from PCP No auth, patient responsible for charges
POS option (tier 3) No auth required Higher OOP for out of network
FORMS Still considered a Medicare beneficiary
An Important Message From Medicare About Your Rights
ENROLLING & DISENROLLING
Between Nov & Dec Medicare beneficiaries can: Enroll in a Sr HMO Switch Sr HMOs Change medical groups Switch back to Medicare New coverage begins Jan 1st
Can also switch between Jan & March (but can’t add or change to a plan with prescription drug coverage unless they already have Medicare drug coverage)
Cannot use Sr HMO & M/C at same time
VERIFYING ELIGIBILITY
Verify with each visit
Call insurance to verify Eligibility Benefits Authorization requirements
WHAT IS NEEDED FOR A CLEAN CLAIM
Name of medical group Group number, if available Policy number Effective date Correct billing address Authorization number, if needed
MCARE HIC# FIELD An extra step is required
On the Misc screen, in the Mcare HIC# field, enter the patient’s Medicare
claim #
Medicare will pay us additional money
To keep the registration process consistent, this extra step is a requirement at all sites.
SUMMARY
Must be enrolled in Medicare Parts A & B
PCP directs care
Authorizations are required
Less OOP expenses for the patient
Verify eligibility with each visit
?QUESTIONS?