HMO Special Needs Plan (SNP)
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1 HMO Special Needs Plan (SNP) BlueCare Plus Tennessee, an Independent Licensee of the BlueCross BlueShield Association BlueCare Plus Tennessee is an HMO SNP plan with a Medicare contract and a contract with the Tennessee Medicaid program. Enrollment in BlueCare Plus Tennessee depends on contract renewal.
2 What is BlueCare Plus (HMO SNP)
3 What is a Medicare Advantage Plan? A Medicare Advantage Plan is a type of Medicare health plan offered by a private company that contracts with Medicare to provide all Part A and Part B benefits. There are many different kinds of Medicare Advantage plans, including HMO, PPO, Special Needs Plan (SNP) and some others. 3
4 What is a Special Needs Plan (SNP)? A Medicare Advantage plan designed for Medicare beneficiaries with unique special needs. There are different types of Special Needs Plans; we offer a Dual Eligible Special Needs Plan called BlueCare Plus. BlueCare Plus includes Part D prescription benefit. 4
5 Dual Special Needs Plan (D-SNP) BlueCare Plus operates as the individual s point of contact for both Medicare and Medicaid. Promotes quality of care and cost effectiveness through the coordination of care for members with complex, chronic or catastrophic health care needs. 5
6 Unique CMS Requirements for DSNP A Model of Care that must be approved by National Committee of Quality Assurance (NCQA) for Centers for Medicare & Medicaid Services (CMS). Provider participation in Interdisciplinary Care Teams (ICT). Provider training in the Model of Care. A Medicare Improvement for Patients and Providers Act (MIPPA) agreement with the TennCare Bureau. 6
7 What is a MIPPA Agreement? BlueCare Plus MIPPA Agreement with the TennCare Bureau: Requires DSNP s and Medicaid MCO s to work together in an accountable manner to coordinate the delivery of Medicare and Medicaid covered services to beneficiaries. Has requirements pertaining to enrollment, member cost sharing, tag lines on marketing materials, etc. Electronic file submitted to the Bureau of TennCare for crossover payments (co-pays, coinsurance and deductibles). 7
8 Interdisciplinary Care Team
9 What is an Interdisciplinary Care Team? The Interdisciplinary Care Team (ICT) is a key component of a successful model of care (MOC). The team consists of health care professionals from diverse fields working together for the common goal for the patient. The composition of the ICT is individualized according to the member s needs. 9
10 The Who, What, When, Where of the ICT Who ICT consists of the PCP, member, BlueCare Plus Care Coordinator and other health professionals working with the member What Opportunity to discuss barriers When Based on member stratification; annually or more often based on member health status Where Teleconference (generally 15 to 30 minutes) Webinar On site 10
11 PCP Participation is Key Codes through 99215) Description If the physician is participating and the patient is in the physician s office, the physician should bill the appropriate office visit evaluation and management code Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by physician Medical team conference with interdisciplinary team of health care professionals, face-to-face with patient and/or family, 30 minutes or more, participation by non-physician qualified health care professional Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by nonphysician qualified health care professional. Thank you for your participation! 11
12 Additional Benefits with BlueCare Plus Vision $0 copay $250 plan coverage limit for routine eye wear per year Dental $0 copay $250 coverage limit every 3 months Advance determination recommended for certain benefits Hearing $0 copay $1.000 plan coverage limit for exams and hearing aids every year Over-the Counter $0 copay $150 every three months 12
13 Providers Most Frequently Asked Questions for Service Line
14 How do I identify a BlueCare Plus member? ID Card ZEU is the member ID number Call the Provider Service line
15 What is the cost sharing for this plan? No cost sharing for the member One claim TennCare uses this information to fulfill its crossover claims payment function for member cost sharing. Member billing A dual eligible member is a Medicare enrollee who is eligible for TennCare and for whom TennCare has a responsibility for payment of the Medicare Cost Sharing Obligations under the State Plan. Providers should not bill BlueCare Plus members for coinsurance, copayments or deductibles for medical services. Register with TennCare/Medicaid number in order to have crossover claims processed. 15
16 What is the cost sharing for this plan? (cont d) If you are a provider who has not received payment from the Bureau of TennCare for the copayment, coinsurance and/or deductible within sixty (60) days of the remittance date, please contact TennCare Cross- Over Claims Provider Hotline at: If a dual eligible member loses their Medicaid eligibility BlueCare Plus will: Cover for 90 days. Assist the member in transition to another plan. 16
17 Top Three Claim Errors/Denials/Rejects
18 Top Claim Errors/Denials/Rejects Z50 Indicates a non-covered procedure has been filed on the claim BlueCare Plus mirror Medicare regulations and guidance. Verify the procedure is reimbursable. Z51 Indicates an invalid procedure has been filed on the claim Z45 Exceeds units Ensure you are using the correct number of units before filing the claim. You may refer to the CMS Correct Coding Initiative page. 18
19 Latest Information and Initiatives Partnering with Million Hearts We are now a partner of Million Hearts, a national initiative to prevent one million heart attacks and strokes by Reporting of observation stays Implementation of observation notification to BlueCare Plus on Sept. 1,
20 Latest Information and Initiatives HIPPS codes required CMS has instructed Medicare Advantage Organizations that as of July 1, 2014, dates of service HIPPS codes are required to be submitted on MAO claims for skilled nursing facilities and inpatient rehabilitation facilities. 20
21 Latest Information and Initiatives Physician Assessment Form (PAF) Includes PCP analysis and health care plan to encourage members to seek regular medical care. Additionally, the PAF provides a mechanism to allow the BlueCare Plus Management staff to coordinate resources for our members, thus reducing timeconsuming work for your staff. Completed once every calendar year for each of our BlueCare Plus members. 21
22 Latest Information and Initiatives P4G (Pay for Gaps) Our goal in partnering more closely with our primary care physicians is to ensure our members get their recommended care, and one way to do that is through incentives or quality bonuses. BlueCare Plus will begin the P4G program early fall. Work with our PCPs to identify those members with gaps in preventive services. BlueCare Plus is initiating a pilot program with full implementation January 1,
23 Contact BlueCare Plus Provider Service Line BlueCare Plus Website bluecareplus.bcbst.com 23
24 Thank you! Susan Carrico (423)
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