Anthem Blue Cross and Blue Shield Healthy Indiana Plan Member Education

Transcription

1 Anthem Blue Cross and Blue Shield 2011 Healthy Indiana Plan Member Education

2 Welcome Thank you for joining Anthem Healthy Indiana Plan! 2

3 Most Important Most HIP members are required to pay a monthly contribution if you are given an amount to contribute you must pay on time every month. You will be removed from the plan if your payment is 60 days late. You will have to wait a year to apply again if you are terminated for not paying on time. You will also have to pay a penalty from any remaining POWER Account funds. You can pay less next year if you have necessary preventive services this year. Money left in your POWER Account fund will be a credit to what you have to pay next year. If you don t get your preventive care, you can only get part of the credit. You won t get the part the state put into the fund. Look through this entire presentation there is more info about your POWER Account including how to pay your monthly contribution. 3

4 Most Important See your primary medical provider (PMP) within the first 90 days to get started on a path to better health and to get the most from your health plan. Also, you will receive a $25 gift card from us because we want you to take action to be healthier. Complete the on-line health survey within first 90 days to receive a $25 gift card. Go to Call us to do the survey over the telephone if you do not have access to the Internet. We will still give you a $15 gift card. Contact your PMP for all your health needs but go to the nearest hospital for a true emergency. You can also go to any family planning provider that participates in Indiana Medicaid without a referral from your doctor. 4

5 What We Will Cover Becoming an Informed Healthcare Consumer HIP Overview Important Things to Do and to Know How to Use Your Health Plan What s Covered - What s Not MyAnthem TM Site and Tools Power Account Statement How to Pay Your Power Account Contribution Programs to Help Keep You Well How to Get Help When You Need it Q & A 5

6 HIP is a new, affordable health care program for uninsured adult Hoosiers (ages 19-64). HIP was approved by the legislature in April 2007 as a part of the Indiana Check-Up Plan. The program is partially funded by an increase in the cigarette tax. Anthem is one of three plan carriers. The program started January 1, In 2011 Hoosier Healthwise and the Healthy Indiana Plan combined to create a Family Plan. 6

7 Guiding Principles Personal Responsibility You control spending from your POWER Account Select your primary doctor Financial Responsibility A required contribution from you (in most cases) Promote Healthy Behaviors Financial incentives to adopt healthy behaviors Promote Appropriate Use of Health Care Services Preventive services goals and rewards 7

8 Schedule of Benefits (see handout) Benefit Period 12 months POWER Account (per person) $1,100 Benefit Period Maximum $300K Lifetime Maximum $1M 8

9 Plan Structure You contribute into your Power Account by paying a monthly amount based on your income. The state pays the remainder to total $1,100. In some cases, the state pays the entire $1,100 contribution. If you get your required preventive services this year, any money left in your Power Account will roll over to next year and reduce the amount you have to contribute next year. When your expenses total more than $1,100 in one benefit period, claims are paid from an insurance policy - up to $300,000 per year and $1 M in your lifetime.. First $500 Preventative Services Free Power Account $1,100 Individual & State Contribution Individual contribution not to exceed 5% of gross income ($0 - $75/mo.) Insurance Coverage $300,000 Annual Coverage $1M Lifetime Coverage You may have an annual physical, flu shot, cholesterol testing, mammogram, blood glucose screening, and more without impacting your POWER Account. The following is paid for by the plan. The first $1,100 comes from your Power Account: See your family doctor or a specialist Go to an urgent care center Get family planning services Get behavioral health services Have surgery, labs or other hospital services Fill a prescription for medication or durable medical equipment 9

10 Example Ms. Red is 48 years old, she is not married, and has no children Ms. Red contributes $66 per month to her Power Account and the state put in $308. Since she had her required preventive service this year, any money left in her Power Account at the end of the year will roll over to next year and reduce the amount she has to contribute to it next year. Ms. Red hasn t used all of her Power Account yet. If she uses all $1,100, her claims will be paid from this insurance policy up to $300,000/ yr. The state pays the entire cost of the insurance for Ms. Red. Up to $500 Free Preventive Services Power Account $1,100 Individual & State Contribution Individual contribution not to exceed 5% of gross income ($0 - $75/mo.) Insurance Coverage $300,000 Annual Coverage $1M Lifetime Coverage Ms. Red had a complete physical, including a mammogram, cholesterol screen, and blood glucose screen. She also had a colonoscopy and a flu shot this year. She went to innetwork doctors, hospital, lab and a radiologist and didn t have to pay anything. Ms. Red got an eye infection and went to the urgent care center. They gave her a prescription for medicine for her eye. Ms. Red paid nothing because she went to an innetwork urgent care center. The claims were paid ($60 for urgent care center and $30 for medicine) and she now has $1,010 left in her Power Account. 10

11 How to access what you need to know? Call Member Services at Speech or Hearing Impaired call Anthem HIP website Get certificate/handbook online * Access the provider directory online - and click Find a doctor Where to get internet access - Anthem Community Resource Centers - Library - Neighborhood Resource Centers - Schools - Churches You should have received a handbook and a provider directory (if you requested one) in your Welcome Packet. 11

12 Accessing Services All HIP members must have a Primary Medical Provider (PMP) - sometimes also called a Primary Care Provider (PCP) If you do not select a PMP during your first 30 days, we select for you. Your PMP must be in our Anthem HIP network The name and number for your PMP is on your ID card Your PMP should be within 30 miles of your home address You can select a PMP that is right for you select based on type, gender, languages spoken, location, and hospital affiliation. Call the Member Helpline to change to a different PMP A Provider Directory was mailed in your Welcome Packet, but be aware that it is continually updated. See the latest version on-line at click Choose a doctor You can also call the Member Helpline to receive help in selecting a medical provider 12

13 Accessing Services Carry your ID card at all times Have a check-up with your PMP right away the name and number is on your ID card. We will give you a $25 Gift Card if you have your appointment within the first 90 days. Your PMP is your medical home don t wait until you are sick or injured. It is important to develop a trusting relationship with your PMP Your PMP will connect you with any other services and providers you need You may use any Indiana Health Coverage Programs (IHCP) family planning provider (contracted with State as a Medicaid provider) In case of a true emergency go to nearest hospital emergency room 13

14 Accessing Services If you need transportation to a doctor s appointment Call the number on your ID card to book non-emergency transportation at least 24 hours in advance You may use the transportation service up to 20 one-way trips (10 round trips) for a total of 50 miles without prior authorization You must have an appointment with a qualified medical provider Transportation is only for you The transportation service will not take you to a pharmacy Be ready ahead of time don t make the driver wait for you 14

15 Accessing Services Pharmacy The state handles your pharmacy benefits not Anthem Web Site to find pharmacies Or call (number is on your ID card) Ask the pharmacy to enter your RID# (on back of your ID Card) and to bill Medicaid 15

16 We will attempt to contact you If your monthly contribution is 45 days late. If your contribution is 60 days late you will be termed for non-payment. If you are termed for Non-Payment, You will have to wait 12 months to re-apply and also have a penalty of 25% applied to any refund of unused POWER Account We will attempt to call you if you have $100,000 / $200,000 and $300,000 in paid services. This is to help determine if you could be better served with a different program. We will attempt to call you when it s time to do your annual re-enrollment. You must send your Redetermination packet on time to the state. If we get a claim that indicates you could be pregnant. We have to contact anyone who could be pregnant to make sure they get moved over to Hoosier Healthwise. HIP does not include maternity benefits. It s easy to complete a change form to move to Hoosier Healthwise. 16

17 You will also hear from us Each year when you start a new benefit period. We make welcome calls to: give you key information make sure you have a primary medical provider answer any questions ask you to complete your Health Needs Survey When we mail or call with health reminders to have preventive or necessary follow-up health services we want you to be as healthy as you can be. 17

18 Health Needs Survey Go to and complete the survey to receive $25 Gift Card Do the survey over the phone in and receive a $15 Gift Card 18

19 What s Covered Doctor Visits and Urgent Care Centers PMP (internists, family physicians, general practitioners) Specialists Prescription Drugs Generic when available need authorization for Brand otherwise Preferred Drug List see FSSA Web Site Go to this site to search for a participating pharmacy or call Hospital Services ER (co-pay $25, $6, or $3 see your ID card. $0 if admitted as inpatient and also waived if you are a caretaker member and you had a true emergency) - POWER Account funds cannot be used to pay your ER co-pay Ambulance (emergency only) Behavioral Health Counseling, therapy, etc. (inpatient and outpatient) Mental health and substance abuse Durable Medical Equipment Supplies for special needs such diabetic testing or ostomy supplies, as well as wheelchairs and other equipment hearing aids are not covered 19

20 More of What s Covered Prosthetic and Orthotic Devices Orthotics examples are splints, slings and cervical collars Family Planning Prescription birth control, pregnancy counseling, etc. Abortion is not covered Physical Therapy, Occupational Therapy and Speech Therapy Limited to 25 sessions each per annual benefit period Skilled Nursing Limited to 60 days per benefit period Home Healthcare / IV Therapy Medical treatment in your home, not custodial care Hospice Care In home or facility Human Organ Transplants Including cornea and kidney Hearing Aids for Ages

21 More of What s Covered Non-emergency Transportation Transportation to and from qualified medical appointments 21

22 What s Not Covered Vision * Dental * Pregnancy (transfer to HHW) Experimental / Investigative Custodial Care Over the Counter Medications Not Medically Necessary Long Term Care (more than 60 days) * vision and dental procedures covered when related to a medical condition (i.e. cataracts, infection in blood stream). And initial dental repairs related to an accident (within 48 hours) are covered. 22

23 Learn about MyAnthem Online Member Services MyAnthem Tour ( Overview Page Provider Finder Page Health HealthCare Advisor MyAccount Page MyClaims Page MyBenefits page Spanish Language Support SpecialOffers@Anthem 23

24 Register for Secure Online Services Members can Register & Login from the HIP public site or from anthem.com. From the home page, enter the User Name and Password created during the registration process 24

25 MyAnthem Tour Overview tab The Overview tab is designed to give quick access to the most commonly used tools and resources at a glance. Secure Message Center Find a Provider Request ID Card Manage Profile Manage Prescriptions POWER Account Activity Quick links to Health Contact Us 25

26 MyAnthem Tour My Provider tab Find a doctor, hospital, pharmacy and other healthcare professionals that participate in the Healthy Indiana Plan. Search by location or name Refine by gender/language spoken Determine if accepting new patients Add desired providers to short-list Get a map with driving directions Available in Spanish 26

27 MyAnthem Tour Health tab Health - Your gateway into leading a better, healthier life and becoming a more informed healthcare consumer Compare Hospitals Health Risk Assessment 3D Symptom Checker Personal Health Record Animated surgery guides Talk to a Health Coach 27

28 HealthCare Advisor Decision Support Health Topics Research procedures and conditions Medical Encyclopedia Links and Resources Hospital Comparison Compare facilities by clinical outcome, safety practices, reputation, & other characteristics PharmaAdvisor Research more than 11,000 drugs Check drug interactions Treatment Cost Advisor Estimate typical in and out-ofnetwork costs for specific health care procedures and services 28

29 HealthCare Advisor PharmaAdvisor The PharmaAdvisor allows you to compare and profile drugs by condition, profile specific drugs, and check drug interactions 29

30 HealthCare Advisor Treatment Costs The Treatment Cost Advisor allows you to find typical costs for common health care services. 30

31 MyAnthem Tour My Account tab Manage your POWER Account with easy-to-use tools and information Account Summary Balance YTD amounts spent on services Most Recent Claim Activity Account Analysis Tool User-friendly Health Statement 31

32 MyAnthem Tour My Claims tab Stay on top of your Medical & Pharmacy claims from one integrated user experience 32

33 MyAnthem Tour My Benefits tab 24/7 access to your Plan Summary, Benefit Details, Certificate Booklet, Benefits Used, & Eligibility information 33

34 Spanish Language Support Spanish language provider directories Health and wellness information WebMD Product information Health Risk Assessment Cost and quality tools Newsletters Health alerts and product recalls Mini health quizzes Condition centers Tools and calculators 34

35 MyAnthem Tour My Special Offers Save money with a unique assembly of discounted programs and services that complement a healthy lifestyle Jenny Craig Eye Med Baby Style Barnes and Noble Weight Watchers Global Fit TruVision VPI Pet Insurance And many more 35

36 POWER Account Contributions are based on income -- not everyone has a required monthly amount. If you do not put in the required monthly amount on-time You will be removed from the plan and have to wait 12 months to get back in. There is currently a freeze on non-caretaker enrollment so it may be even longer if you do not have children in your household. We will refund the pro-rated balance of your unused POWER Account that you contributed, but it will be reduced by a 25% penalty. Payment methods By credit card over the phone Mail Bank draft Cash/debit card at any Indiana Walmart You can also ask your employer to deduct from your pay check (pay roll deduction) and send on your behalf. Your employer can also pay up to 50% of your required contribution. 36

37 POWER Account Mailed Payments First payment Anthem BCBS IN HIP PO Box Louisville, KY All payments AFTER first payment Anthem BCBS IN Individual PO Box Atlanta, GA Include statement with payment and put your Anthem ID# on check or money order. If paying for more than one person be sure to list each person along with their ID# and amount. 37

38 POWER Account Cash or debit card payments At local Walmart store Money Center Take your current Monthly Statement to the store They cannot Process without the statement Pay with cash or debit card You have to pay an extra 88 Cents Allow 3 business days for payment to reach Anthem 38

39 KEEP the POWER Get Your Preventative Care Rollover Option- - if you receive your age/gender appropriate preventative care by the end of your benefit period the entire account balance (including the State s portion) rolls over. - If you don t receive the recommended preventative care, only the unused amount you contributed rolls over. Check Monthly POWER Account balance statements by mail and on-line Don t Miss Out Get an Annual Physical Exam and the Preventive Services recommended for your age and gender 39

40 Preventive Services Required for Rollover of Your Entire POWER Account Balance Everyone Annual Physical Exam, Blood Glucose Test and Tetanus- Diptheria Vaccine Booster (once ever 10 years)* - Women Also Require an Annual Pap Smear Age Everything Listed Above for Your Gender Men Add an Annual Cholesterol Test Women Add an Annual Mammogram Age Everything Listed Above for Your Gender - Women Add Annual Cholesterol Testing Age Everything Listed Above for Your Gender - Men and Women Add Annual Flu Shot 40

41 Preventive Services Required for Rollover of Your Entire POWER Account Balance Your doctor should give you a Tetanus-Diptheria (Td) Booster (or Tdap which includes the pertussis vaccine booster too) if there is no record you have received in the past 5 years. We use claim data to determine if you have had all your required preventive services. We will send you a letter so that you can tell us if you have had any required services not submitted as a claim during your benefit period. Your doctor can submit proof that you had the service (for example, if you had a Tetanus-Diptheria Booster in the past 5 years before you began coverage on the Healthy Indiana Plan). 41

42 Another Word About Use of Emergency Room POWER Account funds can t be used to pay the ER co-pay. You will have to pay the co-pay amount listed on your ID card. The co-pay will be waived if you are admitted to the hospital from the ER. The co-pay will also be waived for caretaker members if the reason for the ER visit is determined to be a true emergency according to prudent lay person guidelines. Call your PMP if possible before you go to the ER. 42

43 Eligibility and Termination Report these changes to the State: Income Number of people living in the household Address Other Insurance Report to Anthem and State if you move or become pregnant 43

44 Eligibility and Termination Changes to Household Income or Number of Individuals in Household Can result in Recalculation of Your Required Contribution. 44

45 If You Become Pregnant You Must Take Action Notify Anthem by calling Request verification of pregnancy from your doctor Complete a change form and send to the FSSA Document Center PO Box 1630 Marion, Indiana Or fax to You Must Also Send the Doctor s Verification of pregnancy Transfer to Hoosier Healthwise If you do not transfer to Hoosier Healthwise, pregnancy related services will not be paid POWER Account balances returned on a pro-rated basis. May re-enroll in HIP following your pregnancy 45

46 How to resolve concerns Always start by Calling Member Services at To File a Grievance (Complaint about administration of your policy, access to health care services, provider care and treatment, etc.). There are three options: Call us at Complete a Grievance form. You can find complaint forms at the places where you get care, such as your Provider s office. Write us a letter to tell us about the concern: Anthem Blue Cross and Blue Shield P.O. Box 6144 Indianapolis, IN

47 To File an Appeal You can file an Appeal if you are don t agree with the response to a Grievance you must file the appeal within 30 days of receiving the decision. You can also file an Appeal if you do not agree with our denial of benefits for health care services. You must file within 30 days. We will send you a Notice of Action letter within 3 days of receiving an Appeal. We have 30 business days to make a decision on the Appeal. You can ask that we handle your Appeal faster if your medical condition needs it. To File an Appeal: Send details of the claims or situations to: Anthem Blue Cross and Blue Shield P.O. Box 6144 Indianapolis, IN

48 Contact Information Customer Service: Hour Nurse-line: Website: 48

49 Thank You! Final questions? Anthem Blue Cross and Blue Shield is the trade name of: In Colorado and Nevada: Rocky Mountain Hospital and Medical Service, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia (excluding the City of Fairfax, the Town of Vienna and the area east of State Route 123.): Anthem Health Plans of Virginia, Inc. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 49