Benefit Explanation The following pages describe the Advocare benefit package generally. When reading the benefit information, keep the following in mind: The regular fee-for-service Medicare program was designed to help pay medical bills. Medicare was never intended to pay all expenses. Medicare alone forces members to be responsible for both professional and facility deductibles. Advocare does not have deductibles, however, members are responsible for copayments and coinsurance on some benefits. Coverage is subject to member eligibility, Medicare, and Advocare guidelines (written in the EOC). Coverage will be provided in accordance with Medicare guidelines. Services that are not covered by Medicare are not covered by Advocare, except as specifically set forth in the Evidence of Coverage (EOC). Benefits are subject to change and verification of benefits should be directed to Security Health Plan Advocare Customer Service representatives at 1-877-998-0998 or 715-221-9897. Copies of the members current Evidence of Coverage which contains the details of Advocare coverage are available upon written request. Coverage Specifics for Certain Services Chiropractic Service Coverage Chiropractic service means the covered health services provided by the Security Health Plan Advocare contracted chiropractors. Coverage is provided for medically necessary office visits, X-rays and manual manipulations of the spine to correct subluxation. It must be provided by a Security Health Plan Advocare contracted chiropractor. The services performed must be within the scope of the chiropractic license. Security Health Plan will reimburse Advocare network providers at the Medicare allowable fee schedule for Medicare covered chiropractic services following a copayment by the member per manipulation. Claims will be adjudicated at the Medicare allowable rate in effect at the time of claim adjudication. Security Health Plan contracts with Allied Health of Wisconsin, Inc. to manage its chiropractic network. Contracted chiropractors are listed in the Advocare Provider Directory. Hearing Coverage A hearing examination for purposes of the Advocare plan is defined as an examination to determine whether a hearing problem exists. Hearing examinations and hearing tests to determine whether a hearing problem exists are a covered benefit. The service should be coordinated with the member s personal provider and be provided by a Security Health Plan ENT specialist (otolaryngologist) or audiologist. Diagnostic hearing exams are covered at 100 percent after the office visit copayment. Hearing aids and evaluation of the hearing aids are not a covered benefit. A 8-1 n 10/10
Vision Coverage A vision examination for purposes of the Advocare plan is defined as an examination to determine whether a vision problem exists. A vision examination to determine whether a vision problem exists is a covered benefit. This service should be coordinated with the member s personal physician and be provided by a Security Health Plan ophthalmologist or optometrist. Refractions are also a covered benefit. An annual routine vision exam is covered at 100 percent after the office visit copayment. Preventive Care Coverage Preventive care coverage includes, but is not limited to, one annual routine physical examination and vision examination, diagnostic hearing exams, mammogram, pap smear, pelvic exam, bone mass measurement test (for individuals at risk), colorectal screening exam, and prostate cancer screening exam. Diabetes self-management services and immunizations also are covered under the preventive care benefit (excluding insulin). Other services may or may not be considered preventive care under the Advocare plan; please call with any questions about coverage for specific services. Services are covered after the copayment per office visit. Mental Health/Chemical Dependency Coverage Outpatient mental health and chemical dependency services are a covered benefit. Outpatient mental health care is defined as outpatient visits or partial hospitalization sessions. Chemical dependency coverage is defined as diagnosis and medical treatment for the abuse of, or addiction to, alcohol and/or other drugs. Diagnostic services, including psychiatric, psychological, and medical laboratory testing are a covered benefit. Therapeutic services that are medically necessary for the treatment of the illness or addiction include services provided by psychiatrists, psychologists, clinical social workers, clinical nurse specialists and other health care professionals who meet Medicare criteria for coverage; and individual rehabilitative therapy and counseling. Family counseling and intervention may be covered only where the primary purpose of such counseling is the treatment of the patient s condition. Services are covered when determined to be reasonable and medically necessary. Services are covered after the copayment per office visit. Contact Security Health Plan for verification of member benefits. Inpatient mental health services are a covered benefit when determined to be medically necessary. There is a lifetime coverage limit of 190 days when an individual is hospitalized in a Medicare designated psychiatric hospital. This limit does not apply to care received on a psychiatric unit of a general hospital. Skilled Nursing Facility Part A: Skilled care in a skilled nursing facility (SNF) is covered at 100 percent of the Medicare approved charge for the first 100 days per incident of illness of skilled care. There is no coverage after the 100 days. SNF care must occur at a Medicare certified Security Health Plan affiliated facility. Admissions will be reviewed based on Medicare s criteria for skilled care. Skilled nursing facilities must notify Security Health Plan of an admission within 24 hours or the next business day of admissions. Part B: Services in a SNF are covered consistent with the Medicare-approved charges. The services must be medically necessary. The SNF is requested to notify Security Health Plan of any admissions. A 8-2 n 10/10
For purposes of the Advocare plan, skilled care services are defined as skilled nursing or skilled rehabilitation services provided according to a physician s order and: require the skills of qualified technical and professional health personnel such as registered nurses, licensed practical nurses, physical therapists, occupational therapists, speech-language pathologists, or audiologists; and must be provided by or under the supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the patient and to achieve the medically desired result. Physician professional services for the evaluation and management of a member admitted to the SNF are reimbursable separately to physicians. Home Health Care Services Home health care agencies must notify Security Health Plan within two business days of the initial assessment. Medicare payment criteria will be used for home health services. The treatment must be reasonable and necessary for the treatment of a specific illness, injury, or disability, and must be consistent with the nature and severity of the member s condition, particular medical need, and accepted standards of medical practice. Home health care services must be provided by a Medicare certified affiliated Security Health Plan home health care provider. Home health services shall consist of one or more of the following: Part-time or intermittent home nursing care by or under the supervision of a registered nurse Part-time or intermittent home health aide services that are part of the home care plan. Services must be provided under the supervision of a registered nurse. Physical, occupational or speech therapy. Medical supplies prescribed by a physician. These are covered to the same extent they would have been covered under the policy if the member was hospital-confined. Medical social services as part of the home care plan. This may include counseling or help in finding resources in the community. Laboratory services by or for a hospital. Medically necessary portable X-rays and EKGs. Nutrition counseling provided by or under the supervision of a registered or certified dietitian where such services are part of the home care plan. Medically necessary durable medical equipment provided by the agency and as ordered by a physician. In order to be eligible to receive home health services, the patient must be: confined to the home or in an institution that is neither a hospital nor primarily engaged in providing skilled nursing or rehabilitation services; under the care of a physician and under a plan of treatment reviewed and approved by a physician; and in need of intermittent or part-time skilled nursing care or physical, occupational or speechlanguage therapy. Transportation required to take a homebound individual to a hospital, SNF, rehabilitation center, clinics, or other place, to receive services that cannot be provided in the home is not a benefit. Ambulance transportation for emergent services is covered. A 8-3 n 10/10
Medical Supplies and Equipment Medical supplies and durable medical equipment (DME) are a covered benefit as defined by CMS, state regulatory agencies, and Security Health Plan rules. Coverage for DME for Advocare members will be provided in accordance with Medicare s guidelines. Advocare pays 100 percent of Medicare mandated benefits. DME must be obtained from a Security Health Plan contracted DME vendor. DME covered under Medicare may include, but is not limited to, the following: Wheelchairs, hospital beds, crutches, or walkers used at home Nebulizers or oxygen equipment used at home Medical supplies such as ostomy bags, catheters and catheter supplies, surgical dressings and splints Breast prosthesis after surgery Artificial limbs and eyes DME must be prescribed by the attending physician or personal provider and is reviewed by Security Health Plan to determine if Medicare criteria for coverage are met. DME may also be approved if coverage is in the best interest of the member as determined by the Security Health Plan case management team and is reviewed on a case-by-case basis. The DME vendor is responsible for assisting Advocare members in obtaining prior authorization of any durable medical equipment. Prior authorization requests should be directed to Security Health Plan. All prospective request determinations will be communicated to the providers within two calendar days, unless additional information is needed to support the medical necessity. In that situation, the determination will be made within 14 calendar days of receiving all necessary documentation. Questions regarding coverage of DME should be directed to Security Health Plan. Requests for coverage of all DME must be prior authorized by Security Health Plan Health Services Department at 1-800-991-8109. Personal Care Nonspecialized, unskilled personal care, services of housekeepers, services of food service arrangements such as Meals on Wheels Programs and full-time nursing care at home are not covered. Renal Dialysis Services Renal dialysis services received while the member is temporarily outside of the service area are covered services. A copayment applies to office visits. A 8-4 n 10/10
Emergent and Urgently Needed Care Coverage Definitions Security Health Plan Advocare defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in any of the following: serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child serious impairment to bodily functions serious dysfunction of any bodily organ or part Emergency services are inpatient or outpatient covered services that are furnished by a provider qualified to furnish emergency services and needed to evaluate or stabilize an emergency medical condition Emergency services are covered, whether or not they are provided by an affiliated provider. Services after a member is stable are not emergency services. Security Health Plan defines urgently needed services as urgent care that is needed sooner than a routine doctor s visit. Urgent care is not emergency care. Urgently needed services are covered services provided when a member is temporarily absent* from the Advocare service area (or, under unusual and extraordinary circumstances, provided when the member is in the Advocare service area but an affiliated provider is temporarily unavailable or inaccessible) when such services are medically necessary and immediately required, and are a result of an unforeseen illness, injury, or condition; and it is not reasonable, given the circumstances, to obtain services through an affiliated provider. Emergency Services Within the Advocare Service Area In the event of an emergency, the member should be instructed to go to the nearest emergency room or to the nearest Security Health Plan Advocare affiliated hospital, or call 911, or the emergency access number for the member s area for assistance. Affiliated hospital emergency rooms should be used whenever possible. Advocare members are asked to notify Security Health Plan within 48 hours of the emergency, or as soon as possible. If the emergency occurs within the service area, all follow-up care must be obtained through contracted network providers. Noncoverage Specifics Specific benefits, limitations, and exclusions are set forth in the Evidence of Coverage issued to each member. In general, covered services must be received from Security Health Plan affiliated providers. Emergency services or urgent care services needed outside the service area are a covered benefit. For all other care, benefits are available from nonaffiliated providers only if covered services are not available from affiliated providers. Security Health Plan member or other provider should contact Security Health Plan prior to receiving nonaffiliated provider services to determine coverage. Members are financially responsible for nonaffiliated provider services that have not been prior authorized by Security Health Plan. Except as described above, services provided by nonaffiliated providers will not be covered. Members who have purchased the Advocare Point of Service rider may have some benefits from nonaffiliated providers. * A temporary absence is an absence from the Advocare service area lasting not more than 6 months. A 8-5 n 10/10
Security Health Plan Copayment Structure Copayment (copay) means a cost-sharing arrangement in which a member pays a specified amount for a specified service. Member copayment information can be obtained from a Advocare Customer Service representative at 1-877-998-0998 or 715-221-9897. Authorization of Inpatient Care Precertification is required for all elective inpatient admissions for Advocare members. Failure to precertify an inpatient admission may result in decreased or denied coverage. Notification of emergent admissions after regular business hours is required of the hospital within 24 hours or the next business day. Call 1-866-688-3400, option 1 or 2, Monday through Friday 7:30 a.m. 5 p.m. to notify Security Health Plan of an admission. The frequency of concurrent review is determined by the member s condition and severity of illness. High End Imaging (HEI) Security Health Plan requires prior notification for all outpatient high-end imaging tests: MRI, CT (excluding SPECT) and PET scans. A complete list of CPT codes requiring notification is available at www.securityhealth.org. Provider portal: Login with your username and password; under NEW From Security Health Plan, then Announcements Main Web site: Select Providers, then Provider Relations Center A prior notification is required for affiliated providers, facilities and ancillary providers for aforementioned high-end imaging procedures prior to performance, with administrative claim denial for non-compliance. The ordering provider maintains final decision authority of which high-end imaging test is performed. If an affiliated provider fails to prior notify, retro-notification will not be accepted. The ordering provider or designee is responsible for obtaining a notification number prior to scheduling high-end outpatient imaging procedures. Prior notification can be completed via telephone by calling 1-800-443-8781 until November 1, 2010. After November 1, 2010, prior notifications will be completed on-line via Security Health Plan s provider portal. For detailed information on Security Health Plan s High-End Notification process such as frequently asked questions, specific CPT codes that require prior notification, either a) visit Security Health Plan s main web site: www.securityhealth.org > Providers > Provider Relations Center b) Visit Security Health Plan s online provider portal > login with your username and password; under NEW from Security Health Plan, then Announcements A 8-6 n 10/10
Psychological Testing Security Health Plan follows original Medicare guidelines for coverage of psychological testing. Mental Health Medication Management There have been a number of questions from providers about billing for outpatient medication management services and the use of appropriate CPT coding, particularly when there is split therapy with a psychiatrist and another provider. Security Health Plan management has attempted to define an approach that is fair and ensures that members receive the proper level of care. Provision of therapy by more than one provider entails many complex issues. Such relationships imply clinical and ethical responsibilities and may involve liability issues. There are three types of recognized relationships when psychiatrists work with other providers, namely collaboration, consultation, and supervision. These relationships can be ambiguous at best with indistinct boundaries, or redundant, counter-productive, or just plain sloppy at worst. There is a mandate to define these respective roles. Delineation of responsibility should be determined by the collaborators then discussed with the patient to clarify roles and to obtain the patient s consent to the arrangement. The clinical record should document this discussion including the date this relationship was established. Questions in this area are not only important in establishing roles and responsibilities but can be quite revealing of the patient s understanding and expectations of the various care givers and treatments. The primary billing codes used are: 90862 Defined as pharmacological management including prescription use and review of medication with no more than minimal psychotherapy 90805 Individual psychotherapy approximately 20 30 minutes face to face, with medical evaluation and management services 90807 Individual psychotherapy approximately 45 50 minutes face to face, with medical evaluation and management services 90809 Individual psychotherapy approximately 75 80 minutes face to face, with medical evaluation and management services 99201 through 99275 Evaluation and Management (E/M) services provided in a physician s office Evaluation and management codes for new and established patients have clearly defined criteria for documentation of history, examination and complexity of medical decision making which are available from Medical Group Management Associates Service Center at 1-303-397-7888. Use of these codes does require a treatment plan. The use of medicine codes (for example 90805, 90807) implies that psychotherapy is being performed along with medical evaluation management services (medication management). Some psychiatrists routinely use CPT codes 90805 and 90807 for all medication management visits. If that psychiatrist is the sole provider and is doing therapy and medication management, then this is an acceptable use of these codes. However, if that patient is in therapy with another therapist such as a social worker or psychologist and is also currently receiving psychotherapy from their psychiatrist, this implies that this is an exceptionally complicated patient and a treatment plan should justify the need for the patient receiving dual psychotherapies and clarify their respective roles. A 8-7 n 10/10
When each patient of a psychiatrist is billed for CPT code 90805, utilization review again questions the validity of such a practice. Sometimes a medication check is just that, and should be billed with a 90862 CPT code. Use of codes 90805 90807 implies that the primary focus of the visit is psychotherapy; likewise use of 90862 indicates the purpose of the visit is mainly medication management. Comments: I only see patients for 30 minutes; anything less than that is unethical. Response: CPT code 90862 is not a time-based code. Sometimes a medication check is just a medication check and it is unethical to bill using a higher level code unless you are doing psychotherapy. Children are complicated; I always use CPT code 90805. Response: Some children are more complicated than others. They may require psychotherapy. The definition of CPT 90862 does involve minimal psychotherapy. Is more than minimal psychotherapy required for the routine refill of ADHD meds for children? The doctor is slow, he always uses CPT codes 90805 and 90807, because of time spent. Response: This is not a justification for the use of these codes. CPT codes 90805 and 90807 pay more. Response: Again, this is not a justification for the use of these codes. When psychotherapy and medication management are needed or in particularly complicated cases that require simultaneous psychotherapy with one provider along with psychotherapy and medication management with a psychiatrist, this need should be justified and documented. At Security Health Plan we are particularly concerned about the appropriate utilization of our members benefits. It is our responsibility to coordinate care and to ensure member care is not redundant or counter-productive and that therapists communicate with each other. We have seen situations where our members benefits do become exhausted prior to the end of the year and/or therapists are not communicating with each other. A 8-8 n 10/10
Continuity and Coordination in Care Security Health Plan believes its members should receive seamless, continuous, and appropriate care through communication between behavioral health providers and primary care providers. The Health Insurance Portability & Accountability Act (HIPAA) privacy regulations supports Security Health Plan s interest in patient safety and coordination of care. When patients present for behavioral health care, they need to be informed about how their records will be handled and, in certain circumstances, to give consent or authorization regarding what information can be shared and with whom. Coordination of care reduces the risk of problems when patients see multiple providers in different settings and when providers lack access to the patient s complete medical record. Important mental health information to be shared would include patient diagnosis, medication and/or treatment plan. In Security Health Plan s effort to provide high quality health care, affiliated behavioral health providers are required to communicate with primary care providers. Security Health Plan monitors this activity through an annual provider survey sent to both behavioral health providers and primary care providers. Providers indicate if they believe it is important to share this information as well as, if the sharing of this information occurs. Security Health Plan appreciates help and cooperation in this matter to improve communication between providers through continuity and coordination of care. Policy Security Health Plan ensures mechanisms are in place for timely, effective, and confidential exchange of information between behavioral health (BH) providers and primary care providers (PCP), medical/surgical specialists, and other relevant medical delivery systems. Procedure Security Health Plan establishes and maintains systems that assess the frequency and substance of information to be exchanged, based on the usage of the patient signed consent allowing exchange of information between their health care providers. Examples of monitoring activities may include: Surveys of BH providers regarding the exchange of health care information between BH providers and other providers Surveys of PCPs regarding information provided to and from BH providers Review of PCP medical records to determine if PCPs receive BH specialist feedback, such as BH hospitalization discharge summaries Assessment of member protection of privacy between BH and medical providers Depression in Primary Care Guideline Clinical practice guidelines, practice protocols and measurements, and treatment guidelines have become important tools in today s provision and management of health care. Security Health Plan has established a clinical practice guideline entitled Guideline for the Management of Depression in Primary Care: Detection, Diagnosis and Treatment. Security Health Plan does recognize that clinical practice guidelines are meant to be guidelines only and should never take the place of an experienced physician s judgement. A 8-9 n 10/10
Security Health Plan s goal in providing this guideline is to: provide a resource for primary care providers who treat depression provide a standard for the management of depression in primary care settings that reduces variation in practice improve quality of patient care by assisting primary care providers in recognizing circumstances that warrant referral to a behavioral health specialist provide a measurement that can be used for on-going quality improvement activities Security Health Plan currently measures appropriate treatment of depression through use of the HEDIS 1 Antidepressant Medication Management measure. This measure consists of three measurements and mirrors aspects of the Guideline for the Management of Depression in Primary Care. The HEDIS Antidepressant Medication Management measures: optimal provider appointments after beginning antidepressant use effective medication usage through the first 84 days or the acute phase of treatment effective medication usage through 180 days or the continual phase of treatment A 8-10 n 10/10