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Agenda Dual Special Needs Plan (SNP) Dual Consumers Dual SNP Plan Benefits Medicare Cost-Sharing Dual SNP Summary 2
Goals of Today s Presentation Understand the dual eligible member and the UnitedHealthcare products and services available to them. Understand how UnitedHealthcare works with physicians, hospitals, and our internal functional areas to ensure a high level of service. Understand how Dual SNP and Cost-Share options work for dual eligibles. 3
4 Dual SNP Consumers
Dual Eligible Consumers Nearly nine million Medicare beneficiaries are eligible for both Medicare and Medicaid. Dual eligibles represent 21 percent of the Medicare population, yet account for more than 36 percent of Medicare expenditures. Dual eligibles represent 15 percent of Medicaid members, yet account for 39 percent of Medicaid expenditures. Total Medicare and Medicaid spending on dual eligibles exceeds spending on all other Medicare beneficiaries. Source: 2010 Medicare Chartbook, Kaiser Family Foundation Other Facts: 38 percent are under age 65 and disabled. 62 percent are female. 55 percent have a high school diploma. 97 percent live in an urban area. 29 percent report trouble with 3-6 daily living activities. Sources: 2010 Medicare Chartbook, Kaiser Family Foundation MedPac Data Book 2010 5
The Opportunity UnitedHealthcare serves more than 350,000 dual eligibles in its Medicare and Medicaid programs. Following the alignment of the Dual SNP plans from UnitedHealthcare Medicare Solutions, we can simplify the delivery of care and offer integrated options for the state and Centers for Medicare & Medicaid Services (CMS). Members covered by our Medicaid Aged, Blind and Disabled/Long-Term Care (ABD/LTC) products and Dual SNP plans share many common characteristics and need a more cohesive delivery system. UnitedHealthcare Dual-Eligible Membership Dual Eligibles in Medicare Plans 280,000 Dual Eligibles in Medicaid Plans 183,000 Dual-Enrolled Members 55,000 C&S Membership (post-alignment) Dual SNP 140,000 Medicaid LTC 130,000 6
The Opportunity to Integrate To provide dual eligible individuals with products and services that meet their unique needs, UnitedHealthcare has created a Complex Care team within its Community Plan business segment. The Complex Care team works with our health plans to build processes and products that link and integrate Medicare dual Special Needs Plans, Medicaid ABD/LTC products. UnitedHealthcare Dual-Eligible Membership Dual Eligibles in Medicare Plans 280,000 Dual Eligibles in Medicaid Plans 183,000 Dual-Enrolled Members 55,000 UnitedHealthcare Community Plan Membership (postalignment) Dual SNP 140,000 Medicaid LTC 130,000 7
Special Needs Plan A Special Needs Plan (SNP) is a Medicare Advantage Prescription Drug (MAPD) plan that exclusively enrolls special-needs members: - Members with severe or disabling chronic conditions (Chronic SNP) - Members who require a nursing home level of care (Institutional SNP) - Members eligible for Medicare and Medicaid (Dual SNP) 8
Special Needs Plan Can include Health Maintenance Organization (HMO), Health Maintenance Organization Point of Service (HMO POS), Preferred Provider Organizations (PPO), or Regional Preferred Provider Organizations (RPPO) network types, but not Private Fee-for-Service (PFFS) Must include Part D coverage Offers clinical programs and special expertise to serve the target population. Claims are paid according to your UnitedHealthcare contractual Medicare fee schedule You do not have to accept Medicaid to be contracted and paid for these products 9
Eligibility Requirements Dual SNP Enrollment Requirements Patient must be: Eligible for Medicare Part A and enrolled in Medicare Part B Enrolled in State Medicaid program Live within the plan service area Not have End Stage Renal Disease (limited exceptions apply) 10
Dual SNP Identification (ID) Card The UnitedHealthcare Dual Complete ID card looks like this: 11
Target Population for Dual SNPs A beneficiary must have Medicare Parts A and B and Florida Medicaid to be eligible for our Dual SNP products Medicaid coverage is not the same for every beneficiary and the best fits for our Dual SNP products are those beneficiaries whose full Medicare cost-sharing is paid by Medicaid. The majority of dual eligibles are: - Those who are Full Benefit Dual Eligible Medicaid recipients, or in the Qualified Medicare Beneficiary (QMB) category - Those in the Specified Low-Income Medicare Beneficiary- Plus (SLMB+) Category Dual eligible patients with partial Medicaid benefits (e.g., SLMB) and Qualified Individual (QI) categories of Medicaid are generally responsible for Medicare cost-sharing, because Medicaid only pays their Part B premium no deductibles or coinsurance. 12
13 Dual SNP Plan Benefits Florida
Our Benefit Strategy Offer key benefits and services to lowincome members that are not typically available in Medicare or Medicaid Maximize available federal and state dollars and subsidies for dual members Medicaid cuts are driving reductions or eliminations in state-based benefits, such as adult dental and vision. Dual SNPs provide low-income members access to benefits they may not be able to receive elsewhere, or afford on their own. 14
Benefit Overview Key Benefits Medicare FFS benefits on Part A and Part B services (most markets) No copays or coinsurance for Medicarecovered services for Full Duals and QMBs Free annual exam No Part D premium, low drug copays due to Low-Income Subsidy (LIS) Preventive screenings, labs No medical copays or cost-sharing for Qualified Medicare Beneficiaries (QMB) Other full duals may have little or no out-of-pocket costs All dual eligibles receive extra help from Medicare with Rx costs All UnitedHealthcare Dual SNPs share the same formulary as other UnitedHealthcare MAPD plans Formulary B aka Saver 15
Benefit Overview Supplemental Benefits (may vary by market) Dental preventive or comprehensive Health products catalog credits for mailorder health care products Vision exam, credit for eyewear Educational newsletter Routine podiatry visits Nurse hotline Hearing aids No medical copays or cost-sharing for QMBs Other full duals may have little or no out-of-pocket costs All dual eligibles receive extra help from Medicare with Rx costs All UnitedHealthcare Dual SNPs share the same formulary as other UnitedHealthcare MAPD plans Formulary B aka Saver 16
2012 Branding Florida Dual SNPs One Plan, One Product One Name UnitedHealthcare Dual Complete (HMO SNP) Evercare Dual SNPs rebranded UnitedHealthcare Dual Complete, effective Jan. 1, 2012 H9011-011 UnitedHealthcare Dual Complete (Miami-Dade) R5287-003 UnitedHealthcare Dual Complete RP - RPPO (Statewide) H1080-036 UnitedHealthcare Dual Complete LP - HMO (Tampa) H5440-001 UnitedHealthcare Dual Complete EV - HMO (Tampa) Note: H5407-011 Citrus Plus (HMO SNP) will be rebranded in 2013 17
MAP
19 Medicare Cost-Share and Balance Billing to Medicaid
Medicaid Cost-Share Explained Background: Cost-sharing obligations means deductibles, coinsurance, and copayments for the Medicare Part A and Part B programs with respect to full dual eligible members. Payments for Part A are up to the Medicaid allowable fee schedule. Full Benefit Dual Eligibles are eligible for both Medicaid and Medicare. Partial Benefit Dual Eligibles are eligible for Medicare and eligible for Medicaid to pay for some or all of their Medicare cost-sharing expenses. Partial Benefit Dual Eligibles are not otherwise eligible for Medicaid, and so are not eligible for any Medicaid benefits. 20
Medicaid Cost-Share Explained Full-Benefit Dual Eligibles: Qualified Medicare Beneficiary-Plus (QMB+): Payment of Medicare Part A and Part B premiums, Medicare Part A and Part B deductibles and coinsurance, and all Medicaid benefits that are not covered by Medicare Specified Low-Income Medicare Beneficiary-Plus (SLMB+): Payment of Medicare Part B premiums, most Medicare Part A and Part B deductibles and coinsurance, and all Medicaid benefits that are not covered by Medicare Other Medicaid/Medicare Dual Eligible: Payment of Medicare Part B premiums in most cases, most Medicare Part A and Part B deductibles and coinsurance, and all Medicaid benefits that are not covered by Medicare QMB: Qualified Medicare Beneficiary-Only (QMB only): Payment of Medicare Part B premiums, Medicare Part A and Part B deductibles, and coinsurance but are not covered for any Medicaid benefits 21
Medicaid Cost-Share Explained Partial-Benefit Dual Eligibles: A small percentage of dual eligibles are enrolled in Medicaid categories like SLMB only and QI. They receive assistance from Medicaid to pay for their Medicare Part B premium, but do not receive assistance for their Medicare cost-share, or have Medicaid medical benefits. 22
Medicaid Cost Sharing Reimbursement UnitedHealthcare has a Coordination of Benefits agreement with the Agency for Health Care Administration (AHCA), which is Florida s state Medicaid agency. AHCA accepts claims for Medicare cost-sharing from physicians and hospitals serving our membership. AHCA reimburses up to the Medicaid allowable amount for the Medicare-covered services balance-billed to the state. 23
Plan and Provider Responsibility Health Plan Responsibility: As the Medicare Advantage insurance carrier for SNP members, UnitedHealthcare will process and issue payment for covered services performed according to the terms of its contract with network providers. Therefore, the provider remittance forms from the plan may indicate cost-share amounts for its dual eligible members. However, even if the provider remittance form from the plan indicates a cost-share amount, the provider cannot collect the costshare amount from a QMB. 24
Plan and Provider Responsibility Physician/Provider Responsibility: The provider determines if the patient is eligible for both Medicare and Medicaid at the time of service. The provider should not attempt to collect cost-share. Instead, bill the Medicaid Crossover Unit. As a Medicare participating provider and as a contracted provider in UnitedHealthcare s Medicare network, you may not discriminate against individuals with regard to their economic status. If the patient is not a QMB, the provider can collect any member responsibility set forth on the Provider Remittance form directly from the member. 25
Legal Protection for QMBs QMBs are not liable for cost-sharing charges in original Medicare and Medicare Advantage plans: - the beneficiary shall not have any legal liability to make payment to a provider or to an MA organization for the service. BBA of 1997 -...the amount of payment made by Medicare plus the amount of payment made by Medicaid (if any) shall be considered payment in full Letter to State Medicaid Directors (11-24-1997) Providers are subject to penalties - Providers who bill QMBs for amounts above the Medicare and Medicaid payments (even when Medicaid pays nothing) are subject to sanctions. Providers may not accept QMB patients as private pay in order to bill the patient directly, and providers must accept Medicare assignment for all Medicaid patients, including QMBs. CMS Memo (2-27-2008) Source: Health Assistance Partnership, May 2010 26
27 Dual SNP Clinical Model
Clinical Model Approach Integrate primary, acute, and long-term care services into one consumer-driven, seamless system of care Care coordinator helps physicians, providers, and caregivers provide timely, medically-necessary health care services in the least restrictive and most appropriate setting Focus on preventive, primary, and secondary care that slows the progression of illness and disability Involve members, physicians, and other providers in the care-planning process Ties to Benefits: Preventive services, such as screening, dental and vision Access to Nurse Hotline with treatment decision support Credits that can be redeemed for health products in a catalog Non-emergency transportation Note: Benefits vary by dual SNP product. Ensure that care managers collaboratively engage with physicians, providers, caregivers, and others who are involved in the patient s care 28
Clinical Model Risk Stratification Comprehensive Health Risk Assessment (HRA), performed within 90 days of enrollment and then annually for all members, determines: - Initial individualized plan of care - Member eligibility for programs HRA Key Points: Performed by vendor, HealthTel Voluntary Does not affect plan enrollment Member may opt out through customer service Members who do not respond are sent paper HRA 29
Clinical Model Low/Moderate Risk Low to Moderate Risk Consumers: Stable, with limited health care needs or gaps in care. No assigned case manager. Focus on primary and preventive care. Low/Moderate Risk Consumer Receives these Services: Interdisciplinary team, PCP-led Periodic assessment Review of claims and Rx data Primary prevention, health education Telephonic access to a nurse Disease management Wellness programs Screening exams/ immunizations Utilization management 30
Clinical Model Risk Stratification High-Risk Consumers: May have one or more of the following complexities: health instability, an acute illness, multiple chronic co-morbid conditions, vulnerable or frail, or at end of life. Members receive all services that low to moderate risk consumers receive and may be eligible for additional services/programs High Risk Consumer Additional Services: Assigned case manager, with frequent telephonic outreach Coordination of Medicare and Medicaid benefits Post-acute transition Advanced Illness program Transition case management/return to home Hospice 31
32 Summary
Dual SNP Key Points Dual eligibles are a vulnerable population. UnitedHealthcare Dual SNP products are generally most appropriate for Full Dual or QMB consumers. Dual SNPs provide low-income beneficiaries access to benefits, services, and clinical programs not available in Medicare or Medicaid alone. Cost-sharing is contracted on the Medicare plan, cost-sharing is billed to Medicaid as COB for full dual eligible members. Dual SNP providers are paid on the Medicare fee schedule and Medicare contract same as every other UnitedHealthcare Medicare product. 33
34 Questions