Overview of Gateway Health Plan Medicare Assured HMO SNP
Training Objectives To provide training on Gateway Health Plan Medicare Assured. To provide training on Gateway s Medicare Compliance Program. To provide Fraud, Waste and Abuse training. 2
Definitions 3
Definitions Centers for Medicare & Medicaid Services (CMS) Federal agency that administers the Medicare program. Department of Public Welfare (DPW) Pennsylvania State agency that administers the Pennsylvania Medicaid program. 4
Medicare Definitions A National Health Insurance Program for people age 65 or older, some disabled people under age 65, and people of all ages with End-Stage Renal Disease. What are the different parts of Medicare? Medicare Part A (Hospital Insurance) Medicare Part B (Medical Insurance) Medicare Part C (Medicare Advantage Plans offering Part A & Part B coverage) Medicare Part D (voluntary Medicare Prescription Drug Coverage) 5
Medicaid Definitions Joint Federal and State Program that helps pay medical costs for some people with limited income and resources. Operated by the State. In Pennsylvania, Medicaid is operated by Department of Public Welfare (DPW). 6
Definitions Medicare Advantage (MA) Special Needs Plans (SNPs) This specialized MA plan type was authorized in the Medicare Prescription Drug Improvement, and Modernization Act (MMA) of 2003. There are 3 types of SNPs: Dual Eligible: For individuals having both Medicare and Medicaid. Institutional: For individuals who reside in or are eligible to reside in an institutional setting for 90 days or longer. Chronic Condition: For individuals having a severe or disabling chronic condition(s). 7
Definitions Medicaid only ( Full Dual )- Individual who is eligible for full Medicaid benefits. Medicaid does not pay out-ofpocket costs for Part D cost-share. QMB Only- Individual who is eligible for Medicaid payment of Medicare cost-share (i.e. Medicare Part A and/or Part B coinsurance, deductible, premium). Medicaid does not pay out-of-pocket costs for Part D cost-share. QMB plus- Individual eligible for full Medicaid benefits and Medicaid payment of Medicare cost-share (i.e. Medicare Part A and/or Part B coinsurance, deductible, premium). Medicaid does not pay for Part D cost-share. 8
About Medicare Assured 9
Medicare Health Plan Type What type of plan is Medicare Assured? HMO (Health Maintenance Organization) Generally, must use in-network providers* Generally, must use in-network pharmacies** *members may obtain care at any emergency room if they reasonably believe emergency care is needed. **members should contact the Plan for assistance in locating a pharmacy. 10
Medicare Health Plan Type What type of HMO Medicare Plan is Medicare Assured? Medicare Advantage-Prescription Drug (MA-PD) Dual Eligible Special Needs Plan (D-SNP). Enrollees must: Be eligible for Medicare Part A Be enrolled in Medicare Part B Have Full Medicaid, or Qualified Medicare Beneficiary (QMB/ QMB Plus) Medicaid eligibility Reside in Gateway Health Plan Medicare Assured service area Not have ESRD (End Stage Renal Disease) at time of enrollment 11
2012 Service Area Where does Medicare Assured Operate? 28 Counties in PA: Adams, Allegheny, Armstrong, Beaver, Berks, Blair, Butler, Cambria, Cumberland, Dauphin, Erie, Fayette, Indiana, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Mercer, Northampton, Northumberland, Perry, Philadelphia, Schuylkill, Somerset, Washington, Westmoreland, York 12
2012 Benefits What are the Medicare Assured 2012 Benefits? Gateway Health Plan Medicare Assured provides Original Medicare benefits plus: Prescription Benefits Dental Benefits Hearing Benefits Vision Benefits Health & Wellness Education Fitness Program Transportation Benefit, and Bathroom Safety Products 13
2012 Benefits Gateway utilizes delegated entities to administer some Plan benefits PBM (Pharmacy Benefit Manager): Argus Health Systems, Inc. (Argus) Dental United Concordia Companies, Inc. (UCCI) Vision Davis Vision 14
2012 Benefits Gateway utilizes delegated entities to administer some Plan benefits (cont.) Transportation: Medical Transportation Management, Inc. (MTM) Fitness: American Healthways Services, Inc. (Healthways) Behavioral Health: Community Behavioral HealthCare Network of Pennsylvania (CBHNP) 15
Prescription Benefits Gateway uses a formulary Gateway members may obtain medications at any pharmacy that accepts Argus Drugs covered under Medicare Part B: $0 Deductible $0 Co-payment 16
Prescription Benefits Cont d Drugs covered under Medicare Part D: Nearly all Gateway members are eligible for the Low Income Subsidy (LIS) $0 Deductible Co-Payments: Generic: $0 or $1.10 or $2.60 depending on income level Brand: $0 or $3.30 or $6.50 depending on income level 17
Dental Benefits $0 co-payment for covered services All Medicare covered services, plus routine services: One oral exam every 6 months One cleaning every 6 months One dental x-ray every 6 months One panoramic x-ray every 5 years 18
Dental Benefits cont d Comprehensive Services: Up to $500* every 2 years toward minor restorations (such as fillings) *Unused monies do not carry forward Dentures: 1 set every 5 years (includes one upper and one lower) 19
Hearing Benefits $0 co-payment for covered services All Medicare covered services, plus: Diagnostic hearing exams Routine hearing test Fitting and evaluation for hearing aids Hearing Aids covered up to $1000 every 2 years 20
Vision Benefits $0 co-payment for covered services All Medicare covered services, plus: Outpatient physician eye care services Up to 4 routine eye exams per year One pair of eyeglasses every year* Up to $90 towards non-vendor frames One pair standard contact lenses, or up to $150 toward specialty lenses, per year * $150 limit per calendar year for eyewear 21
Health and Wellness Education $0 co-payment for all Medicare covered services, plus: Heart Disease Program Diabetes Program Asthma Program Smoking Cessation Newsletter 22
Fitness Program $0 co-payment for all covered services Must use participating fitness center Access to 1 fitness center per calendar month Standard fitness center membership 23
Transportation Benefit $0 co-payment for all covered services Non-emergent, non-urgent transportation Up to 36 one-way trips to plan approved locations per calendar year Plan approved locations include medical, dental, vision, hearing, pharmacy, fitness center and behavioral health services Must schedule at least 3 days in advance 24
Bathroom Safety Benefit $0 co-payment for all covered services Up to $100* per calendar year for bathroom safety products such as bath/ shower chairs, bathtub rails, bathtub stool or bench *unused amount may not be carried over to another year 25
Special Needs Plan (SNP) Enrollment and Disenrollment 26
SNP Enrollment / Disenrollment Enrollment Dual Eligible individuals may change plans monthly Enrollment can be done: In person, with a Gateway marketing representative Phone, by calling Gateway Phone, by calling 1-800-MEDICARE Internet (through Medicare website) 27
SNP Enrollment / Disenrollment Voluntary Disenrollment can be done: By calling Gateway. The disenrolling member will receive a disenrollment form that must be completed and returned. By calling 1-800-MEDICARE. By enrolling in another Plan; the member will automatically disenroll from Gateway. 28
SNP Enrollment / Disenrollment Involuntary Disenrollment includes, but not limited to the following: Move out of Gateway s Medicare Assured service area. Loss of Medicaid coverage Covered on plan for 90 days ( deemed period). 29
Member Materials 30
Commonly Used Terms Evidence of Coverage (EOC) book Contract between the Plan and member: Explains benefits and services Explains what the member has to pay Explains rules and responsibilities Explains disenrollment process Explains appeals and grievances. Formulary book List of covered drugs 31
Commonly Used Terms Summary of Benefits (SB) Primary pre-enrollment document used by Plans to inform potential members of Plan benefit packages. Compares Gateway Health Plan Medicare Assured to Original Medicare. Explanation of Benefits (EOB) Notice sent to member explaining claims payment. Gateway members may receive multiple EOBs Pharmacy Medical Dental Vision 32
Medicare Compliance Program 33
Medicare Compliance Program Medicare Administration Department Gateway Health Plan s Medicare Regulatory and Compliance Department Staff Medicare Compliance Officer Medicare Compliance Specialists Government Affairs Specialist Primary Liaison with CMS All contact with regulatory agencies must be directed to Medicare Administration Department 34
Medicare Compliance Program Responsible for assuring compliance with CMS requirements Responsible for oversight of Gateway s Medicare Assured product. Conducts joint investigations with Corporate Compliance when appropriate 35
Medicare Compliance Program CMS Medicare Compliance Program Requirements: Gateway has adopted and implemented an effective Medicare compliance program, which includes measures that prevent, detect, and correct noncompliance with CMS' program requirements as well as measures that prevent, detect, and correct fraud, waste, and abuse. 36
Medicare Compliance Program The compliance program, at a minimum, includes the following [7] core requirements: 1.Written policies, procedures, and standards of conduct 2.Compliance Officer and Compliance Committee 3.Effective training and education 4.Effective lines of communication 5.Enforcement of Standards 6.Monitoring and auditing 7.Procedures and Systems for prompt Response to Compliance Issues 37
Medicare Compliance Program Medicare compliance issues must be reported to Medicare Compliance Officer or Gateway Health Plan Fraud & Abuse/Compliance hotline within 24 hours of becoming aware of the incident. 38
Medicare Compliance Program Reporting Medicare compliance issues: Send issue via e-mail to: MedicareComplianceOfficer@gatewayhealthp lan.com OR Call Fraud & Abuse/Compliance Hotline 412-255-4340 or 800-685-5235 (Call can be anonymous). 39
Audits / Oversight CMS Compliance Actions CMS Compliance Actions include but not limited to the following: Executive Conference Call/Meeting Notice of Non-Compliance Warning Letter Various Suppressions and Exclusions Suspend Marketing & Enrollment Activities Request for Corrective Action Plan New Applications/Service Area Expansion (SAE) Denials Audit Selection Enforcement and Termination 40
Fraud, Waste and Abuse Training 41
Fraud, Waste and Abuse Overview of Training: The Fraud and Abuse policy for Gateway Health Plan The laws and regulations related to fraud, waste and abuse The types of fraud, waste and abuse that can occur The process for reporting suspected fraud, waste and abuse The protections for employees, and first tier, downstream and related entities, who report suspected fraud, waste and abuse 42
Fraud, Waste and Abuse The Fraud and Abuse policy for Gateway Health Plan can be obtained by logging onto www.gatewayhealthplan.com and clicking on the Fraud and Abuse link located at the bottom of the page. 43
Fraud, Waste and Abuse Definition of Fraud, Waste and Abuse Fraud - An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law. (42 CFR 42 455.2) Waste - Over-utilization of services, or other practices that result in unnecessary costs. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources. 44
Fraud, Waste and Abuse Definition of Fraud, Waste and Abuse (cont d) Abuse - Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid, Medicare Advantage or Medicare Part D program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for healthcare. It also includes recipient practices that result in unnecessary cost to the Medicaid, Medicare Assured, or Medicare Part D program. (42 CFR 455.2) 45
Fraud, Waste and Abuse The Laws and Regulations Related to Medicare Advantage and Part D Fraud, Waste and Abuse include, but not limited to, the following (see Handout for more detail): False Claims Act: Impacts any person or entity who submits a false or fraudulent claim for payment to the US Government. Violators must repay three times the amount of damages suffered plus civil penalty of $5500 to $11,000 per claim. Stark Law: Prohibits physicians referrals for the furnishing of any designated health services for which payment may be made under the Medicare Part B program (and to some extent, Medicaid) to any entity with which the referring physician (or immediate family member) has a financial relationship. Anti-Kickback Statute: Prohibits the offer or receipt of certain remunerations in return for referrals for, or recommending purchase of, supplies and services reimbursable under government health care programs. 46
Fraud, Waste and Abuse Fraud, waste and abuse can come from many sources: Member Providers Pharmacy Benefit Manager (PBM) Pharmacies Agents 47
Fraud, Waste and Abuse Person(s) responsible for Identifying Fraud and Abuse All Gateway Health Plan employees and Board of Directors All Gateway Health Plan First Tier, Downstream and Related Entities 48
Fraud, Waste and Abuse Person(s) responsible for monitoring and auditing fraud, waste and abuse at Gateway Health Plan The (Special Investigations Unit) SIU performs the following activities to protect Gateway Health Plan from potential fraud, waste and abuse: Perform monthly audits Perform monthly reviews of State and Federal provider exclusion lists Perform peer review ranking reports to identify outlying activity of providers and members Perform periodic reviews with an emphasis on the audits identified in the annual Office of Inspector General (OIG) work plan 49
Fraud, Waste and Abuse The methods for reporting Fraud, Waste and Abuse include but are not limited to the following: Standardized Referral Process Form Fraud and Abuse Hotline Method Call the dedicated hotline to report suspected incidents of fraud, waste and abuse. Hotline Number: (412) 255-4340 (800) 685-5235 (Toll Free) Calls can be anonymous 50
Fraud, Waste and Abuse The protections for individuals who report suspected fraud, waste and abuse Whistle blowers are offered certain protections against retaliation for bringing an action under the False Claims Act (31 U.S.C. 3729). Employees who are discharged, demoted, harassed, or otherwise confront discrimination in furtherance of such an action or as a consequence of whistle blowing activity are entitled to all relief necessary to make the employee whole. 51
Gateway Health Plan Product Test Please click here to begin the required test. When you have completed the test, you must hit submit or your answers will not be recorded. A Gateway Agent Specialist will provide you with your score within approximately 2 weeks. 52