Important Information for Providers Medicare Insurance That Keeps Healthcare Decisions in the Hands of Local Providers INT.197.07 Underwritten by Sterling Life Insurance Company
Sterling Life Insurance Company offers a family of insurance products designed for Medicare beneficiaries. Sterling Health Plans have been created to be a secure, cooperative and financially sound partner for providers and to offer the Medicare population healthcare insurance solutions they can afford. Choice and mobility make the Sterling family of products unique. 1
The companies behind Sterling Health Plans Olympic Health Management Sterling Life Insurance Company (Sterling) Sterling s administrator, Olympic specializes in the development, marketing and administration of Medicare insurance products. Established in 1958; became a subsidiary of Chicago-based Combined Insurance Company of America (Combined) in 1990 First company to offer a private fee for service plan An A.M. Best A- (excellent) rated insurer Sterling, Olympic, and Combined are subsidiaries of Aon Corporation. Aon Corporation Highly diversified worldwide corporation, Aon-owned companies have 46,000 employees working in 500 offices in more than 120 countries. 2
What healthcare insurance options do Medicare beneficiaries have? Original Medicare Original Medicare, plus a Medicare Supplement plan (also known as a Medigap plan) Medicare Advantage plans (include HMOs, PPOs, and Private Fee For Service plans) Medicare-approved Prescription Drug Plans 3
The Sterling Family of Products Standard Medicare Supplement Insurance Standard Medicare Supplement Insurance (with Network Hospital restrictions) (not available in all areas) A Medicare Advantage Private Fee For Service Plan A Medicare Advantage Private Fee For Service Plan featuring Prescription Drug Coverage and Sterling also offers: and (not available in all areas) 4
Sterling Premier Medicare Supplement Insurance Sterling Medicare Select* Supplement Insurance Sterling Option II SM A Medicare Advantage Private Fee For Service Plan featuring Prescription Drug Coverage Sterling Option I A Medicare Advantage Private Fee For Service Plan Premium Higher Moderate Low Lower Choice of Hospital Freedom to choose. Hospital and Facility Network. Open access physicians. Choose your own hospital. Hospital must accept the Sterling Option II SM Terms and Conditions. Choose your own hospital. Hospital must accept the Sterling Option I Terms and Conditions. Choice of Physician Freedom to choose. Freedom to choose except when hospital services needed. Choose your own physician. Physician must accept the Sterling Option II SM Terms and Conditions. Choose your own physician. Physician must accept the Sterling Option I Terms and Conditions. Out-of-pocket Expenses Typically none; any amount dependent on selected plan s coverage of Medicare-approved services. Typically none; any amount dependent on selected plan s coverage of Medicare-approved services. Moderate copays or coinsurance for most services. Moderate copays or coinsurance for most services. *Network Restrictions Apply 5
Sterling Premier Medicare Supplement Insurance Sterling Medicare Select* Supplement Insurance Sterling Option II SM A Medicare Advantage Private Fee For Service Plan featuring Prescription Drug Coverage Sterling Option I A Medicare Advantage Private Fee For Service Plan Payment to Providers Pays deductibles and coinsurance to extent covered by plan. No capitated payments. Pays deductibles and coinsurance to extent covered by plan. No capitated payments. Minimal discounts may apply for some Network Hospitals and Facilities. Medicare Allowable less any enrollee cost sharing. No capitated payments. Medicare Allowable less any enrollee cost sharing. No capitated payments. Typical Claims Payment Turnaround 10 business days 10 business days of receipt of of receipt of clean claim clean claim 14 business days of receipt of clean claim 14 business days of receipt of clean claim Media Used For Filing Turnaround Electronic or paper Electronic or paper Electronic or paper Electronic or paper Utilization Review None None None None *Network Restrictions Apply 6
Medicare Advantage A Medicare Advantage Private Fee For Service Plan SM A Medicare Advantage Private Fee For Service Plan featuring Prescription Drug Coverage 7
What are Medicare Advantage Private Fee For Service Plans? Created by the Balanced Budget Act of 1997 Members still in the Medicare program Same coverage as Original Medicare, but with additional benefits Providers can accept members on a case-by-case basis 8
and Medicare Advantage Private Fee For Service Plans Sterling receives a capitated payment from the Centers for Medicare & Medicaid Services (CMS) but reimburses physicians, hospitals and other providers at the equivalent of Medicare allowable rates. Reimbursement is made on a fee-for-service basis without placing the providers at risk. 9
and What are the advantages? Low monthly plan premiums (Sterling Option I :$9, Sterling Option II SM : $28.70) No network restrictions. Providers have a right to decide if they will accept Sterling s terms & conditions of payment. No referrals are required. No utilization review and no pre-authorization required. No capitated payments. Providers are paid for the services they provide. Sterling Option II SM includes Part D prescription drug coverage. Full coverage for members traveling in the U.S. Coverage for emergency and urgently needed care while traveling abroad. 10
and Additional benefits for members Preventive dental services Hearing services Vision services Annual physical exam Sterling Forever Fit program Free gym membership at participating facilities 11
and Sterling s Care Coordination Program Innovative care coordination program to assist enrollees with their healthcare concerns. Services include: A telephone Nurse Advice Line is available 24 hours a day, 7 days a week. Access to educational healthcare information. Voluntary case management. Voluntary disease management. 12
2007 Service Area Sterling Option I 2007 Service Area Excluded from Service Area 13
2007 Service Area Sterling Option II SM 2007 Service Area Excluded from Service Area 14
and Sample Enrollee Identification Cards 15
and Reimbursement for RHC covered services is as follows: 80% of the lesser of the provider specific all-inclusive rate or the national limit ($74.29) unless cost based; plus 20% of the RHC s actual charge for the RHC covered service; minus Beneficiary s cost sharing under the Sterling plan. (Currently $10). 16
and Reimbursement (Continued): All non-rhc covered services are reimbursed according to their respective fee schedules. Non-RHC services are billed on the revised CMS-1500 with POS 72. Effective for dates of service on or after January 1, 2007, Sterling will reimburse rural health clinics on a retrospective basis for encounters paid at less than the all-inclusive Medicare allowable amount as determined after filing the cost report with Medicare. Reimbursement will be at the same rate allowed by Original Medicare. 17
and Billing Information Providers must bill Sterling utilizing Medicare billing guidelines and forms, e.g. revised CMS 1500 or UB92/UB04 form. Sterling follows Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) All claims will be paid by Sterling Life Insurance Company, not by a Fiscal Intermediary or Part B Carrier. 360-day timely filing limit 18
and Billing Information - continued Claims should be sent electronically through Emdeon (formerly known as WebMD), ClaimsNet or The Health Information Network (THIN) using Sterling s Payor ID# 91151 or mailed to Sterling Health Plans, P.O. Box 69314, Harrisburg, PA 17106-9314. Rendering physicians must include their UPIN on the revised CMS 1500 claim form in box 24j prior to May 23, 2007. After this date, the NPI must be included. Prior notification on DME items over $750 Providers may appeal Sterling s payment and coverage determinations within 60 days of the Explanation of Payment (EOP) statement date. Appeal rights are posted on the back side of the EOP. 19
National Provider Identifier (NPI) Implementation Sterling s implementation of the NPI will occur in separate stages, as shown in the table below: Readiness Schedule January 2, 2007 May 22, 2007 NPI Implementation Sterling will accept an NPI on both electronic and paper claims, but an existing legacy Medicare number must also be on the claim. May 23, 2007 Forward Sterling will only accept NPI numbers on electronic and paper claims. 20
and Provider Terms and Conditions of Participation Sterling Option I and Sterling Option II SM do not contract with providers, rather providers may choose to become deemed. Providers are considered deemed if prior to providing services to the enrollee: 1) they have knowledge that a Medicare beneficiary is enrolled in Sterling Option I or Sterling Option II SM and 2) they have a reasonable opportunity to obtain Sterling s Terms and Conditions and subsequently render services to that enrollee. A provider who chooses not to accept these Terms and Conditions may not provide services to a Sterling Option I / Sterling Option II SM enrollee or bill the enrollee. 21
Help cover both brand name and generic prescription drugs. Sterling Rx SM Affordable monthly premium $100 yearly deductible $10 copay for generic drugs 4-tier formulary that covers the top drugs used by Medicare beneficiaries Over 60,000 participating pharmacies Sterling Rx Plus SM Moderate monthly premium $100 yearly deductible No copay for generic drugs throughout the entire year No-cost option for generic drugs through the Coverage Gap Same formulary and pharmacy features as Sterling Rx SM 22
Marketing & Sales Local captive agents Comprehensive Marketing strategy Brochures Direct Mail Newspaper Television and Radio Telemarketing Seminars Marketing material and sales tools all approved by Department of Insurance and/or by CMS 23
A unique concept in Medicare insurance plans For Medicare beneficiaries: Choices Different plans for different needs. Mobility The ability to change plans should those needs change. For Providers: Allows providers to practice medicine the way they were meant to. Once enrolled in a Sterling Medicare plan, unless prohibited by state or federal law, Sterling offers its policyholders the ability to move between its Medicare Advantage and Medicare Supplement or Medicare Select plans A, B or C without additional underwriting as such plans are available in the market where the individual lives. Effective January 1, 2006, federal law may limit the movement into or out of a Medicare Advantage plan. 24