Presentation: Humana Gold Choice

Slide 1 - Humana Medicare Products (A New Vision in Health Benefits)

Presented by: Elizabeth Strombom
March 13, 2007
RHC TA Teleconference Series - Medicare Advantage

Slide 2 - The Changing Landscape of Medicare

• Enrollment in MA plans grew in 2006 to 17 percent, almost half of the growth was in MA PFFS plans
• Beneficiary access to health plan choices improved from as low as 51% 5 years ago to 100% in 2007 (PFFS and PDP)
• On average beneficiaries are saving >$1200 annually on their drug costs
• Independent surveys consistently show over 75% are satisfied with coverage

    2007 Humana Update:

• #1 in growth, enrolled nearly 500k PFFS members
• Implemented comprehensive process improvements and system updates in recognition of the unique RHC, CAH, FQHC, MDH, SCH, RRC payment and program requirements
• Expanded service area and product offerings (PFFS and PDP)
• Launched a national reimbursement education program focused on rural health setting
• Nationally 82% of hospitals accepting HGC (some expansion states excluded)

Slide 3 - Humana is Here Today, Here Tomorrow

Humana is a national health plan with 11 million medical members in the U.S.

Commitment:

• Humana has a long history with Medicare (20+ years experience)
• Largest career agent Medicare sales force that is year around
• On average, our Medicare members stay with Humana for 7 years
• Humana has the largest Medicare PPO footprint
  - 23 RPPO states, Local PPO in 26 markets
  - Contracted 70% of physician and hospital network goal

Education:

• Innovative and user-friendly tools to provide plan guidance such as the SmartSummary Rx benefit statement.
• Dedicated provider outreach and education department

Consistency and reliability:

• Humana was named top payer in the industry by Athenahealth in 2006.
• Developed infrastructure specifically designed to manage the complexities of Medicare reimbursement, including the rural setting.

Slide 4 - Humana’s Medicare Advantage Markets for 2007

States are in one of the following categories:

• Regional PPO, PFFS & PDP states
• PFFS & PDP states only
• PFFS (select counties) & PDP states only
• PFFS, HMO, SNP & PDP Markets
• PDP only states

Certain cities are in the following categories:

• Local PPO & HMO markets
• Local PPO only markets
• Local HMO only markets
• Local HMO & SNP markets
• Local PPO, HMO & SNP markets

Slide 5 - Humana Group Medicare 2007 Service Areas

States are in one of the following categories:

• PFFS* & PDP states
• Regional PPO, PFFS* & PDP states

Certain cities are in the following categories:

• HMO market
• Local PPO and HMO markets
• Local PPO markets

* If your employer group or labor organization is headquartered in one of the approved states, you can offer coverage to retirees nationwide. This particular Group Medicare product is not filed in Washington, D.C. at this time. If your group is primarily located in Washington, D.C., please speak with a Humana Group Medicare sales representative to discuss options that may be available to your group.

Slide 6 - Humana’s Suite of Medicare Products

Slide 7 - Why Seniors Choose Humana

Original Medicare

• A and B coverage
• Low or no deductibles
• 20% coinsurance
• Limited coverage of outpatient drugs
• No coverage outside U.S.
• Limited preventive care

Humana Medicare Products

• A and B coverage
• No or low deductibles
• Copayments and coinsurance
• Outpatient drug coverage
• Worldwide urgent/emergent care
• Routine physicals and hearing exams
• Humana Active Outlook
• Silver Sneakers and Silver Steps
• Posit science
• Vision care discounts
• Discounts on non-covered drugs
• HumanaFirst - a 24 hour nurse triage service
• Case management and disease management
• Drugs for weight loss, smoking cessation, hair loss

Slide 8 - Humana Choice PPO & Humana Group Medicare PPO

• Members may receive services from both in-network and out-of-network providers
  - Member cost share is lower with in-network providers
• Prior authorization is required for cosmetic, bariatric, and any Medicare non-covered service
• Prior notification is requested for all other inpatient admissions.
  - Member cost share for inpatient admissions can be lower at non-participating hospitals if prior notification occurs.
• No referrals, no PCP assignment
• Secondary billing limited to employee secondary plans and hospital shadow billing for Operating IME

Slide 9 - Humana Gold Choice PFFS & Humana Group Medicare PFFS

• Same patients – strong value proposition
• Network is non-contracted
• Reimbursement is equivalent to Medicare and in accordance with Humana’s terms and conditions
• Prior notification is requested for inpatient admissions to help members maximize their benefits (case and disease management)
• Medicare certified equals PFFS certified
• No authorizations or referrals required
• No secondary billing in most cases (hospital shadow billing)

Slide 10 - PFFS Participating Providers – No Contract

CMS Regulation:

A participating provider

• Has had reasonable opportunity to obtain Humana's terms and conditions (posted on website)
• Has knowledge that a member is enrolled in a Humana Medicare Advantage PFFS plan
• Provides sevices to the member

Acceptance deemed if claim received

• Exception: ER providers

Physician Medicare Status and MA

• Accepting assignment
• Not accepting assignment
• Opted out/private pay

Slide 11 - PFFS Participation Terms

• Must be a licensed provider and eligible for Medicare payments
• Providers who accept Medicare assignment agree not to balance bill the patient
• Providers who do not accept Medicare assignment may bill the patient up to the limiting charge

Slide 12 - RHC and CAH Payments

CAH payment requirements:

• The most current copy of your FI rate setting letter
• Your decision if you’ve chosen to bill using Method I or Method II for services
• (If you bill Method II) A list of providers and their tax IDs for whom you bill
• A list of your subproviders, if applicable

RHC payment requirements:

• The most current copy of your FI rate setting letter
• Pneumococcal & influenza vaccines are paid at 100% of reasonable costs

Questionnaire completion – please send an email to: imilton@humana.com

Slide 13 - Admission Notification/Authorization

Admission notification is requested for all inpatient services for PPO and PFFS

• Hospital and skilled nursing facility admissions
• Notification phone number: 1-800-523-0023

Why notification?

• Guidance:
  Optional disease management
  Optional case management

Prior authorization is required for certain PPO services

• Gastric Bypass
• Cosmetic Surgery
• Other Original Medicare Noncovered Services

Slide 14 - Claims Information

Claims may be filed electronically or on paper

• Humana accepts claims from most clearinghouses
• Paper claims should be sent to address on back of member’s ID card

Because billing procedures follow Original Medicare guidelines, we recommend:

• Using Medicare billing staff
• Using Medicare editing software

HPSA/PSA Bonus Payments

• It is not necessary for a provider to request this bonus payment in writing to the Settlement Unit. This process is handled automatically.

Slide 15 - E-capabilities

Humana website: Humana.com

Registered providers may:

• Check eligibility
• Review benefits
• View claim status
• Submit claims

Humana is ranked number six among all U.S. companies in all sectors for technology leadership, according to Forrester Research.

Slide 16 - Humana -- Guidance when you need it most

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