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
|
Health
Maintenance
Organization
(HMO) |
Preferred
Provider
Organization
(PPO) |
Private
Fee-for-Service
(PFFS) |
Medicare
Supplement |
Prescription
Drug
Plans
(PDPs) |
Gatekeeper |
Yes |
No |
No |
No |
No |
Referral |
Yes |
No |
No |
No |
No |
Admission
notification |
Required |
Requested |
Requested |
No |
N/A |
Provider
choice |
Local
network |
National
network |
Providers that agree to terms & conditions |
Open
access |
National
network |
Out-of-
network
benefits |
Emergency |
Yes |
N/A |
N/A |
N/A |
Rx benefits |
Yes |
Yes |
Yes |
Discount |
Yes |
Other health
benefits |
Yes |
Yes |
Yes |
No |
Limited |
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
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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