Transcript Joyce Landers Highmark Blue Cross
Highmark Blue Cross Blue Shield WV May 15, 2014
HEALTH CARE EXCHANGE/ MARKETPLACE WHAT IS IT?
The Affordable Care Act (ACA) marketplace, referred to as a requires that each state establish an online health insurance marketplace or exchange , through which qualified individuals may enroll in qualified health plan coverage. Eligible individuals that qualify for financial assistance to purchase coverage must purchase their coverage through a marketplace in order to receive the cost savings, which may include advance premium tax credit or cost-sharing reductions for those individuals who qualify.
The marketplaces, or exchanges, were scheduled to permit consumers in each state to begin the plan selection and enrollment process as early as October 1, 2013 for coverage that began January 1, 2014, the date when the individual coverage mandate became effective.
Health insurance marketplaces will support functions other than permitting qualified individuals to shop for qualified health plans. Consumers can also find out if they are eligible for public health programs such as Medicaid, and they can take steps to enroll in those programs.
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Health Care Exchange Products
Our Products & Formularies
ACA sets the requirements for Qualified Health Plans (QHPs) in terms of metal levels, out-of-pocket maximum limits, essential health benefits and more. Health plans on the exchanges are offered in a tiered format with several plans in each tier to choose from. Plan tiers are based on metal levels that match the percentage of costs covered (the actuarial value of the plan) as follows:
Bronze (60 percent) Gold (80 percent) Silver (70 percent) Platinum (90 percent)
Essential health benefits must be covered under each tier
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• ambulatory patient services • emergency services • • • • hospitalization maternity and newborn care mental health and substance use disorder services, including behavioral health treatment prescription drugs • • • • rehabilitative and habilitative services and devices laboratory services preventive and wellness services and chronic disease management pediatric services, including oral and vision care 3
Health Care Exchange Products Helpful Tips……..
• No separate contract agreements to participate • Follows Highmark WV Commercial Network Medical Policies Authorization process Management programs Services requiring authorization 4
Highmark Member Cards
Cards will look the same as other lines of business for Highmark WV. Copays will be listed but not metallic tier.
NaviNet should be utilized to verify eligibility and covered benefits.
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How will this affect you and your provider….
THE 90-DAY GRACE PERIOD
The Affordable Care Act (ACA) requires a 90-day premium delinquency grace period for individuals who purchased insurance through the Health Insurance Marketplace (HIM) and received an Advanced Premium Tax Credit (APTC).
Within this 30-day period, the member is placed in delinquency and the first delinquency letter is sent to the member
. Claims are still being paid to providers at this point.
After 60 days with no premium payment(s) made, a second delinquency letter will be sent to the member, with the future termination date if payment is not made in full
. Claim payment to providers is suspended at this point.
Alpha Prefixes Specific to Market Place Policies (subject to change) ZPL
-On Exchange
ZPI
- Off Exchange
If 90 days pass and the account is not paid up to date, the member's coverage will be terminated and the claims rejected for payment back to the provider
. Once a member's coverage is terminated for non payment of premiums, he/she is responsible for claim payment to the provider.
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PROVIDER RELATIONS REPRESENTATIVES SERVICING AREAS – January 1, 2014
MELANIE CLYDE
(304) 547-2229
SHERRI DEAN
(304) 424-7719
JOE LIPPOLI
(304-547-2264)
MARY DELAROSA
(304) 347-7799
JAMIE RAY
(304) 347-7792
JAMI WITT-LEWIS
(304) 347-7695
CINDY GORBY
(304)-917-7604
05 Brooke 15 Hancock 26 Marshall 31 Monongalia* 35 Ohio 09 Doddridge 18 Jackson 37 Pleasants 43 Ritchie 48 Tyler 53 Wirt 52 Wetzel 54 Wood 44 Roane 02 Berkeley 12 Grant 14 Hampshire 16 Hardy 19 Jefferson 29 Mineral 33 Morgan 36 Pendleton 39 Preston 31 Monongalia* 10 Fayette 13 Greenbrier 24 McDowell 28 Mercer 32 Monroe 34 Nicholas 38 Pocahontas 41 Raleigh 45 Summers 51 Webster 55 Wyoming 03 Boone 06 Cabell 22 Lincoln 23 Logan 27 Mason 30 Mingo 40 Putnam 50 Wayne 04 Braxton 07 Calhoun 08 Clay 11 Gilmer 20 Kanawha 01 Barbour 17 Harrison 21 Lewis 25 Marion 42 Randolph 46 Taylor 47 Tucker 49 Upshur 07 Belmont, OH 15 Columbiana, OH 41 Jefferson, OH 56 Monroe, OH 30 Green, PA 26 Fayette, PA 05 Athens, OH 84 Washington, OH 58 Morgan, OH 61 Noble, OH 01 Allegany, MD 11 Frederick, MD 12 Garrett, MD 22 Washington , MD 08 Augusta, VA 22 Clarke, VA 34 Frederick, VA 53 Loudoun, VA 79 Rockingham, VA 82 Shenandoah, VA 03 Alleghany, VA 09 Bath, VA 11 Bland, VA 14 Buchanan, VA 23 Craig, VA 35 Giles, VA 45 Highland, VA 89 Tazewell, VA 10 Boyd, KY 64 Lawrence, KY 77 Martin, KY 98 Pike, KY 27 Gallia, OH 44 Lawrence, OH 53 Meigs, OH * Melanie Clyde and Joe Lippoli share Mon County – Melanie is responsible for WVU Hospital and connected Physicians as well as Mon General and connected physicians. 9
Highmark West Virginia website
www.highmarkbcbswv.com
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Resource Center Health Care Reform
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NETWORK PARTICIPATION
• The WVFH network is an extension of the Highmark BCBS WV PPO Network. Existing PPO providers who participate with Medicaid are offered participation with WVFH by agreeing to the amendment of the current agreement with Highmark WV • Reimbursement for covered services is 105% of West Virginia Medicaid 12
Primary Care Providers
Each West Virginia Family Health member will choose a Primary Care Practice as their Patient Centered Medical Home.
The PCP works in conjunction with the member to coordinate all appropriate medical care.
Members are able to change PCP’s on a monthly basis if requested.
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Referrals
In certain instances, members do not require a referral from the PCP to see a network specialty care practitioner.
Members may self refer for the following services:
• • • • • • OB/GYN Services Family Planning Services (Family Planning services do not have to be rendered by a Network provider) Dental services Routine vision Chiropractic services (an authorization must be obtained by the chiropractic office, including the initial evaluation) Mental health/substance abuse services 14
Claims and Billing
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Bill all appropriate modifiers
• Bill all encounters, regardless of payment expected • Timely filing Criteria ₋ Initial Bills must be received within 12 month of date of service or payment from the ₋ primary carrier.
• All EPSDT claims and primary care services should be submitted within 60 calendar days from the date of service to permit accurate member outreach.
Corrected claims or requests for review must be received within 180 days from the date of the remittance advice • Claims submitted with any attachments, such as EOBs from Primary Carriers must be submitted on paper
West Virginia Family Health – Claim Department P.O. Box 69319 Harrisburg, Pa. 17106
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Claims and Billing
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Electronic Billing
Electronic claims accepted through Emdeon or Relay Health Please refer to the following grid for Emdeon Payer ID’s and RelayHealth CPID’s (clearinghouse Process ID):
CPID
45276 45276
PAYER NAME
West Virginia Family Health (WVFH) West Virginia Family Health (WVFH)
PAYER ID
45276 45276
CLAIM TYPE
Professional institutional • Hospital should include their West Virginia Family Health issued legacy • • number in your 837I submissions Loop 2010BB REF01 with a qualifier of 'G2‘ REF02 should be WVFH Issued ID# • PCP’s and Specialists should bill under their individual NPI# 16
WVFH PROVIDER RELATIONS REPRESENTATIVES SERVICING AREAS - January 1, 2014
Melissa Johnson 304-547-2267 [email protected]
05 Brooke 15 Hancock 26 Marshall 31 Monongalia 35 Ohio 52 Wetzel 09 Doddridge 02 Berkeley 12 Grant 14 Hampshire 16 Hardy 19 Jefferson 29 Mineral 33 Morgan 36 Pendleton 39 Preston 37 Pleasants 43 Ritchie 48 Tyler 01 Barbour 21 Lewis 25 Marion 17 Harrison 42 Randolph 46 Taylor 47 Tucker 49 Upshur Alana DeJesus 304-347-7692 [email protected]
04 Braxton 18 Jackson 07 Calhoun 08 Clay 11 Gilmer 53 Wirt 20 Kanawha 54 Wood 44 Roane 03 Boone 06 Cabell 22 Lincoln 23 Logan 27 Mason 30 Mingo 40 Putnam 50 Wayne 10 Fayette 13 Greenbrier 24 McDowell 28 Mercer 32 Monroe 34 Nicholas 38 Pocahontas 41 Raleigh 45 Summers 51 Webster 55 Wyoming 17
West Virginia Family Health Website
www.wvfh.com
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Policy & Procedure Manuals Complete Formularies Online Provider Directory WVFH Forms
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ATTENTION SKILLED NURSING HOMES
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Highmark has engaged the services of the Matrix Medical Network to help us complete health risk assessments for Medicare Advantage Plan beneficiaries
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There is no cost to the member
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Assessments help Highmark on-going commitment to quality care
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Highmark WV Workshop Schedule
June 10 th June 11 th June 17 th June 18 th
Charleston Marriott Salons A&C on the 2 nd floor Huntington Pullman Plaza Virginia/Maryland Rooms Bridgeport Conference Center Ballroom Wheeling Oglebay Conference Center Wilson Lodge Banquet Rooms 1, 2 and 3 20
FY 2015 Quality Blue Hospital Program Focus Streamlined to Six Components
Quality Bundle
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Hospital employed physician practices quality of care metrics Readmissions Healthcare Associated Adverse events (HAAE)
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Acute Care 3 and 30 day readmissions return to ED within 7 days following acute care discharge
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Healthcare Associated Infections (HAI): CDC-NHSN data Venous thromboembolism Advance Care Planning and/or Palliative Care for Complex Patients
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Palliative care consults for targeted populations (POLST/POST) for SNF and LTAC discharges Perinatal
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Low risk birth mothers C-section rate (AHRQ IQI 33) Efficiency Measure (Medicare Spending Per Beneficiary –MSPB)
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CMS Medicare Spending Per Beneficiary Ratio
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Measures included in the Quality Bundle: 20 CMS Star Measures C01 C02 C03 C04 C10 C14 C15 C16 C17 C18
Breast Cancer Screening
C20
Disease Modifying Anti- Rheumatic Drug Therapy for Rheumatoid Arthritis Colorectal Cancer Screening
C23
Plan All-Cause Readmissions : Medicare Advantage Cholesterol Management for Patients with Cardiovascular Conditions: LDL-C Screening
D11
Use of High Risk Medication in the Elderly Comprehensive Diabetes Care: LDL-C screening Adult BMI Assessment Osteoporosis Management in Women who had a Fracture Comprehensive Diabetes Care: Eye exam ( retinal) performed Comprehensive Diabetes Care : Medical attention for nephropathy Comprehensive Diabetes Care: HbA1c Control ( ≤9%)
D12 D13 D14 D15 C51
Diabetes: Appropriate Treatment for Hypertension Medication Adherence for Diabetes Medication Medication Adherence for Hypertension: Renin Angiotensin System Antagonists (RASA) Medication Adherence for Cholesterol (Statins) Annual Wellness and Initial Preventive Physical Exam Rate
DMC 16
Pharmacotherapy Management of COPD Exacerbation: Systemic Corticosteroid within 14 days Comprehensive Diabetes Care: LDL-C Control ( < 100 mg/dL)
DMC17 * Measures in blue denote Static measures
Pharmacotherapy Management of COPD Exacerbation: Bronchodilator within 30 days 22
Highmark WV Quality Blue Hospital Program Participants
Current Participants
United Hospital Center Berkeley Medical Center Camden Clark Medical Center Jefferson Medical Center West Virginia University Hospital Monongalia General Fairmont General Logan General Cabell Huntington Hospital Weirton Medical Center Wheeling Hospital
Future Participants
Bluefield Regional [FY2016] Thomas Memorial St. Francis Greenbrier Valley Medical Center Princeton Raleigh Pleasant Valley 23
THANK YOU
For questions or additional information please contact: Joyce Landers Cindy Heiskell 304-347-7730 304-347-7717 [email protected]
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