CLAIMSCLAIMSClaims

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HOST CLAIM VOLUMES 20092009

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Mountain State Host/Par Claims

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Medical Policy andPre Certification/Pre AuthPre-Certification/Pre-Auth

Router

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Medical Policy and Pre-certification/Pre-Authorization RouterPre Authorization Router

•Effective October 1, 2010, providers will have access to medical policies and general pre-cert/pre-authmedical policies and general pre cert/pre auth requirements of the Home Plan

•Provider will enter alpha prefix in a designatedProvider will enter alpha prefix in a designated area(s) on the local Plan’s Web site

•Provider will be routed to the Home Plan’s medical policy and/or pre-cert requirements

•Providers must have access without logging in on the H Pl ’ W b itHome Plan’s Web site

•Once medical policy and/or pre-cert requirements are viewed provider will be re connected to local Plan’s

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viewed, provider will be re-connected to local Plan s Web site

www.msbcbs.com

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MEDICAL POLICY

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Medical Policy Screens

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Out of Area Member Medical Policy

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Out of Area Member Medical Policy Router Pageg

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DEFAULT CLAIMSRESOLUTIONRESOLUTION

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Default Claims

•Effective October 20, 2010

•60 days from the timeframe the partner receives the claim if•60 days from the timeframe the partner receives the claim if not processed it will be priced at the Host Plan’s Allowance and processed for payment.

•Payment is based on 100% of contracted fee schedule allowance. This is an exception to standard claim processing and is not an overpayment. The provider is to keep any money collected from the member during the usual business process.

A d ill th id itt / EOB•A message code will appear on the provider remittance/ EOB. Based on policy this payment constitutes payment in full.

C i ti i th f f l tt ill l b t

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•Communication in the form of a letter will also be sent.

Business Drivers

•Reduce the number of aged claims and eliminate severely aged claimsseverely aged claims.

•Improve provider satisfaction by addressing a major cause of dissatisfaction.cause of dissatisfaction.

•Incentive Partner Plans to resolve claims voluntarily before they reach 60 days.before they reach 60 days.

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MEDICARE ADVANTAGE

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Medicare Advantage Provider Billing Reminderg

How do I identify a Medicare Advantage member?

Medicare Advantage members have distinctive product logos on their medical ID card to help you recognize them. g p y gAll logos have Medicare Advantage in the design.

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What is Medicare Advantage?

•Medicare Advantage (MA) is a government program under which Medicare beneficiaries can opt-out ofunder which Medicare beneficiaries can opt out of original Medicare and enroll with a private carrier.

•Medicare beneficiaries opt-out of traditional MedicareMedicare beneficiaries opt out of traditional Medicare and elect benefits through private carriers, including Blue Plans.

•Centers for Medicare and Medicaid Services (CMS) allows private plans to offer eight different Medicare Advantage productsAdvantage products.

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Medicare Advantage Submission Requirementsq

•Electronic Claims must be submitted with NAIC Code of 71768. This is necessary to accommodate network sharing of Medicare Advantage PPO Networks.

•Paper Claims must be submitted to:p

Mountain State Blue Cross Blue Shield20th & Chapline Street20 & Chapline StreetP.O. Box 7004Wheeling, WV 26003

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Medicare Advantage MarketProduct Enrollment

October 2007 to May 2009

The MA Market has 11.1 million members as of Sept. 2009and increasing by 11% annually

October 2007 to May 2009

2 347 466381 873383,447

383,539392,440 394,050

10,000,000

12,000,000

280 401330,765

398,498 412,113

468 397602,974 652,107

767,319895,167 917,465

1,615,568

1,848,559

2,076,1082,193,889

2,243,0472,328,938 2,347,466

658,072

416,188

381,873

8,000,000

203,979232,025

261,040 280,401,

415,857468,397

4,000,000

6,000,000

5,615,4246,038,407 6,297,113 6,390,563 6,565,161 6,789,027 6,829,740

2,000,000

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-October '07 January '08 April '08 July '08 January '09 April '09 May '09

HMO/HMOPOS Regional PPO Local PPO PFFS Other

Inter-Plan Medicare AdvantageProduct Enrollment

In 2009, Blue Plans offers Medicare Advantage products in 31 states and enrolled 1 86 million members in MAin 31 states and enrolled 1.86 million members in MA Plans as of Sept. 2009.

Members 2008 2009Members 2008 2009

HMO/POS 898,014 908,611

Local PPO 270,083 438,332

Regional PPO 66,460 83,988

PFFS 312,301 386,832

Cost 46,974 39,909, ,

Total 1,593,832 1,857,672

All out-of-area Blue Medicare Advantage claims are sent through

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g gInter-Plan systems

COORDINATION OFBENEFITS QUESTIONNAIREBENEFITS QUESTIONNAIRE

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Coordination of Benefits Questionnaire

•Member COB questionnaires are available on Mountain State Blue Cross Blue Shield web-sites TheState Blue Cross Blue Shield web sites. The questionnaires can be used for MSBCBS members as well as BlueCard members.

•Under forms – OPL/COB Questionnaires

•Give a copy to the patient during their visitGive a copy to the patient during their visit

•Mail back to Mountain State Blue Cross and Blue Shield

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REAL TIME CLAIMMEMBER LIABILITYMEMBER LIABILITY

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Member Liability Estimation for Mountain State Members

•MLE is an estimation of member cost sharing at aMLE is an estimation of member cost sharing at a specific time.

•This estimation will be used by providers to understandThis estimation will be used by providers to understand what members may owe for services.

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Real Time Estimator

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Member Liability EstimationFor BlueCard Claims

•Deferred implementation until December 31, 2014 or when Healthcare Reform requires implementation, whichever is earlier.

•The value and importance of implementing Real Time Claims is recognized and the Association continues to support implementation on a voluntary basis.pp p y

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ITS 11.1RT/MLE – Plans Implementing as Homep g

•Highmark•NEPA•NEPA

•West Virginia

•Alabamaaba a•Arkansas•FloridaFlorida•Premera•South CarolinaSouth Carolina•HCSC (IL & TX pilot)•Tennessee

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Tennessee•Mississippi

Medicare CrossOver Claims

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•Medicare claims with secondary coverage will be automatically crossed over and secondary claims do not need to be submitted.

•Providers receive notice on their MEOB that the claim has crossed over.

Eli ibilit b ifi d b b itti HIPAA 270•Eligibility can be verified by submitting a HIPAA 270 electronic transaction, reviewing Navinet or by calling.

Cl i t t b ifi d b b itti HIPAA 276•Claim status can be verified by submitting a HIPAA 276 electronic transaction, reviewing Navinet or by calling.

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Questions?

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2011 Benefit Changes

Presentation Topics

• Changes Impacting Medicare Advantage

• Eliminating Private Fee for Service

• 2011 FreedomBlue PPO benefit changes

• New Product – FreedomBlue HD

• Important Dates

New CMS Bid Requirements ImpactAll Medicare Advantage Plansg

Requirement ImplicationEstablish maximum out-of- Moves closer to standardized pocket limits, both voluntary and mandatory.

Medicare Advantage products.

Creates monetary thresholds to Clearly defines the parameters ydifferentiate plans. Out-of-pocket costs between plans within a contract must vary by

y pfor product differentiation.

$20 based only on benefits.

Holds employer groups to the same cost sharing and maximum

Applies some direct pay provisions to employer group

out of pocket limits as direct pay plans.

plans.

Encourages all plans to cover preventive screenings.

CMS mandated documents will identify those plans that do not cover preventive screenings.

The Health Care Reform Legislation included several changes to Part D coverage. Some take effect this year.

Phases in of elimination of Part D coverage gap (2010) –Medicare beneficiaries who reached the coverage gap during 2010

g y

Medicare beneficiaries who reached the coverage gap during 2010 will receive a $250 rebate check from the federal government. Additional discounts on brand-name and generic drugs will be phased in to completely close the "doughnut hole" by 2020phased in to completely close the doughnut hole by 2020.

Phases-in of federal subsidies for brand-name prescriptions in the Medicare Part D coverage gap (2013) In 2011in the Medicare Part D coverage gap (2013) – In 2011 Medicare beneficiaries who reach the coverage gap will receive a 50 percent discount from manufacturers that participate in the Centers for Medicare & Medicaid Services discount program Medicarefor Medicare & Medicaid Services discount program. Medicare beneficiaries will also receive a 7 percent discount on generic drugs in the coverage gap if their insurer does not cover generic drugs in ththe gap.

Eliminating Private Fee for Service

• The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) eliminated nonProviders Act of 2008 (MIPPA) eliminated non-network private fee for service plans in most areas effective January 2011. y

• Private fee for service plans must be network based in areas where two or more network based products

il bl are available. • FreedomBlue PFFS will not be available after

January 1 Members will receive information about January 1. Members will receive information about other coverage options in late September.

• FreedomBlue PFFS employer group members will be FreedomBlue PFFS employer group members will be automatically transitioned to FreedomBlue PPO coverage.

Limited benefit changes for 2011

FreedomBlue made 2011 FreedomBlue PPO FreedomBlue made minimal benefit changes – beyond those mandated by CMS

2011 FreedomBlue PPO Benefit Changes

Value Standard Deluxemandated by CMS.CMS mandated changes included:

Value Standard Deluxe

No service level maximums for inpatient hospital

Same changes as Value and Standard

• 100% coverage for preventive services;•$3,400 in-network

inpatient hospital, skilled nursing facility or DME.

AdditionalChanges:

$3,400 in network out-of-pocket maximum; and•$5 100 catastrophic

Increased skilled nursing facility daysfrom 15-55 to 15-

• Added cost sharing to labs and imaging. •$5,100 catastrophic

out-of-pocket maximum.

75.g g

• Added podiatry and chiropractor visits

FreedomBlue PPO HD – New for 2011

• Zero premium with a $1 000 d d tibl

Service Coverage Level

Preventive Covered at 100 percent

$0 premium with $1,000 deductible for Region 1 and Region 2

$1,000 deductible. • Preventive care covered at 100 percent.

Doctor’s office visits do

Preventive care

Covered at 100 percent

Physicianoffice visits

$15 for PCP and $30 for Specialists• Doctor’s office visits do

not apply to the deductible and are covered after a

office visits Specialists

Inpatient Hospital

5 percent coinsurance after $1,000 deductible up to $1,000 out-of-pocket maximum.

copayment. • Basic prescription drug coverage is included.

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Prescription Drug

No gap coverage.

Dental Routine dental and denture • 5 percent coinsurance on some services until the member reaches the in-network out-of-pocket

coverage.

Hearing $500 hearing aid allowance and routine exam.network out of pocket

maximum or the catastrophic maximum.

Vision Routine vision exam, eyewear allowance or frames and lenses from Davis Vision.

Important Dates and Events

Health Care Reform Legislation made several changes to the time periods associated with Medicare Advantage enrollment.

• June 7, 2010 – 2010 Local MA Plan Bids and Benefits Submitted to CMS

S t b 2010 T t ti CMS

New time periods for 2011Elimination of MA Open Enrollment Period

• September 2010 – Tentative CMS Approval of 2010 Local MA Plan Bids and Benefits

(January 1 – March 31)Implementation of MA “Disenrollment-only” Period (January 1 – February 15)

• October 1, 2010 – 2011 Plan Marketing Activity Begins

No ember 15 2010 2011 Ann al

New Annual Enrollment Period (November 15 – December 31 to October 15 – December 7)

• November 15, 2010 – 2011 Annual Election Period “Fall Enrollment” Begins

• December 31, 2010 – 2011 Annual Election Period Ends

Questions?

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