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Medicare Advantage Participating Provider Training
Provider Experience
Part A Part B Part C Part D
Also known as Hospital Insurance program, covers inpatient hospital, skilled nursing facility, some health visits and hospice care
The Supplementary Medical Insurance program, helps pay for physician, outpatient, some home health and preventive services
Also known as the Medicare Advantage program, allows beneficiaries to enroll in a private plan, such as a health maintenance organization (HMO) or preferred provider organization (PPO), as an alternative to traditional Medicare
The outpatient prescription drug benefit is a voluntary benefit delivered through private plans that contract with Medicare; enrollment in Part D is voluntary Private plans can be
either stand-alone prescription drug plans (PDPs) or Medicare Advantage prescription drug plans (MA-PD)
The four parts that make up the Medicare Program are:
Medicare Overview
2 November 2018
Medicare Cost vs. Medicare Advantage
Medicare Cost Medicare Advantage
When Kaiser Permanente refers and/or authorizes services outside our Medical Centers, Kaiser Permanente is responsible for paying Original Medicare coinsurance and deductibles for our Cost members.
Members can use their Original Medicare cards to seek services from Medicare providers outside of the Kaiser network without a referral from their Kaiser provider.
Also known as Medicare Part C, Medicare Advantage covers Medicare Parts A, B, and D for participating members as well as benefits above and beyond what someone would receive under Medicare alone.
CMS pays Kaiser Permanente a capitated rate to manage the health care of a member. Members must use the Kaiser Permanente Medicare Advantage network and may not use their red, white, and blue Medicare card to receive services outside of the network.
Medicare members must have Medicare Part A and B to be eligible to join a Medicare Advantage plan that is offered in their area.
3 November 2018
2018 Medicare Advantage Launch2018 Kaiser Permanente Mid-Atlantic States
Medicare Service Areas
2018 January April July OctoberMA membership 1,600 2,700 3,600 4,300
Cost membership
73,100 72,400 72,200
Starting January 1, 2018, we began offering Medicare Advantage (MA) plans. As of May, we have enrolled ~3k Medicare Advantage members.
MA plans are offered to people who live in Washington, DC, as well as Anne Arundel, Baltimore, Baltimore City, Harford, Howard, Montgomery, and Prince George’s county in Maryland
Current individual (~48k) and group (~26k) members stayed in Cost unless they actively elected to move to a Medicare Advantage plan
4 November 2018
For 2019, we intend to close our Cost plans in counties where Medicare Advantage was launched for 2018. This includes DC, Anne Arundel, Baltimore, Baltimore City, Harford, Howard, Montgomery, and Prince George’s county in Maryland
As a result of our Cost plans being closed, we will automatically renew our members in the counties above in to new MA plans. This applies to group and individual members. There will be no Cost plan members in the area highlighted in blue with the exception of Charles County.
We will also launch Medicare Advantage new in Charles County for 2019.
All group membership in Charles County will be moved to Medicare Advantage in 2019
All Charles County residents who are newly enrolling in KP Medicare plans will enroll in Medicare Advantage
Existing individual Cost members in Charles County will be able to actively enroll in a Medicare Advantage plan if they choose to
All remaining parts of the service area will continue to offer Medicare Cost plans. This includes VA, Calvert, Frederick and Carroll.
2019 Medicare Advantage Launch2019 Kaiser Permanente Mid-Atlantic States
Medicare Service Areas
Looking ahead…We continue to evaluate the opportunity to expand Medicare Advantage into the rest of our Medicare service area
5 November 2018
Eligible Kaiser Permanente Medicare Advantage
members may receive PRIMARY and SPECIALTY care services at any Kaiser
Permanente location throughout the entire Kaiser
Permanente Mid-Atlantic service area, regardless of whether or not the location
is in the Medicare Advantage service area.
Kaiser Permanente Medicare Advantage members may also
see select Participating Primary and Specialty care
providers within Kaiser Permanente’s Medicare
Advantage Network.
Medicare Advantage Primary and Specialty Care Locations
6 November 2018
Medicare Advantage NetworkBecause a Medicare Advantage member can only utilize the network of the Medicare Advantage Organization (MAO), there are rigorous network adequacy guidelines (time and distance requirements) that all MAOs must meet. These vary by the population density of a given area as well as the type of provider.
The KP-MAS Medicare Advantage Network is its own network and differs from the Select network.
All providers in the Medicare Advantage network required to meet network adequacy must be listed in the provider directory.
With an approved authorization, Members may choose from any provider in the Medicare Advantage network.
7 November 2018
Kaiser Permanente Medicare Advantage members will be able to fill prescriptions at ANYKaiser Permanente pharmacy center location across the Mid-Atlantic States region.
Medicare Advantage Pharmacy Locations
Kaiser Permanente Medicare Advantage members also have the option to use non-Kaiser Permanente participating network Pharmacies in the KP-MAS service area, including but not limited to the following:
• Giant • Walmart• Target• CVS• Rite Aid• Walgreens• Contracted Independent Pharmacies
https://healthy.kaiserpermanente.org/static/health/en-us/pdfs/mid/Medicare_2018_MID/mid_ma_dcmd_pharmacy_directory.pdf
8 November 2018
ID Cards
MA Signature MA SelectCard Color White TanProvider Information included
No Yes
Rx Info Included Yes Yes
Members may have different ID cards depending on whether they are in a plan with the Medicare Advantage Signature network or the Medicare Advantage Select network. The differences appear in the card color as well as the information included on the card.
9 November 2018
Participating Providers enrolled with KP HealthConnect AffiliateLink may verify eligibility and benefit information online by logging on at: www.providers.kp.org/mas
Participating Providers or members may call Member Services at 1-855-249-5019 or for TTY 1-866-513-0008 regarding:• General enrollment questions• Clarification of eligibility verifications• Clarification of member benefits• Members terminated greater than 90 days• Members presenting with no Kaiser Permanente identification number• Clarification of claims issues
Enrollment and Eligibility
10 November 2018
Kaiser Permanente Medicare Plus (Cost)
Standard Plans
Kaiser Permanente Medicare Advantage
Standard Plans
Kaiser Permanente Medicare Plus (Cost)
High Plans
Kaiser Permanente Medicare Advantage
High Plans
Inpatient Hospital $850 per benefit period
$250/day for days 1-5; $0 unlimited thereafter
(STAY)Per admission
$350 per benefit period
$225/day for days 1-5; $0 unlimited thereafter
(STAY)Per admission
Skilled Nursing Facility: Days 0-20
Days 21-100$0
$160/day $0
$160/day $0
$110/day$0
$110 /day
Cost vs Advantage - Direct Pay / Individual
Note: The above copays are examples. Please verify eligibility and benefits prior to rendering services.
Benefit differences in 2019
11 November 2018
Cost vs Advantage – Group Plan ChangesMedicare Group Plan ChangesDue to the service area changes, employer groups will offer a Cost plan to their employees who reside in the Cost service area and Medicare Advantage to their employees who reside in the Medicare Advantage service area. Charles County group members will be in Medicare Advantage.
Although plan types may be different within the same group, cost sharing is the same between Cost and Advantage plans.
Inpatient Hospitalizations:- Medicare Advantage Group plans will administer a “per benefit period” structure. This
does not align with Medicare Advantage individual plans, which have a per day co-pay
12 November 2018
Appointment and Access StandardsPer the Medicare Managed Care Manual, Chapter 4 - Benefits and Beneficiary Protections, Section 110.1.1 – Provider Network Standards Hours of operation are convenient to, and do not discriminate against, enrollees. When medically necessary, services are available 24 hours a day, 7 days a week Examples of reasonable standards for primary care services are:
– (1) urgently needed services or emergency - immediately; – (2) services that are not emergency or urgently needed, but in need of
medical attention - within one week; and – (3) routine and preventive care - within 30 days
13 November 2018
Referrals and Authorizations
Specialty Care Referrals
• Initial Consultation• Referral must be authorized by PCP or Specialist• Referral valid for 90 days (3 months), or as otherwise specified on the
referral
• Additional Visits and Expired Referrals• After an approved initial consult you do not have to call the PCP to request
additional visits• Complete a Maryland Uniform Consultation Referral Form to initiate a new
request, fax to UMOC for processing• UMOC FAX Numbers: 1-800-660-2019 – Alternate Fax: 855-414-1693
14 November 2018
Referrals and AuthorizationsUtilization Management Operations Center (UMOC)
Referral Management Unit: 8:00am –4:30pm, weekdays
Concurrent Review Unit: 8:30am –5:00pm, weekdays
Home Care/DME Unit: 8:30am –5:00pm, weekdays
Emergency Care Center (ECC): 24/7, 365 days/year
Referrals, authorizations hospital observation & inpatient admissionsGeneral Number (listen for prompts): 1-800-810-4766Fax Numbers• Specialty Care Referrals: 1-800-660-2019 or 855-414-1693• Homecare/DME (Please send clinical information): 855-414-1695• Rehab Re-Authorizations (Please send clinical information): 855-414-1698• DCSM Concurrent Review: 855-414-1704• NOVA Concurrent Review: 855-414-2659• Baltimore Concurrent Review: 855-414-1702• Emergency Care Center: 855-414-2634
15 November 2018
Claims & Billing Procedures
Billing Address:Mid-Atlantic Claims AdministrationKaiser PermanenteP.O. Box 371860Denver, CO 80237-9998
Clearinghouse Payor IDs for KP:ChangeHealthcare: 52095Office Ally: 52095Availity: 54294OptimumInsight/Ingenix: NG008Relay Health: RH010
Timely Filing: 180 days (6 months) fromdate of serviceTimely appeals filing: 180 days (6 months) from date of denial“Clean Claim”: Standard format/completed fields, attachments, current industry standard data codingAll patient services must be billed on CMS 1500 or UB04
Kaiser Permanente is the primary payor for Medicare Advantage. Claims should be sent to Kaiser Permanente, not CMS. However, the same billing requirements for CMS are applicable to all claims billed to Kaiser Permanente. Please verify the member’s plan to ensure that the claim is submitted to the correct payor.
16 November 2018
Provider Appeals
All provider appeals should be sent to:Mid-Atlantic Claims AdministrationKaiser PermanenteP.O. Box 371860Denver, CO 80237-9998
17 November 2018