Transcript Document

Humana Inc.
North Carolina Medical Society
Alan Wheatley
President – East Region
Humana Inc.
Humana Highlights
 Founded in 1961; headquartered in Louisville, KY
 Fortune 200 company
 7 million health plan members
– 2 million Medicare members
 Ranked number six among all U.S. companies in all
sectors for technology leadership, according to
Forrester Research
 Full spectrum of innovative products
 20 + years working with the Medicare Advantage
Program
Humana’s Medicare Footprint
WA
ME
MT
ND
VT
NH
MN
OR
SD
ID
MA
NY
WI
CT
MI
RI
Milwaukee
WY
NE
Salt Lake City
NV
Denver
CO
CA
IL
Boulder
UT
ClevelandPA
OH Columbus
Dayton
IN
Cincinnati
Indianapolis
WV
VA
Louisville
Lexington
Chicago
IA
Kansas City
KS
MO
KY
St. George
NC
NJ
DE
MD
DC
Raleigh
Nashville
TN
AZ
Memphis
OK
AR
NM
Phoenix
Dallas
SC
Atlanta
MS
AL
GA
Shreveport
TX
Austin
San Antonio
Jacksonville
LA
Baton Rouge
Houston
Daytona Beach
New Orleans
Tampa
Ft. Myers
AK
FL
Orlando
Treasure Coast
Corpus Christi
HI
PUERTO RICO
Local Markets
Feb 25, 2005 v3
PDP States
Medicare Advantage/PDP
PFFS & HMO Markets only
Medicare’s History
1965
Medicare & Medicaid
established
1972
Eligibility extended to
people with disabilities
1977
HCFA created
1997
BBA creates M+C
program
2003
MMA
passed
Medicare Beneficiary Coverage Options
For a Medicare beneficiary, there are several different
health plan options available today including:
 Original Medicare
 Original Medicare, plus a Medicare Supplement (or
MediGap policy)
 A Medicare Advantage plan – choices include HMO,
PPO and PFFS plan designs (depending on the service
area)
 Prescription Drug Plan
* No matter which option is chosen, the beneficiary is still in the Medicare program.
Medicare Advantage Plan Options
 Private Fee-for-Service (PFFS)
 Preferred Provider Organization (PPO)
 Health Maintenance Organization (HMO)
 Prescription Drug Plans (PDP)
What Is Medicare Private Fee-for-Service?
 Created by the Balanced Budget Act of 1997
 Medicare Advantage design that works like
Original Medicare, but with enhanced benefits
 Providers can accept members on a patient-bypatient basis
 Humana began offering PFFS plans in 2002
– Individual plans in 34 states and Puerto Rico
– Group plans in 50 states and Puerto Rico
What Is Medicare Private Fee-for-Service?
Defined by the Centers for Medicare and
Medicaid Services (CMS)
as a plan that:
 Reimburses providers on a fee-for-service basis
 Does not place providers at risk
 Does not vary payment rates based on utilization
 Does not restrict provider selection among those
who agree to accept the plan’s payment terms
and conditions
Private Fee-for-Service (PFFS)
 Members can seek care from any Medicare-approved
provider that is willing to provide care and accepts the
plans terms and conditions
 Plan benefits must include all services covered by
Medicare Parts A and B
 Extra benefits may be offered by the plan
 A premium, in addition to the monthly Part B premium,
may be required.
 Follows Medicare medical policies and guidelines
 Referrals and authorizations are not required
 Provider payments follow Medicare reimbursement
methodologies
 Medical care is available outside of the plan’s service
area
Why Seniors Choose Humana’s Medicare Advantage Plans
Original Medicare
Medicare Advantage
o A and B Coverage
o A and B Coverage
o Low or no deductibles
o No A and B deductibles
o 20% coinsurance
o Co-payments
o Limited coverage of
o Outpatient drug coverage
outpatient drugs
o Worldwide urgent/emergent care
o No coverage outside U.S.
o Routine physicals
o Limited preventive care
o Routine hearing exams
o Routine vision discounts
o Silver Sneakers
o Personal Nurse/Case Manager
o Disease Management
o New member services
SilverSneakers® and Silver Steps
 SilverSneakers® – Reside within 15 miles of a
metropolitan statistical area (MSA), free membership
to a network of fitness centers at no additional cost
– Staff trained in senior needs
– Specialized classes for seniors
– Motivational incentives
 SilverSneakers Steps – Reside more than 15 miles
from a MSA, self-directed walking program
– Online, telephone and mail support
– Prize incentives
 Offers social, as well as health, benefits to seniors
Member Cost Share Impact
20% Cost Share by DRG
$8,000
$6,000
$4,000
$2,000
$0
DRG 9
DRG 76
MA
DRG 531
Non-Par
DRG 106
Understanding benefits- PFFS
 Sales associate are required to articulate the product
specifics
– Closely monitored. Constant reinforcement
 In bound and outbound verification calls
– Expanded hours of operation
– Expanded questionnaire
 Pre enrollment kits explaining benefits
 Welcome Calls
– Describing Health Management Programs
– Health Risk Assessment
– Explaining Benefits
 Provider education
Why Medicare PFFS?
Medicare Advantage Plan
 Same patients
 Patient receive better benefits
 Same reimbursement
 Same medical policies and guidelines
 No additional credentialing
– Medicare certified = Humana certified
 No authorizations or referrals required
 No secondary billing in many cases
 Less bad debt
Primary Care Provider
Original Medicare
Primary Care w/procedure
(Office visit 99212 + procedures)
Billed charges
Medicare allowable
$ 532.00
$ 332.12
Patient coinsurance (20%) $ 66.42
Medicare pays (80%)
$265.70
Total to Provider
$ 332.12
Humana Gold Choice
Primary Care w/procedure
(Office visit 99212 + procedures)
Billed charges
Medicare allowable
Patient copay
Humana pays
Total to Provider
$ 532.00
$ 332.12
$
$
15.00
317.12
$ 332.12
Hospital Examples
Emergency Room
ER visit 99283 w/lab work
(ER allowed based on APC, lab
allowed based on fee schedule)
Billed charges . . . . . . $ 317.00
APC rate . . . . . . . . . . 113.30
Lab rate . . . . . . . . . . . 8.74
Tot. Medicare allow . $ 122.04
Patient copay . . . . $
24.41
Humana pays . . . . . . $ 97.63
Total to provider . . . . . .$ 122.04
Inpatient DRG
3 day length of stay, billed
charges - $19,540
DRG….. . . . . . . . . . . . $3,908.98
Add-ons . . . . . . .
984.55
________
Tot. Medicare allow . $ 4,893.53
Patient copay. . . . . $
540.00
Humana pays . . . . . $ 4,353.53
Total to Provider . . . $ 4,893.53
Preferred Provider Organization (PPO)
 Most common and popular type health plan for
Americans
 Available on both a regional and local level
 Members may seek care from any provider that
accepts Medicare
– Member out-of-pocket costs are lower when
receiving care from network providers
 Referrals are not required for specialty care
 Plan benefits must include all services covered by
Medicare Parts A and B
 Extra benefits may be offered by the plan
CMS PPO Regions
Health Maintenance Organization (HMO)
 Members choose a Primary Care Physician when
they join the plan
 Referrals are required for specialty care or for certain
services
 Members receive most care from network providers
 Only emergency and urgent care is covered outside
of the service area
 Provider payments are based on their contract with
the health plan
 Plan benefits must include all services covered by
Medicare Parts A and B
 Extra benefits may be offered by the plan
Prescription Drug Plans
 Part D is a voluntary program
 It is designed to provide coverage for outpatient prescription
medications
 Part D will replace Medicare-approved drug discount cards,
which will phase out by 5/15/06
 Available as:
– Stand-alone prescription drug plans (PDPs)
– Medicare Advantage + prescription drug (MA-PD) plans
 If MA members enroll in a PDP, they will lose their MA
membership
PDP Regions
WA
ME
MT
ND
VT
NH
MN
OR
WI
SD
ID
CT
MI
WY
PA
IA
OH
NE
NV
IL
IN
UT
WV
CO
KS
MO
VA
KY
CA
NC
TN
OK
AZ
SC
AR
NM
MS
TX
AK
AL
GA
LA
FL
HI
Note: Each territory is its own PDP region.
MA
NY
RI
NJ
DE
MD
DC
PDP Enrollment
To receive Medicare prescription drug coverage,
beneficiaries must:
– Have Medicare Part A and/or be enrolled in Part B
AND
– Enroll in a Medicare-approved prescription drug plan
offered by a Medicare-approved organization
OR
– Enroll in a Part D benefit offered by
employers/unions responsible for retiree benefits
OR
– Enroll in a fully insured MA plan with PD coverage
offered by a Medicare-approved health benefits
company
PDP Enrollment
 Members eligible for both Medicare and Medicaid:
– Will be automatically enrolled in a PDP plan if they do
not enroll on their own
• If automatically enrolled in one plan, the member
can switch to another plan at any time
– Will no longer receive prescription drug coverage from
Medicaid
 No new supplements with prescription drug coverage will
be sold after January 1, 2006
Filling Prescriptions
 Humana members can have their prescriptions
filled at more than 50,000 retail pharmacies
nationwide
– Including Wal-Mart, Sam’s Club and
Neighborhood Store pharmacies
 Members may also use mail order program for
maintenance medications
HUMANA'S Prescription Drug Plans
Humana Standard Plan
For the first
$250 of total drug costs:
▪ $0 Generic
▪ $30 Preferred
▪ $60 Non-preferred
▪ 25% Specialty
Balance of costs
Balance of costs
For the next
$2000 of total drug costs:
25% of costs ( = $500)
For the next
$2000 of total drug costs:
▪ $7 Generic
▪ $30 Preferred
▪ $60 Non-preferred
▪ 25% Specialty
For the next
$2000 of total drug costs:
▪ $7 Generic
▪ $30 Preferred
▪ $60 Non-preferred
▪ 25% Specialty
Plan pays
75% of costs ( = $1500)
Balance of costs
Balance of costs
MEMBER PAYS
The next
$2850 of total drug costs
(This brings your total
out-of-pocket costs to $3600)
The next
$2,850 of total drug costs
(This brings your total
out-of-pocket costs to $3600)
For the next
$2850 of total drug costs:
▪ $7 Generic
▪ $30 Preferred
▪ $60 Non-preferred
▪ 25% Specialty
This is the coverage gap
This is the coverage gap
NO COVERAGE GAP
MEMBER PAYS
Plan pays
STAGE
2
STAGE
3
$0
MEMBER PAYS
Plan pays
STAGE
4
Humana Complete Plan
For the first
$250 of total drug costs:
▪ $0 Generic
▪ $30 Preferred
▪ $60 Non-preferred
▪ 25% Specialty
$250 deductible
STAGE
1
Humana Enhanced Plan
MEMBER PAYS
Plan pays
$0
$0
Balance of costs
5% of total drug costs for
the rest of the year
5% of total drug costs for
the rest of the year
5% of total drug costs for
the rest of the year
95% of total drug costs for
the rest of the year
95% of total drug costs for
the rest of the year
95% of total drug costs for
the rest of the year
Formulary for all Humana plans includes 97 of the top 100 drugs.