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UPMC Medicare Special Needs Plans
UPMC Health Plan
Medicare Special Needs
M. 2 At a Glance
M. 7 Covered Benefits and Services
M.14 Services Not Covered
M.16 Member Appeals and Grievances
M.19 UPMC Medicare Special Needs Plans Model of Care
M.24 UPMC Medicare Special Needs Plans Model of Care – Care Management Programs
M.29 Quick Reference Guide
UPMC Health Plan www.upmchealthplan.com
© 2014-2015 All rights reserved.
UPMC Medicare Special Needs Plans At a Glance Plan Options As of January 1, 2013, UPMC Health Plan no longer offers UPMC for Life Specialty Plan.
Approximately 14,000 members have been transitioned into the new dual SNP plan UPMC for You Advantage.
UPMC for You Advantage (HMO SNP) UPMC for You Advantage is a Medicare Special Needs Plan that provides medical and prescription drug benefits for beneficiaries eligible for both Medicare Parts A and B and full Medical Assistance.
UPMC for You Advantage offers enhanced dental, vision, and fitness benefits for dual eligible beneficiaries, along with extra benefits and services that help members manage their overall health and wellness. UPMC for You Advantage can also help coordinate Medicare and Medical Assistance services.
UPMC for Life Options (HMO SNP) UPMC for Life Options is a Medicare Special Needs Plan that provides medical and prescription drug benefits for older beneficiaries who demonstrate long-term care needs. UPMC for Life Options uses a small network of specialized providers and facilities to help members age in place in a setting they choose. UPMC for Life Options also offers extra services and benefits to give members and their loved ones the peace of mind they deserve. UPMC for Life Options has an enhanced model of care which utilizes two new clinical programs to meet the needs of its beneficiaries based on their location of usual care. UPMC for Life Options and UPMC Community Care have an intensive care coordination and primary care component.
Overview of UPMC for Life Options (HMO SNP) Staying-At-Home with UPMC* A unique clinical model for community-based members that focuses on in-place, attentive care with an emphasis on care coordination. Staying-At-Home with UPMC uses an integrated team, including a nurse, a social worker, physical and occupational therapists, a pharmacist, and a nutritionist to provide care to members in their home.
UPMC Health Plan “Care Through Transitions”* A new clinical model for members in a nursing home, Care Through Transitions is designed to reduce unnecessary and interruptive transitions of care. Care Through Transitions uses a nursing home-
*Also available for dual eligible members.
The UPMC for Life Options provider network is limited … why?
The UPMC for Life Options provider network has been carefully designed so specialized providers and facilities can offer a highly communicative, responsive, and care-managed model. A small, specialized network of primary care practitioners and UPMC specialists, hospitals, and ancillary providers will provide continued support to members. These physicians are experienced not only in treating members’ clinical needs, but also in working within a system of coordinated care designed to meet the entirety of the members’ needs. Through private practice and service delivery at network nursing facilities, these physicians have the necessary community presence that is best suited to meet the needs of nursing facility clinically eligible members within the scope of a coordinated delivery model.
UPMC Community Care (HMO SNP) UPMC Community Care is a Medicare Chronic Care Special Needs Plan that provides medical and prescription drug coverage for beneficiaries diagnosed with a Serious Mental Illness. UPMC Community Care operates in Allegheny, Blair, Cameron, Elk, Erie, and Potter counties.
A serious mental illness (SMI) is defined as having one of these five medical conditions: bipolar disorder, major depressive disorder, paranoid disorder, schizophrenia, and schizoaffective disorder.
Members will choose a behavioral health-led medical home that will assist them in attaining their personal goals and move them toward overall wellness and recovery. A dedicated wellness coach will work with members to develop and implement an individualized care plans (ICP) that can include ways to treat conditions, cope with stress, and improve health by accessing different wellness techniques and centers.
Access to a Medical Home A medical home provides additional care to its patients so that their physical and behavioral health services are coordinated at the same office location. UPMC Community Care members receive assistance with explaining health problems to their doctor and getting the support they need to help themselves. Doctors and nurses are always available at the medical home and the medical home team can include a pharmacist, a service coordinator, a nutrition expert, a wellness coach, and peer support.
PCP Selections for All Plan Choices All plan members must select a primary care provider, or PCP, to receive coverage. If a PCP is not selected, a Member Services representative will contact the member and assist with PCP selection. All services, whether coordinated through a PCP or self-directed, must be performed by a UPMC Medicare Special Needs Plans provider. UPMC Medicare Special Needs Plans allow members to see participating specialists without a referral from their PCP. Women may self-direct care to ob-gyns for routine annual exams.
Closer Look at Self-Directed
Non-emergent, self-directed care performed by out-of-network specialists is not covered unless prior authorization is obtained through Medical Management at 1-800-425-7800. Representatives are available Monday through Friday from 8 a.m. to 4:30 p.m.
This chapter contains information providers need to deliver care to members enrolled in UPMC Medicare Special Needs Plans. Plan benefits change annually. Providers need to go to www.upmchealthplan.com/snp to get the most current information regarding a specific member’s benefits or to address other issues not covered in this manual.
Providers should verify member eligibility before they perform a service. Providers may verify member information through Provider OnLine at www.upmchealthplan.com. Or they may call UPMC Health Plan’s Interactive Voice Response (IVR) system at 1-866-406-8762.
See Identifying Members and Verifying Eligibility, Member Administration Chapter I.
Balance Billing Instructions The annual Part B deductible and/or coinsurance may apply to plan services. Providers may submit any unpaid balance remaining after UPMC Health Plan payments to the appropriate State source for consideration. However, providers may not attempt to collect copayments or coinsurance from members enrolled in UPMC for You Advantage, including during the period of time in which a member has lost full Medical Assistance coverage but is deemed “continued eligible” for the “Grace Period” of up to 120 days. Attempting to collect copayments or coinsurance from members will hereafter be referred to as balance billing.
Medical Assistance. A non-dual eligible UPMC for Life Options or UPMC Community Care member is responsible for copayments and coinsurance and may be subject to provider balance billing.
What is a grace period?
A grace period is a length of time that follows a member’s loss of special needs status during which the plan continues to pay for covered services. For UPMC for You Advantage, the grace period begins when a member loses his or her special needs status (e.g., through loss of Medical Assistance eligibility) and continues for a period of up to 120 days. For UPMC for Life Options, the grace period begins when a member is assessed as no longer Nursing Facility Clinically Eligible and continues for a period of up to 120 days. For UPMC Community Care, the grace period begins when a member no longer is diagnosed with a serious mental illness. During this time, all balance billing guidelines continue to apply. If a member does not regain his or her special needs status by the end of the grace period, he or she will be disenrolled from the UPMC Medicare Special Needs Plan.
Outpatient rehabilitation therapy includes physical therapy, speech and language therapy, occupational therapy, and cardiac/pulmonary therapy.
Medicare-covered outpatient surgical procedures performed at an ambulatory surgical center, an outpatient hospital facility, or the physician’s office are covered.
UPMC Medicare Special Needs Plans members are covered for certain podiatry services, such as treatment of injuries and diseases of the feet (e.g., hammertoe or heel spurs).
UPMC Medicare Special Needs Plans members receive comprehensive dental benefits, which include fillings and simple tooth extractions.
Covered Benefits and Services UPMC Medicare Special Needs Plans members receive all the benefits offered by Original Medicare as well as additional benefits. Plan members must use providers that participate in the UPMC Medicare Special Needs Plans networks. Some benefits and services require authorization.
See the Quick Reference Guide, UPMC Medicare Special Needs Plans, Chapter M.
A provider may bill a UPMC Medicare Special Needs Plans member for a non-covered service or item
if the provider informs the member before performing the service. Information should include:
The nature of the service;
That the service is not covered by either the UPMC Medicare Special Needs Plan or Medical Assistance;
That the UPMC Medicare Special Needs Plans will not pay for the service; and What the estimated cost to the member is for the service.
The member must agree in writing on an approved Medicare form (sometimes called an advance beneficiary notice or ABN) that he or she will be financially responsible for the service.
Providers should refer to www.upmchealthplan.com/snp for detailed information about the member’s specific benefits and possible service limitations.
Ancillary Services Call Medical Management at 1-800-425-7800 for assistance with the coordination of complex
ancillary services such as:
Chiropractic care Diagnostic services (e.g., lab, x-ray), including special diagnostics Home health care (including skilled/intermittent nursing; physical, speech, and occupational therapy; medical social services; home health aides; and registered dietitian services) Home infusion therapy Durable medical equipment (DME), including custom wheelchairs and rehabilitation equipment Hospice care Laboratory services Non-emergency ambulance Nursing care at a licensed skilled nursing facility Orthotics and prosthetics Respiratory equipment, including oxygen therapy Page8 UPMC Health Plan www.upmchealthplan.com © 2014-2015 All rights reserved.
UPMC Medicare Special Needs Plans Chiropractic Care Manual manipulation of the spine to correct subluxation, which is the chiropractic coverage offered by Original Medicare, is available to all UPMC Medicare Special Needs Plans members. Children under the age of 13 require prior authorization for chiropractic services.
These chiropractic services do not have to be coordinated by a member’s PCP, but they must be performed by network providers. Coinsurance applies for Medicare-covered benefits.
See Balance Billing Instructions, UPMC Medicare Special Needs Plans, Chapter M.
Dental Services UPMC Health Plan’s routine dental benefit vendor is Avesis Third Party Administrators, Inc.
UPMC Medicare Special Needs Plans members have coverage for routine oral exams, cleanings, and xrays every six months. In addition, UPMC Medicare Special Needs Plans members receive comprehensive dental benefits that include fillings and simple tooth extractions. Providers should contact Avesis at 1-888-729-7951 for specific benefit information.
Closer Look at Non-Routine Dental Services Coverage is provided via UPMC Medicare Special Needs Plans (not by Avesis) for Medicarecovered dental procedures along with emergency coverage for accidents or injury to natural teeth.
For questions about non-routine dental services, providers may call Provider Services at 1-866Members may call Member Services directly at 1-800-606-8648.
Diagnostic Services Diagnostic services include x-rays, laboratory services, and tests. All UPMC Medicare Special Needs Plans members need a prescription to obtain any diagnostic service.
Use the radiology decision support tool prior to prescribing high-technology imaging services.
The preferred provider for laboratory and diagnostic procedures is Quest Diagnostics.
Emergency Department Care All UPMC Medicare Special Needs Plans members have a copayment for emergency department care.
There is no waiver of the emergency copayment, even if the member is admitted to the hospital within three days of the emergency department visit for the same condition. Members should notify their PCPs within 24 hours or as soon as reasonably possible after receiving the emergency service.
See Balance Billing Instructions, UPMC Medicare Special Needs Plans, Chapter M.
Alert—Emergency Care All members, if they believe that they are experiencing a true medical emergency, may utilize any emergency department or office. Out-of-network care for emergencies, including ambulance services, is covered.