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«UPMC for Life (Medicare) UPMC for Life (Medicare) F.2 At a Glance F.3 UPMC for Life HMO F.5 UPMC for Life PPO F.7 UPMC Health Plan Medicare ...»

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UPMC for Life (Medicare)

UPMC for Life

(Medicare)

F.2 At a Glance

F.3 UPMC for Life HMO

F.5 UPMC for Life PPO

F.7 UPMC Health Plan Medicare Supplement

F.8 Benefits and Services for HMO and PPO Members

F.16 Services Not Covered

F.17 Services Requiring Prior Authorization

F.18 Member Appeals and Grievances

F.21 Quick Reference Guide

UPMC Health Plan www.upmchealthplan.com

© 2013-2014. All rights reserved.

UPMC for Life (Medicare) At a Glance UPMC Health Plan offers Medicare beneficiaries a line of health benefit plans called UPMC for Life.

These Medicare Advantage plans, formerly known as “Medicare+Choice,” replace traditional Medicare coverage with managed care options.

UPMC for Life HMO and PPO offer choices for more enhanced services and care options than are available through traditional Medicare, including routine vision care.

HMO members must select a primary care provider, or PCP, and they must use providers, services, and facilities within the UPMC for Life networks. HMO members are able to self-direct care to network specialists; however, they are encouraged to coordinate care with their PCP.

PPO members are not required to select a PCP.

Closer Look at PPO Benefits PPO members are offered the same menu of benefits and services regardless of whether they use network or out-of-network providers. PPO members incur lower out-ofpocket costs if they use network providers and facilities.

This chapter contains information providers need to know to deliver care to HMO and PPO members enrolled in UPMC for Life. Because HMO and PPO member benefits change annually, providers should go to www.upmchealthplan.com to get the most current information regarding a specific member’s benefits or to address other issues not covered in this manual.

Additionally, providers may call UPMC for Life Provider Services at 1-877-539-3080 from 8 a.m. to 5 p.m., Monday through Friday.

Page2 UPMC Health Plan www.upmchealthplan.com © 2013-2014. All rights reserved.

UPMC for Life (Medicare) UPMC for Life HMO UPMC for Life HMO members may select from four benefit plans: UPMC for Life HMO, which does not offer Medicare Part D prescription drug coverage, UPMC for Life HMO Deductible with Rx, which is an HMO with a deductible and offers Medicare Part D prescription drug coverage, UPMC for Life HMO Rx, which offers Medicare Part D prescription drug coverage, and UPMC for Life HMO Rx Enhanced, which offers Medicare Part D prescriptiondrug coverage and enhanced medical coverage. Employer groups may offer variations of the two latter HMO Rx plans, so coverage and member cost-sharing can vary.

All UPMC for Life HMO members must select a primary care provider, or PCP, in order to receive coverage. If a PCP is not selected, a UPMC for Life Member Services representative will assist in that selection. All services, whether coordinated through a PCP or self-directed, must be performed by a UPMC for Life network provider.

Unlike a traditional HMO, this enhanced access HMO allows members to see specialists without a referral from their PCP. Women may self-direct care to ob-gyns for routine annual exams.

Most UPMC for Life HMO members have copayments for physician office visits, emergency room visits, and pharmaceuticals. The following preventive services are covered with a $0 copayment: annual wellness exam, immunizations (e.g., flu, pneumonia, and Hepatitis B), and screening exams (mammograms, Pap and pelvic exam, prostate exam, bone mass measurement, colorectal exam, depression screening, dilated diabetic retinal eye exam, glaucoma screening, HIV screening, screening and counseling to reduce alcohol misuse, and screening for sexually transmitted infections), and smoking cessation. A separate copayment may apply if additional medical services are rendered during the same visit as a preventive screening exam.

See Benefits and Services for HMO and PPO Members, UPMC for Life (Medicare),

Chapter F.

Providers should verify eligibility and copayment responsibility before the service is performed. Providers may verify member information through Provider OnLine at www.upmchealthplan.com or by calling UPMC Health Plan’s Interactive Voice Response (IVR) system at 1-866-406-8762.

–  –  –

Key Points  PCP is mandatory.

 Network providers and facilities must be used.

 Routine physicals, immunizations (please refer to the member’s benefit plan for specific immunization coverage), and annual screening exams are covered.

 Emergent care by any provider is covered if the member believes that his or her health is in serious danger. Urgent care by any provider is covered if the member believes that left untreated, his or her condition could rapidly become a medical emergency. Emergency services, urgently needed care, and emergency ambulance transportation may incur copayments. Only copayments for emergency services and urgently needed care are waived if the member is admitted to a facility within three days for the same condition. The emergency ambulance transportation copayment is not waived.

–  –  –

Closer Look at Self-Directed Care Non-emergent, self-directed care by out-of-network specialists is not covered unless prior authorization is obtained through Medical Management at 1-800-425-7800 from 8 a.m.





to 4:30 p.m., Monday through Friday.

–  –  –

UPMC for Life PPO UPMC for Life PPO members do not need to select a primary care provider, or PCP, in order to receive coverage but it is preferred that they do. PPO members are offered the same menu of benefits and services regardless of whether they use network or out-of-network providers. PPO members incur lower out-of-pocket costs if they use UPMC for Life network providers and facilities.

Members may select from two benefit plans: UPMC for Life PPO High Deductible with Rx, which is a PPO with a deductible and offers Medicare Part D prescription drug coverage, and UPMC for Life PPO Rx Enhanced, which also offers Medicare Part D prescription drug coverage and enhanced medical coverage. Employer groups may offer variations of these plans, so coverage can vary. The

following preventive services are covered with a $0 copayment when using a network provider:

annual wellness exam, immunizations (e.g., flu, pneumonia, and Hepatitis B), and screening exams (mammograms, Pap and pelvic exam, prostate exam, bone mass measurement, colorectal exam, depression screening, dilated diabetic retinal eye exam, glaucoma screening, HIV screening, screening and counseling to reduce alcohol misuse, and screening for sexually transmitted infections), and smoking cessation. A separate copayment may apply if additional medical services are rendered during the same visit as the preventive screening exam. Members receiving preventive services outof-network may have a higher cost-share amount.

UPMC for Life PPO members may have copayments for physician office visits, emergency department visits, or pharmaceuticals when care is received within the UPMC for Life network.

Members may have deductibles, copayments, or coinsurance when care is received outside the UPMC for Life network. UPMC for Life PPO High Deductible with Rx members have a deductible and may have either a copayment or coinsurance for network or out-of-network services.

Providers should verify eligibility as well as deductible, copayment, or coinsurance responsibility before the service is performed. Providers may verify member information through Provider OnLine at www.upmchealthplan.com or by calling UPMC Health Plan’s Interactive Voice Response (IVR) system at 1-866-406-8762.

–  –  –

Key Points

Network Care:

 Members have lower out-of-pocket costs (e.g., copayments and coinsurance) when using network providers and facilities.

 Annual deductibles, copayments, maximum limits, and coinsurance may apply.

 Routine physicals, immunizations (please refer to the member’s benefit plan for immunization coverage), and annual screening exams are covered.

Out-of-Network Care:

 Members have higher payments for out-of-network providers or services.

 Annual deductibles, copayments, maximum limits, and coinsurance may apply.

 Routine preventive services are covered out-of-network; however, applicable deductibles, copayments, or coinsurance limits may apply.

 Members may be responsible for the difference between the provider’s charges and UPMC Health Plan’s payment (reasonable and customary amount).

Emergency Services:

 Emergent care by any provider is covered if the member believes that his or her health is in serious danger.

 Urgent care by any provider is covered if the member believes that left untreated, his or her condition could rapidly become a medical emergency.

 Emergency services, urgent care services, and emergency ambulance transportation incur copayments. Only copayments for emergency services and urgently needed care are waived if the member is admitted to a facility within three days for the same condition. The emergency ambulance transportation copayment is not waived.

–  –  –

UPMC Health Plan Medicare Supplement UPMC Health Plan offers two types of Medicare Supplement plans. A Medicare Supplement plan allows a member to see any provider for professional and facility services. A Medicare Select plan is a type of Medicare supplement plan that has a provider network limitation. The UPMC Health Plan Medicare Select plan allows members to see any professional provider, but they must use the UPMC for Life facility network in order to have facility services and treatments covered.

Traditional Medicare is the primary payer for Medicare supplement plans, and all claims must be submitted to Medicare first. Medicare Supplement plans will receive the claim after traditional Medicare has paid its portion. Providers should verify eligibility and member cost-sharing responsibility before the service is performed.

UPMC Health Plan’s Medicare Supplement product offers three standard plans: A, B, and F. The Medicare Select product offers four standard plans: A, B, C, and H. Each plan offers a different combination of benefits for members, who can select the plan most appropriate for their health care needs.

–  –  –

Benefits and Services for HMO and PPO Members Covered Benefits UPMC for Life members receive all the benefits offered by traditional Medicare as well as additional benefits.

Although the covered services for HMO and PPO members generally are identical, HMO members must use UPMC for Life network providers. PPO members may use out-of-network providers and facilities at higher out-of-pocket costs. Some benefits and services require authorization.

See UPMC for Life Quick Reference Guide, UMPC for Life (Medicare), Chapter F.

A provider may bill a UPMC for Life member for a non-covered service or item only if, before

performing the service, the provider informs the member:

 Of the nature of the service;

 That the service is not covered by UPMC for Life, and UPMC for Life 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 for detailed information about a member’s specific benefits and possible service limitations.

–  –  –

Copayments or coinsurance may apply.

Chiropractic Care Manual manipulation of the spine to correct subluxation, which is the chiropractic coverage offered by traditional Medicare, is available to all UPMC for Life members. Children under the age of 13 require prior authorization for chiropractic services.

For HMO members: These services do not have to be coordinated by a member’s PCP but must be performed by network providers. In addition to manual manipulation of the spine to correct subluxation, some HMO plans give members coverage for routine chiropractic visits, which is a benefit not covered by traditional Medicare. Copayments apply, and some plans have visit limitations for routine chiropractic care. Providers should verify the member’s benefits to determine which members have this enhanced benefit.

For PPO members: Medicare-covered benefits do not need to be coordinated or performed by network providers. Copayments apply for care performed by network providers.

Copayments and deductibles may apply for care performed by out-of-network providers.

Member costs may be higher for out-of-network care. In addition to manual manipulation of the spine to correct subluxation, some PPO plans give members coverage for routine chiropractic visits, which is a benefit not covered by traditional Medicare.

Dental Services In general, preventive dental benefits (such as cleaning) are not covered for HMO or PPO members.

Some employer group plans may provide limited dental coverage. Please refer to Provider OnLine at www.upmchealthplan.com, or call UPMC Health Plan’s Interactive Voice Response (IVR) system at 1-866-406-8762.

Diagnostic Services Diagnostic services include x-rays, laboratory services, and tests. All UPMC for Life members need a prescription for any diagnostic service.

Prior authorization, deductible, copayments, and/or coinsurance may apply to high-technology xray services (CT, MRA/MRI, PET scan, nuclear medicine, etc.).

–  –  –

Emergency Care Emergency department care typically requires a copayment, which is waived if the member is admitted to the hospital within three days for the same condition.

HMO members should notify their PCP within 24 hours or as soon as reasonably possible after receiving the emergency service.

Closer Look at Emergency Care The hospital or facility must contact Medical Management at 1-800-425-7800 within 48 hours or on the next business day after the emergency admission.



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