05/01/2014. Medicare has 4 parts A: Hospital coverage National Training Program. Session Objectives. The Basics. B: Outpatient medical coverage
|
|
- Kristin Marsh
- 5 years ago
- Views:
Transcription
1 2015 National Training Program Medicare Prescription Drug Coverage Parts A, B and D Session Objectives This session should help you Differentiate when/under what scenarios drugs are covered under the various parts of Medicare Part A vs. Part B vs. Part D 2 The Basics Medicare has 4 parts A: Hospital coverage B: Outpatient medical coverage C: Medicare Advantage D: Prescription Drug Coverage Medicare Prescription Drug Coverage 1
2 Medicare Benefit Structure Part A Hospital Insurance Part B Medical Insurance Part C Medicare Advantage Plans (like HMOs/PPOs) Includes Part A, Part B, and sometimes Part D coverage Part D Medicare Prescription Drug Coverage 4 Medicare Prescription Drug Coverage Prescription drug coverage under Part A, Part B, or Part D depends on Medical necessity Health care setting Medical indication (why you need it the drug) Any special drug coverage requirements This information applies if you have Original Medicare 5 PART A 6 Medicare Prescription Drug Coverage 2
3 Part A Prescription Drug Coverage Part A generally pays for all drugs during a covered inpatient stay Received as part of treatment in a hospital or skilled nursing facility Drugs used in hospice care for symptom control and pain relief only 7 PART B 8 Self Administered Drugs in Hospital Outpatient Settings Hospital Admission vs. Observation Status Distinction is KEY! Part B doesn t cover self administered drugs in a hospital outpatient setting Unless integral to the procedure or hospital service If enrolled in Part D, drugs may be covered If not admitted to hospital May have to pay and submit for reimbursement 9 Medicare Prescription Drug Coverage 3
4 Part B Prescription Drug Coverage Part B provides outpatient drug coverage in limited situations Most injectable and infusible drugs given as part of a doctor s service Antigens administered for allergy testing Drugs and biologicals used for the treatment of End Stage Rena Disease Drugs which require use of Part B covered durable medical equipment (DME) 10 Part B Part D Medicare Prescription Drug Coverage 4
5 Medicare Part B vs. Part D Some drugs/drug classes may be covered by either Part B or Part D depending on the situation Drug classes where such uncertainty exists: Insulin Vaccines Hepatitis B vaccine Immunosuppressants Oral anti cancer drugs Oral anti emetic drugs Erythropoietin Medicare Part B vs. Part D? BV is a 68 year old beneficiary with type 1 diabetes, congestive heart failure, and chronic pain. BV takes all of her medications orally except her insulins; one of which she self injects 5 10 minutes before each meal and the other which she injects every evening. BV presents her Medicare card which identifies that she has both Medicare Parts A and B. She also shows a separate card which shows that she has a Part D plan. BV gives both cards to the pharmacy. Based on the above presented information, which part of Medicare should the pharmacy bill for BV s insulins? Answer: Medicare Part D; Medicare Part B covers external insulin pumps and the insulin that the device uses under durable medical equipment for people who meet certain conditions. Since BV does not have a pump (this is evident by the fact that she self injects multiple times a day) the insulin would not be covered under Part B, and thus her Part D plan should be billed. Coverage category: Insulin Scenario: Beneficiary would like to fill their insulin Part B Administered with an insulin pump Part D All other situations Medicare Prescription Drug Coverage 5
6 Coverage category: Vaccines Scenario: Prophylactic Vaccines Part B flu, pneumococcal, and Hepatitis B* (medium high risk individuals) vaccines Part D for all other vaccines Coverage category: Hepatitis B vaccine Scenario: Beneficiary would like to receive the Hepatitis B vaccine series Part B Medium/High risk beneficiary Part D All other beneficiaries Medicare Part B vs. Part D? GH is a 73 year old beneficiary who has high blood pressure, high cholesterol, diabetes, and a thyroid disorder. After consulting with her health care provider, GH realizes that she needs to get the Hepatitis B vaccine series. GH has both parts of Original Medicare and a stand alone prescription drug plan through Medicare. GH proceeds to go to her local pharmacy and indicates that she wouldlikethefirstdoseofthehepatitis B vaccine series. Based on the above presented information, which part of Medicare should the pharmacy bill for her first Hepatitis B vaccine dose? Answer: Medicare Part B; because GH has diabetes, which places her in a High Risk category, the Hepatitis B vaccine series would be covered under Medicare Part B. Medicare Prescription Drug Coverage 6
7 Hepatitis B Risk Categories Intermediate risk groups Staff in institutions for the mentally handicapped Workers in health care professions who have frequent contact with blood/blood derived body fluids during routine work High risk: ESRD Hemophilia Clients of institutions for the mentally handicapped Those who live in the same household as a HBV carrier Homosexual men Illicit injectable drug abusers Diabetes Medicare Part B vs. Part D? GH is an 82 year old beneficiary with autoimmune hepatitis. She was recently prescribed the immunosuppressant prednisone to help with her condition. GH has both parts of Original Medicare and a stand aloneprescriptiondrugplan(partd).ghgoestothe pharmacy to get her prescription of prednisone filled. Based on the above presented information, which part of Medicare should the pharmacy bill for GH s prednisone? Answer: Medicare Part D. Drugs used for immunosuppressive therapy in a beneficiary that received a transplant from a Medicare approved facility would be billable to Medicare Part B, but since that does not appear to be the case GH s Part D plan should be billed for her prednisone prescription. Coverage category: Immunosuppressants Scenario: Drugs used for immunosuppressive therapy in a beneficiary that received a transplant from a Medicare approved facility Part B for Medicare covered transplant Part D for all other situations Medicare Prescription Drug Coverage 7
8 Coverage category: Oral chemotherapy agents used in cancer treatment Scenario: Oral chemotherapy drugs for which there is an infusible version of the drug Part B for cancer treatment Part D for all other indications Coverage category: Oral anti emetic drugs Scenario: Oral anti nausea drugs used in cancer treatment as replacement for IV anti emetic drugs before, at, or within 48 hours of chemotherapy Part B within 48 hours of receiving chemo NOTE: In order to bill Part B, CMS requires that the prescriber indicate on the prescription that the oral anti emetic is being used as full therapeutic replacement for an IV anti emetic drug as part of a CA chemotherapeutic regimen. Part D for all other situations Coverage category: Erythropoietin Scenario: Treatment of anemia for a person with ESRD who is on dialysis Part B treatment of anemia for beneficiaries with chronic renal failure undergoing dialysis Part D for all other situations Medicare Prescription Drug Coverage 8
9 PART D 25 Prescription Drug Coverage Two ways to get outpatient prescription drug coverage through Medicare 1. Medicare Advantage Prescription Drug Plan (MA PD) Part C Bundles health & Rx coverage together 2. A stand alone Prescription Drug Plan (PDP) NOTE: A patient CANNOT add a PDP to an MA PD Part D Formulary Requirements Each plan will have its own formulary Each formulary must include all therapeutic drug classes Must cover a minimum of two agents from each drug class The two drug minimum must be met through the provision of two chemically distinct drugs Plans must have an authorization process for non formulary medications Medicare Prescription Drug Coverage 9
10 Protected Classes ( Classes of Clinical Concerns ) All plans should cover all or substantially all of the drugs in six therapeutic categories: Antidepressants Anticonvulsants Antipsychotics Antiretrovirals Antineoplastics Immunosuppressants Medicare Part D Excluded List Weight loss or weight gain Fertility promotion Cosmetic purposes/hair growth Erectile dysfunction used for treatment of sexual dysfunction Products for cough/cold symptom relief Prescription vitamins/minerals OTC drugs Medicare Part D Excluded Drugs Certain plans may cover these drugs as a supplemental benefit to their plan. Not benchmark plans! However, any amount you spend for a drug in one of these categories is not counted toward any deductibles, initial coverage or out ofpocket limits. Does not count towards TrOOP! Medicare Prescription Drug Coverage 10
11 CMS National Training Program (NTP) To view all available NTP materials, or to subscribe to our list, visit CMS.gov/outreach andeducation/training/cmsnationaltrainingprogram/ For questions about training products Medicare Prescription Drug Coverage 11
Issues for Part D Compliance
HCCA- MEDICARE PRESCRIPTION DRUG PART D COMPLIANCE CONFERENCE Issues for Part D Compliance Craig Miner, RPh, JD Division of Drug Plan Policy Babette S. Edgar, Pharm.D., MBA Division of Finance and Operations
More informationMedicare Parts B/D Coverage Issues
2/14/2006 Medicare Parts B/D Coverage Issues This table provides a quick reference guide for the most frequent Medicare Part B drug and Part D drug coverage determination scenarios facing Part D plans
More informationTimely Topic Medicare Coding And Billing For Vaccinations. Wednesday, June 28, :00 4:30 PM ET
Timely Topic Medicare Coding And Billing For Vaccinations Wednesday, June 28, 2017 3:00 4:30 PM ET Welcome and Reminders Please be prepared for sharing and open discussion Slides and a recording from today
More informationMedicare Preventive Services. Disclosure Statement
Medicare Preventive Services LCDR Tunesia Mitchell CMS/Region 2 Disclosure Statement The planners and presenters do not have any financial arrangements or affiliations with any commercial entities whose
More information2018 HDHP. Denver Health Medical Plan, Inc. Career Service Employees (CSE) and Denver Employee Retirement Plan (DERP) HighPoint Denver Plus Network
2018 HDHP Denver Health Medical Plan, Inc. Career Service Employees (CSE) and Denver Employee Retirement Plan (DERP) HighPoint Denver Plus Network HighPoint Denver Cofinity Network Out of Network Deductible
More informationBaltimore City Public Schools Health Plan Comparison Chart Benefits Effective January 1, 2017
HOSPITAL INPATIENT SERVICES Baltimore City Public Schools Health Plan Comparison Chart Benefits Effective January 1, 2017 About this chart: This chart is to be used as a guide only and does not contain
More informationExhibit 2 - YHP Plan Changes Service YHP Benefit Aetna Durable Medical Equipment including orthotics Prosthetic Devices Home Health Care $ 100 ded/80% to $ 5,000 annual maximum 100% up to $5,000 max Agreed
More informationNEW YORK STATE TEAMSTERS COUNCIL HEALTH & HOSPITAL FUND APPENDIX A SCHEDULE OF BENEFITS SUPREME BENEFITS
BENEFIT GUIDE NEW YORK STATE TEAMSTERS COUNCIL HEALTH & HOSPITAL FUND APPENDIX A SCHEDULE OF SUPREME IN NETWORK FEATURES Primary Care Physician Not Required 2 Physician Referrals Not Required 2 Out of
More informationSchedule of Benefits Summary Group Name: Nebraska Bankers Association VEBA Effective Date: January 01, 2018
Schedule of Benefits Summary Group Name: Nebraska Bankers Association VEBA Effective Date: January 01, 2018 Payment for Services Covered Services are reimbursed based on the Allowable Charge. Blue Cross
More information2016 Rochester Regional Health PPO Medical Plan Summary
Out of Annual Deductible Annual Deductible includes co-pays, coinsurance. The amounts are combined across all s. None Single Two-Person EE + Children Family $1,800 $3,600 $5,400 $5,400 Annual Out of Pocket
More informationSchedule of Benefits Summary Group Name: Nebraska Bankers Association VEBA Effective Date: January 01, 2018
Schedule of Benefits Summary Group Name: Nebraska Bankers Association VEBA Effective Date: January 01, 2018 Payment for Services Covered Services are reimbursed based on the Allowable Charge. Blue Cross
More informationSchedule of Benefits Summary Group Name: Nebraska Bankers Association VEBA Effective Date: January 01, 2018
1 Schedule of Benefits Summary Group Name: Nebraska Bankers Association VEBA Effective Date: January 01, 2018 Payment for Services Covered Services are reimbursed based on the Allowable Charge. BlueCross
More informationAn Overview of Medicare Covered Diabetes Supplies and Services
News Flash - Understanding the Remittance Advice: A Guide for Medicare Providers, Physicians, Suppliers, and Billers serves as a resource on how to read and understand a Remittance Advice (RA). Inside
More informationMedicare Coverage of Mental Health Services
Medicare Coverage of Mental Health Services Medicare Coverage of Diabetic Services and Supplies July 2015 For Those Who Counsel People With Medicare What is Diabetes? Chronic disease in which your body
More information08/10/2015. Medicare Coverage of Diabetes Services and Supplies. What is Diabetes? 2015 National Training Program
2015 National Training Program Medicare Coverage of Diabetes Services and Supplies July 2015 For Those Who Counsel People With Medicare What is Diabetes? Chronic disease in which your body can t make or
More information2018 Anthem Blue Cross Senior Secure HMO - Southern CA - Post 65 (Medicare Eligible)*
General Information Lifetime Maximum Benefit Annual Maximum Benefit Coinsurance Percentage Precertification Requirements Prior authorization is required for select services. Services must be coordinated
More informationSCHEDULE OF BENEFITS PLAN H1
SCHEDULE OF BENEFITS PLAN H1 Effective June 1, 2018 This Plan is a High Deductible Health Plan (HDHP), designed to qualify for use with a Health Savings Account (HSA). All charges except charges for preventive
More information2018 Anthem Blue Cross HMO*
General Information Lifetime Maximum Benefit Annual Maximum Benefit Coinsurance Percentage 100.00% Precertification Requirements Pre-certification is required for certain services. However, this is an
More informationSCHEDULE OF BENEFITS PLAN M7
SCHEDULE OF BENEFITS PLAN M7 Effective September 1, 2017 When you need to see a physician, a physician network, PHCS, is utilized for all physician services (primary care and specialists) and ancillary
More informationAnthem Blue Cross High HMO
Anthem Blue Cross High HMO HMO HIGH SELECT NETWORK Modified Premier HMO 10/100% This Summary of Benefits is a brief overview of your plan's benefits only. For more detailed information about the benefits
More informationMVP PREMIER PLUS SCHEDULE OF BENEFITS Gold 4 MVP Health Plan, Inc. Embedded Deductible Off Exchange
COST-SHARING Deductible Individual Family Prescription Drug Deductible Individual Family Out-of-Pocket Limit Individual Family OFFICE VISITS Primary Care Visits (or Home Visits) Specialist Visits (or Home
More informationParticipating Provider Non- Participating Provider Limitations & Exceptions. deductible applies. 75% of the Fund's fee schedule; deductible applies
Medical Benefits for eligible Pension Members and their eligible dependents who are not Eligible for Medicare effective 1/1/2019. NOTE $50,000.00 lifetime major medical maximum effective 1/1/2013 Out-of-network
More informationUNIVERSITY OF THE INCARNATE WORD, S2855 BRONZE RBP PLAN GRANDFATHERED PLAN BENEFIT SHEET
BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children birth to 26 Filing Limit 365 days Mailing Address Remit claims to: Gilsbar, Inc., P.O. Box 2947, Covington,
More informationExcellus BluePPO Signature Deduct 3
Excellus BluePPO Signature Deduct 3 Drug Coverage Excluded Benefit Time Period: 01/01/2017-12/31/2017 Trinity Health - Syracuse HSA General Cost Sharing Expenses - Single Domestic - $1,300 $2,500 $3,500
More informationUNIVERSITY OF THE INCARNATE WORD, S2855 SILVER RBP PLAN GRANDFATHERED PLAN BENEFIT SHEET
BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children birth to 26 Filing Limit 365 days Mailing Address & PPO Company Remit claims to: Gilsbar, Inc., P.O. Box
More informationArizona Clover Health Choice PPO (040) 2019 Medical Benefits
Arizona 2019 Medical Benefits Effective Date: 1/1/2019 Version 1.0 Part D Deductible For Part D Copay information, see page 26. /year for Part D prescription drugs /year for Part D prescription drugs Out-of-Pocket
More informationTusculum College. Benefit Summary Option/Quote: 2. 30% after Deductible. $35 Copay. 30% after Deductible
Benefit Plan Features: Annual Deductible Effective Date: 4/1/2018 Network: S Benefit Summary Option/Quote: 2 Your Cost In-Network Individual/Family $1250/$2500 Annual Out-of-Pocket Maximum Tusculum College
More informationPennslyvania Green (Plan 028) 2018 Medical Benefits
Pennslyvania Green (Plan 028) 2018 Medical Benefits Effective Date: 1/1/2018 Version 1.0 Part D Deductible For Part D Copay information, see page 25. $150/year for Part D prescription drugs Tiers 1 and
More informationPlease refer to your Benefit Handbook for further information about how your In-Network and Out-of- Network coverage works.
Schedule of Benefits The Harvard Pilgrim Health Care of New England USNH-STAFF/FACULTY POS Services listed are covered when Medically Necessary. Please see your Benefit Handbook for details. UI, 10/09
More informationGeorgia Green (Plan 026) 2018 Medical Benefits
Georgia Green (Plan 026) 2018 Medical Benefits Effective Date: 1/1/2018 Version 1.0 Part D Deductible For Part D Copay information, see page 26. Out-of-Pocket Max $100/year for Part D prescription drugs
More informationTusculum College. Benefit Summary. $25 Copay. $25 Copay. after Deductible. 20% after Deductible 20% after Deductible
Benefit Plan Features: Annual Deductible Benefit Summary Your Cost In-Network Individual/Family $750/$1500 Annual Out-of-Pocket Maximum Individual/Family $3500/$7000 4th Quarter Carry-over Covered Services
More informationPLAN DESIGN & BENEFITS PROVIDED BY AETNA HEALTH OF CALIFORNIA INC. - FULL RISK
PLAN FEATURES Deductible (per calendar year) Out-of-Pocket Maximum (per calendar year) None Individual None Family $2,000 Individual $4,000 Family In-Network expenses include coinsurance/copays and deductibles.
More informationPLAN DESIGN & BENEFITS PROVIDED BY AETNA HEALTH OF CALIFORNIA INC. - FULL RISK
PLAN FEATURES Deductible (per calendar year) Out-of-Pocket Maximum (per calendar year) PLAN DESIGN & BENEFITS None Individual None Family $1,500 Individual $3,000 Family In-Network expenses include coinsurance/copays
More informationIndividual Market Schedule of Benefits
Individual Market Schedule of Benefits Deductible and Out-of-Pocket Maximum Plan Deductible Individual Family $600 per Member $1,200 per Family $7,400 per Member $14,800 per Family Separate Prescription
More informationMEDICAL SCHEDULE OF BENEFITS
MEDICAL SCHEDULE OF BENEFITS Plan(s) 011 (F) All health benefits shown on this Schedule of Benefits are subject to the following: Lifetime and annual maximums, Deductibles, Co-pays, Plan Participation
More informationMetroPlus Health Plan SCHEDULE OF BENEFITS MetroPlus Gold
SECTION XXIV MetroPlus Health Plan SCHEDULE OF BENEFITS MetroPlus Gold COST-SHARING Deductible Individual Family Out-of-Pocket Limit Individual Family $0 $0 $7,150 $14,300 except as required for emergency
More informationFlexRx 6-Tier. SM Pharmacy Benefit Guide
FlexRx 6-Tier SM Pharmacy Benefit Guide Welcome to FlexRx The AllWays Health Partners FlexRx SM program is built for choice, savings, and convenience with benefits including: Low-cost drug tier for many
More informationSchedule of Benefits. Harvard Pilgrim Health Care, Inc. THE HARVARD PILGRIM POS MAINE
Schedule of s Harvard Pilgrim Health Care, Inc. THE HARVARD PILGRIM POS MAINE ID: MD0000017736_A6 X This Schedule of s states any Limits and amounts you must pay for Covered s. However, it is only a summary
More information2015 National Training Program. Wo r k b o o k. Module: 7 Medicare Preventive Services
2015 National Training Program Wo r k b o o k Module: 7 Medicare Preventive Services ii Module Description Centers for Medicare & Medicaid Services (CMS) National Training Program (NTP) Instructor Information
More informationUNIVERSITY OF THE INCARNATE WORD, S2855 PPO PLAN GRANDFATHERED PLAN BENEFIT SHEET
BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB Dependents Children birth to 26 Filing Limit 365 days Mailing Address & PPO Company Remit claims to: CIGNA Physicians & Hospitals
More informationPLAN DESIGN & BENEFITS PROVIDED BY AETNA HEALTH OF CALIFORNIA INC. - FULL RISK
PLAN FEATURES Deductible (per plan year) Out-of-Pocket Maximum (per plan year) None Individual None Family $250 Individual $500 Family In-Network expenses include coinsurance/copays and deductibles. Pharmacy
More informationSchedule of Benefits - CENTRAL HMO Group CITY OF MARSHFIELD Benefit Year: January 1st through December 31st Effective Date: 01/01/2017
Security Health Plan certifies that you and any covered dependents have coverage as described in your Certificate and Schedule of Benefits as of the effective date shown on the letter you received with
More informationBenefit Name In Network Out of Network Limits and Additional Information. Benefit Name In Network Out of Network Limits and Additional Information
BluePoint 3 Benefit Time Period: 06/01/2015-05/31/2016 Broome County - Red HMO Plan General Information Cost Sharing Expenses Deductible - Single $0 Deductible - Two Person $0 Deductible - Family $0 Services
More informationBenefit Name Domestic In Network Out of Network. Benefit Name Domestic In Network Out of Network. 30% Coinsurance Subject to Deductible
Excellus BluePPO $5/$45/$90 Integrated Rx Benefit Time Period: 01/01/2019-12/31/2019 Thompson Health General Cost Sharing Expenses Deductible - Single $1,350 $1,350 $2,700 Deductible - Family $2,700 $2,700
More informationPLAN DESIGN & BENEFITS PROVIDED BY AETNA HEALTH OF CALIFORNIA INC. - FULL RISK
PLAN FEATURES Deductible (per calendar year) Out-of-Pocket Maximum (per calendar year) None Individual None Family $3,500 Individual $7,000 Family In-Network expenses include coinsurance/copays and deductibles.
More informationYour 2010 Medical Benefit Chart PFFS Plan Xerox Effective 01/01/2010
Inpatient Services Inpatient hospital care Your 2010 Medical Benefit Chart PFFS Plan Xerox Effective 01/01/2010 Hospital days are unlimited. Covered services include, but are not limited to, the following:
More informationConnecticut Teachers' Retirement Board 2019 Medicare Supplement Plan Benefits -- Administered By Stirling Benefits. General information
Provider access Covered Benefits Deductible General information All providers who accept If covers a charge, then the TRB plan covers that charge The 2019 deductible is $185. The member pays the Part B
More informationSee the benefits table below. $250 per Member per Calendar Year $500 per family per Calendar Year
Schedule of s HMO MASSACHUSETTS ID: MD0000017703_A9 X This Schedule of s states any Limits and the Member Cost Sharing amounts you must pay for Covered s. However, it is only a summary of your benefits.
More informationSCHEDULE OF BENEFITS PLAN M7
SCHEDULE OF BENEFITS PLAN M7 Effective September 1, 2016 All benefits, unless otherwise specified, are based on Usual, Customary and Reasonable (UCR) charges, or the network contracted amounts, and are
More informationPreventive Services Explained
Preventive Services Explained Medicare covers many preventive care services without charge. Most of these services have been recommended by the U.S. Preventive Services Task Force. However, which beneficiaries
More informationPrincipal Benefits for Kaiser Permanente Traditional Plan (10/1/16 9/30/17)
Benefit Summary SISC-SELF INSURED SCHOOLS OF CALIFORNIA Principal Benefits for Kaiser Permanente Traditional Plan (10/1/16 9/30/17) The Services described below are covered only if all of the following
More informationExcellus BluePPO Signature Hybrid 5
Excellus BluePPO Signature Hybrid 5 Drug Coverage Excluded Benefit Time Period: 01/01/2017-12/31/2017 Trinity Health - Syracuse Essential General Cost Sharing Expenses - Single Domestic - $1,000 $2,500
More informationPharmaceutical Management Medicaid 2019
Pharmaceutical Management Medicaid 2019 Toll-free Contact Number: (888) 327-0671 Pharmacy Administration: (810) 244-1660 Introduction Pharmaceutical Management promotes the use of the most clinically appropriate,
More informationNEIGHBORHOOD HEALTH PARTNERSHIP HMO SUMMARY OF BENEFITS
. (EV-4) 25/45/1000 w/access Rider NEIGHBORHOOD HEALTH PARTNERSHIP HMO SUMMARY OF BENEFITS A quick glance at this Summary of Benefits will introduce you to the important advantages of the Neighborhood
More information2013 UPDATE ON PREVENTION & SCREENING IN THE ELDERLY West Virginia Geriatrics Society October 3, 2013
2013 UPDATE ON PREVENTION & SCREENING IN THE ELDERLY West Virginia Geriatrics Society October 3, 2013 Joy Pelfrey, RN, MSN, FNP, NEA-BC Director of Senior Service Line Objective Providers will understand
More informationSee the benefits table below. None. $2,000 per Member per Calendar Year $4,000 per family per Calendar Year
Schedule of s Harvard Pilgrim Health Care, Inc. THE HARVARD PILGRIM HMO MAINE ID: MD0000017741_A4 X This Schedule of s states any Limits and Member Cost Sharing amounts you must pay for Covered s. However,
More informationSCHEDULE OF BENEFITS PLAN C
SCHEDULE OF BENEFITS PLAN C Effective September 1, 2016 All benefits, unless otherwise specified, are based on Usual, Customary and Reasonable (UCR) charges, or the network contracted amounts, and are
More informationRegence HSA Individual Direct Plan Highlights
Plan Features Provider choice: Member coinsurance levels are lowest for In-Network providers. If a member chooses an Out-of-Network provider, the member may be required to pay costs above the allowed amount.
More informationAbout UnitedHealthcare Dual Complete Medicare Advantage Plans. Program Highlights. Doc#: PCA _
Understanding UnitedHealthcare Dual Complete RP (Regional PPO-SNP) and UnitedHealthcare Dual Complete (HMO-SNP), offered by UnitedHealthcare Community Plan of Virginia Dual Special Needs Plans (DSNP) Key
More informationBenefit Interpretation
Benefit Interpretation Subject: Part B vs. Part D Vaccines Issue Number: BI-039 Applies to: Medicare Advantage Effective Date: May 1, 2017 Attachments: Part B Vaccines Diagnosis Code Limits Table of Contents
More informationBETTER WAYS TO PAY FOR CANCER CARE Creating Win-Win-Win Approaches for Oncologists, Cancer Patients, and Payers
BETTER WAYS TO PAY FOR CANCER CARE Creating Win-Win-Win Approaches for Oncologists, Cancer Patients, and Payers Harold D. Miller President and CEO Center for Healthcare Quality and Payment Reform Physicians
More informationSchedule of Benefits PPO MASSACHUSETTS
Schedule of s PPO MASSACHUSETTS ID: MD0000017711_A5 X This Schedule of s states any Limits and the amounts you must pay for Covered s. However, it is only a summary of your benefits. Please see your Handbook
More informationCoventry Health Care of Georgia, Inc.
Coventry Health Care of Georgia, Inc. PRESCRIPTION DRUG RIDER (for High Deductible Health Plans) This Prescription Drug Rider is an attachment to the Coventry Health Care of Georgia, Inc. ( Health Plan
More informationIndividual Market Schedule of Benefits
Individual Market Schedule of Benefits Deductible and Out-of-Pocket Maximum Plan Deductible Individual Family $150 per Member $300 per Family $8,000 per Member $16,000 per Family Out-of-Pocket Maximum
More informationCARD/MAIL/PRE-APPROVAL/PREFERRED RIDER FOR PRESCRIPTION DRUG [INSURANCE] [Policy]holder: Group Policy No: Effective Date:
RIDER FOR PRESCRIPTION DRUG [INSURANCE] [Policy]holder: Group Policy No: Effective Date: CARD/MAIL/PRE-APPROVAL/PREFERRED The Prescription Drug Coverage under this Rider [replaces] [supplements] the Prescription
More informationIntensive Behavioral Therapy for Obesity Guidelines
Health First Technologies Inc. dba Renua Medical 777 E. William Street, Suite 210 Carson City, NV 89701 877-885-1258 775-546-6156 E-fax www.renuamedical.com Intensive Behavioral Therapy for Obesity Guidelines
More informationState of Wisconsin 2013 Benefits Summary Active Employees & Non-Medicare Annuitants
Member Family Policy Annual Deductible None None Policy Co-insurance 10% unless specified below 10% unless specified below Policy Annual Maximum Out of Pocket () $500 $1,000 Policy Lifetime Benefit Maximum
More informationPrincipal Benefits for Kaiser Permanente Traditional HMO (1/1/16 12/31/16)
Benefit Summary 128742, 35995 ACWA/JPIA Principal Benefits for Kaiser Permanente Traditional HMO (1/1/16 12/31/16) The Services described below are covered only if all of the following conditions are satisfied:
More informationNew York Essential Plan cost-sharing matrix
New York Plan cost-sharing matrix On January 1, 2016, Empire BlueCross BlueShield HealthPlus (Empire) is offering a new comprehensive and affordable health insurance program. The Plan is a health benefit
More informationBased on Medicare FFS Beneficiaries Assigned July 1, 2011 December 31, 2011
July 2012 Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration Medical Home Feedback Report Based on Medicare FFS Beneficiaries Assigned July 1, 2011 December 31, 2011 Practice Number Practice
More informationSubject to Routine Physical Exam benefit. Same as applicable participating provider office visit member cost sharing Allergy Testing
PLAN FEATURES Deductible (per calendar year) Out-of-Pocket Maximum (per calendar year) None Individual None Family $2,000 Individual $4,000 Family Member cost sharing for certain services may not apply
More informationHUSKY Health Benefits and Prior Authorization Requirements Grid* Behavioral Health Partnership Effective: January 1, 2012
Behavioral Health Health and Behavior Assessments (CPT 96150-96155) When Performed by Psychologists Mental Health Inpatient 100% covered under medical benefit for members with diagnoses outside the range
More informationUnlimited except where otherwise indicated. Primary Care Physician Selection
PLAN FEATURES Deductible (per calendar year) None Individual None Family Out-of-Pocket Maximum (per calendar year) $2,000 Individual In-Network expenses include coinsurance/copays and deductibles. $4,000
More informationBenefit Name In Network Out of Network Limits and Additional Information. Benefit Name In Network Out of Network Limits and Additional Information
Excellus BluePPO Benefit Time Period: 01/01/2016-12/31/2016 COLGATE UNIVERSITY Cost Sharing Expenses Deductible - Single $250 $750 Deductible - Family $750 $2,250 0% 30% Annual Out of Pocket Maximum -
More informationPrincipal benefits for Kaiser Permanente Traditional HMO Plan (10/1/18 9/30/19)
Disclosure Form SISC - Self Insured Schools Of California Home Region: California Principal benefits for Kaiser Permanente Traditional HMO Plan (10/1/18 9/30/19) Accumulation Period The Accumulation Period
More informationGILSBAR GROUP HEALTH PLAN S2202 OPTION 2 NON-GRANDFATHERED PLAN BENEFIT SHEET
BENEFIT SHEET GENERAL PLAN INFORMATION Coordination of Benefits Standard COB The Plan will cover all dependent Dependents children up to age 26 Filing Limit 12 months from date of service Mailing Address
More informationPLAN DESIGN. Customer Name: High Desert & Inland Employee-Employer Trust. Effective Date: Plan: HMO Plan. Location(s): California
PLAN DESIGN Customer Name: High Desert & Inland Employee-Employer Trust Plan: HMO Plan Location(s): California Organization Name: Aetna PLAN FEATURES Deductible (per calendar year) Out-of-Pocket Maximum
More information2016 OPEN ENROLLMENT RETIREE HEALTH PLANS
2016 OPEN ENROLLMENT RETIREE HEALTH PLANS SERVICES Inpatient Hospital (Part A) COMPANIONCARE/Medicare Supplement Plan BENEFIT SUMMARY (Based on Calendar Year) MEDICARE 2016 Benefits Pays all but first
More information$250 (Deductible does not apply to Tier 1 and Tier 2) $500 (Deductible does not apply to Tier 1 and Tier 2)
Benefit Summary Outpatient Prescription Drug Illinois 5/50/100/250 Plan 455 Your Co-payment and/or Co-insurance is determined by the tier to which the Prescription Drug List (PDL) Management Committee
More informationChapter 4 Section Combined Heart-Kidney Transplantation (CHKT)
Surgery Chapter 4 Section 24.3 Issue Date: May 7, 1999 Authority: 32 CFR 199.4(e)(5) 1.0 POLICY 1.1 is a TRICARE benefit that requires preauthorization. 1.1.1 A TRICARE Prime enrollee must have a referral
More informationQ2034 And The New Flu Shot Medicare Reimbursement Codes
Q2034 And The New 2012 2013 Flu Shot Medicare Reimbursement Codes 9/29/2012 Medicare pricing just released for flu shots see pricing added to the codes below. Download this excellent 2012 2013 grid that
More informationIN-NETWORK MEMBER PAYS. Out-of-Pocket Maximum (Includes a combination of deductible, copayments and coinsurance for health and pharmacy services)
HMO-OA-CAL-15-15-0-0-03 HMO Open Access Calendar Year Plan Benefit Summary This is a brief summary of benefits. Refer to your Membership Agreement for complete details on benefits, conditions, limitations
More informationBilling & Coding Guide
Billing & Coding Guide CMS established a unique J-code to facilitate reimbursement of ENVARSUS XR J7503 Suggested Coding and Medicare Allowables Coding Overview and Payment Rates Used to Report Code Description
More informationPart D Benefits & Clinical Research Trials: What's Covered
Part D Benefits & Clinical Research Trials: What's Covered Presented by: Ryan Meade, JD Meade & Roach, LLP 312.498.7004 RMeade@MeadeRoach.com Health Care Compliance Association December 12, 2005 Baltimore,
More informationUnitedHealthcare Enrollment Service Area Nationwide. UnitedHealthcare Group
UnitedHealthcare v UnitedHealthcare Enrollment Service Area Nationwide UnitedHealthcare Group The Value of UnitedHealthcare and the PHIP Partnership National coverage that follows you where ever you are
More informationUnitedHealthcare Enrollment Service Area Nationwide. UnitedHealthcare Group
UnitedHealthcare v UnitedHealthcare Enrollment Service Area Nationwide UnitedHealthcare Group The Value of UnitedHealthcare and the PHIP Partnership National coverage that follows you where ever you are
More informationPHARMACY BENEFITS MANAGER
PHARMACY BENEFITS MANAGER CU GME Benefits Office Prescriptions should be obtained at participating pharmacies using your Benefits ID card. A list of participating pharmacies may be obtained by calling
More informationPrincipal benefits for Kaiser Permanente Traditional Plan (10/1/15 9/30/16)
Disclosure Form SISC-SELF INSURED SCHOOLS OF CALIFORNIA Principal benefits for Kaiser Permanente Traditional Plan (10/1/15 9/30/16) The Services described below are covered only if all of the following
More informationPreventive Services Update: Fall Prevention Services and Intimate Partner Screening and Intervention
Date: April 29, 2013 Market: All Preventive Services Update: Fall Prevention Services and Intimate Partner Screening and Intervention Overview On August 1, 2011 HHS published an amendment to the September
More informationCHAPTER 3 SECTION 1.6E COMBINED LIVER-KIDNEY TRANSPLANTATION. TRICARE/CHAMPUS POLICY MANUAL M DEC 1998 Surgery And Related Services
TRICARE/CHAMPUS POLICY MANUAL 6010.47-M DEC 1998 Surgery And Related Services CHAPTER 3 SECTION 1.6E Issue Date: October 26, 1994 Authority: 32 CFR 199.4(e)(5) I. PROCEDURE CODE RANGE 47150 II. POLICY
More informationDiabetes Management, Equipment and Supplies
Coverage Summary Diabetes Management, Equipment and Supplies Policy Number: D-001 Products: UnitedHealthcare Medicare Advantage Plans Original Approval Date: 11/01/2006 Approved by: UnitedHeatlhcare Medicare
More information1-844-FAX-A360 ( )
1-844-ASK-A360 (1-844-275-2360) 1-844-FAX-A360 (1-844-329-2360) www.myaccess360.com For more information, call AstraZeneca Access 360 at 1-844-ASK-A360, Monday through Friday, 8 am to 8 pm ET. IMFINZI
More informationThe Facts about Reimbursement for Self-administered Drugs. By William L. Malm, N.D., R.N.
The Facts about Reimbursement for Self-administered Drugs By William L. Malm, N.D., R.N. Table of Contents Introduction 3 Background 3 Coverage 3 Definition of Self-administered 4 SADs that are Integral
More informationPreventive Care Survey for Employers
Preventive Care Survey for Employers Business Health Care Group April, 05 Purpose of Survey Educate members of BHCG on the safe harbor example of compliance with the ACA mandate on tobacco cessation coverage
More informationPharmacy benefit guide
FlexRx SM 5-Tier Pharmacy benefit guide 1 Welcome to FlexRx The NHP FlexRx SM program is built for choice, savings, and convenience with benefits including: Low-cost drug tier for many common medications
More information