johns hopkins healthcare llc...comparison chart the chart below details the in-network benefits...

Johns Hopkins HealthCare LLCOverview and Changes to Health Plans in 2020

Presented by: 1/3/2020Presented by: Johns Hopkins HealthCare Provider Relations Department

Agenda

• Welcome• About JHHC• Provider Website Review• Product Updates 2020

Advantage MD EHP Priority Partners MCO USFHP

• Resources

2

1/3/20201/3/2020

Johns Hopkins HealthCare

Welcome:Johns Hopkins HealthCare LLC (JHHC) provides health care services for four health plans: Johns Hopkins Advantage MD, Johns Hopkins Employer Health Programs (EHP), Priority Partners Managed Care Organization, and Johns Hopkins US Family Health Plan (USFHP).

Our Mission

• Our mission is to improve the health of our members and provide them with high quality service and care.

• Provider office staff and physicians play a critical role in the member’s experience with our plan.

• With our provider partners, we aim to deliver world-class health care to our members while helping them to navigate the health care continuum.

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Johns Hopkins HealthCareProvider Website: www.jhhc.com > For ProvidersProvider website includes:

– Provider manuals– Forms– HealthLINK@Hopkins portal access– Online provider directory

• Find participating providers on www.jhhc.com– Policies and procedures– Compliance guidance– Communications repository

http://www.jhhc.com/https://www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physicians/resources_guidelines/manuals.htmlhttps://www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physicians/resources_guidelines/forms.htmlhttps://www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physicians/healthlink/http://www.jhhc.com/https://www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physicians/policies/https://www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physicians/resources_guidelines/forms.htmlhttps://www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physicians/resources_guidelines/provider_communications/repository

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Johns Hopkins HealthCareProvider Website: www.jhhc.com > For Providers

http://www.jhhc.com/

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Johns Hopkins HealthCareProvider Website: www.jhhc.com > For Providers > Resources & Guidelines


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Johns Hopkins HealthCareProvider Website: www.jhhc.com -> For Providers > Resources & Guidelines > Priority Partners > Outpatient Referral Guidelines


Advantage MD Product Overview

HMO,PPO, PPO Plus, PPO Premier & Group

Advantage MD Medical Benefit OverviewOur plans cover all services covered under Original Medicare.We also offer benefits beyond Original Medicare:

• Preventive dental, routine vision, routine podiatry, hearing exam and low-cost hearing aids.

• Our PPO Plus, Premier and Group plans offer acupuncture coverage, fitness, routine chiropractic services and worldwide emergency and urgent coverage.

• Our HMO, PPO and PPO Plus plans have supplemental dental and fitness benefits.

• Our HMO plan offers post-discharge home meals services to members who have been discharged from an inpatient or skilled nursing facility (SNF) stay, coordinated by Johns Hopkins Health Services department.

Advantages of Being an Advantage MD Provider

Health System/Provider:• Care Management support through Johns Hopkins

Advantage MD.• The Medicare Three-Day Rule for accessing post-acute care

does not apply to Advantage MD. Members can be admitted to a skilled nursing facility (SNF) when it is clinically appropriate.

Johns Hopkins Advantage MD Service AreaService Area is defined as a geographic area where a health plan can accept members.–Anne Arundel County–Baltimore City–Baltimore County–Calvert County–Carroll County–Frederick County–Howard County–Montgomery County–Somerset County–Washington County–Wicomico County–Worcester CountyNOTE: Advantage MD Group is available in Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, Pennsylvania, South Carolina and Virginia.

Johns Hopkins Advantage MDNew for 2020

2020 New Member Benefits for All Johns Hopkins Advantage MD Plans

• DECIDE is a literacy-adapted, online, self-paced program that helps adults learn how to change everyday behaviors to better manage their type 2 diabetes. This program is intended for patients who have struggles with the management of their diabetes.

• Act2 is an online, interacted, year-long support and engagement program. This program is intended for patients at high risk of developing type 2 diabetes.

If your patients would benefit from DECIDE or Act 2, both of which go into effect January 1, 2020, please refer them to us in one of the following three ways:

• PHONE: 866-809-2073 • EMAIL: [email protected]• ONLINE: bit.ly/hopkinsdiabetes

For all referrals, please include the following information:Patient’s name; address; home phone #; mobile phone #; email addressReferring provider’s name; NPI #; office address; office phone #; mobile phone #; email address.For more information on DECIDE or Act2, call 866-809-2073.

mailto:[email protected]

2020 Pharmacy Change • As of January 1, 2020, some pharmacies are not participating in the Advantage

MD Pharmacy network. Impacted members were mailed a letter starting in October about the pharmacy network change effective January 1, 2020.

The impacted pharmacies are:• Martins Pharmacy • PillPack

If a member uses one of these pharmacies, they will need to start using an in-network pharmacy as of January 1, 2020. In-network pharmacies can be located on the Pharmacy Locator at www.hopkinsmedicare.com. Prescriptions can be transferred from the old pharmacy to the new pharmacy, or you can send in a new prescription to the new in-network pharmacy. Members can also sign up for mail-order prescriptions online at www.hopkinsmedicare.com or call Advantage MD Customer Service at 877-293-4998 for HMO or 877-293-5325 for PPO.

http://www.hopkinsmedicare.com/http://www.hopkinsmedicare.com/

2020 NEW PRODUCT

PPO Premier – Montgomery County Only

Introducing Johns Hopkins Advantage MD Premier (PPO)

• Exclusive PPO plan available only to residents of Montgomery County, Maryland

• Starting January 1, 2020 residents in Montgomery County, Maryland in the Advantage MD PPO and PPO Plus will be disenrolled.– Members were notified via letters and calls in early October to select a

different type of Medicare coverage (Advantage MD HMO, Advantage MD PPO Premier, another MAPD plan, Original Medicare with or without a Medicare Supplemental plan and/or a PDP plan, etc.)

– Additional information will be provided to providers to assist any affected members.

PPO Premier Highlights• Simple design with member cost sharing the same in-network and out-of-

network• Members have flexibility and can see any doctor in-network or out-of-network.• Members can visit any doctor in the United States for the same in-network cost

sharing (great for snowbirds!).• Many benefits beyond original Medicare, including coverage of

• Acupuncture• Chiropractic • Preventive and Comprehensive Dental • Vision Exams and Eyewear • Hearing Exams and Aids• Worldwide Emergent and Urgent Services • Fitness Center or At-Home Fitness Kits

PPO Premier OverviewBenefits Member Cost-Sharing

PremiumMOOP

$350 $1500 IN / $5000 OON

Inpatient Hospital $200 per admit / stay

Emergency CareUrgent Care

$50 $20

PCP Specialist

$0$10

Outpatient – HospitalOutpatient – ASC

$100$50

RX (Part D) $3 / $10 / $40 / $90 / 33%

Preventive and Comprehensive Dental $0 to $400

Routine Chiropractic $10 copayment (12 visits a year)

Routine Podiatry $10 copayment (12 visits a year)

Acupuncture $300 allowance

Fitness (Silver&Fit) $0

Health Education (DECIDE) $0

Vision Eyewear - $300 every two years

Hearing Hearing Aids - $399 / $699 copay

Visitor / Traveler Benefit IN cost-sharing nationwide

Available in Montgomery County only

Same cost sharing in-network and out-of-network

Easy to understand plan design

Attractive all-in-one design with rich supplemental benefits

Low pharmacy copayments and robust formulary

No deductibles

PPO, PPO Plus, PPO Premier & Group• Flexibility in choosing physicians and specialists• Monthly premiums higher than HMO plans• No referrals needed, but higher out-of-pocket costs than

HMO• Coverage outside of the plan network (cost sharing may be

higher)• Robust supplemental benefits expected from premium

products

Differences Between PPO & HMO Plans

HMO•Primary care physician coordinates all care for the member•All care must be within the plan network (no out-of-network coverage), unless in an emergency situation•Lower out-of-pocket costs•Monthly premiums are lower than PPO plans•Referrals are required for specialty care only; please provide a copy to the patient and submit to JHHC.

Differences Between PPO & HMO Plans

Advantage MD PPO Member ID Card

Note: The circled area indicates the type of plan the member is enrolled in.

2020 Advantage MD PPO Benefits Comparison Chart

The chart below details the in-network benefits comparison between the three programs: Advantage MD, Advantage MD Plus, and PPO Premier*

*NOTE: Advantage MD PPO Premier is available only in Montgomery County, Maryland.

2020AdvantageMD PPOBenefits ComparisonChart (cont.)

Advantage MD PPO Advantage MD PPO Plus

Advantage MD PPO Premier*

Urgent Care Visits $40 copay $40 copayCoverage available in the United States and worldwide.

$20 copayCoverage available in the United States and worldwide.

Emergency Room Visits $90 copay;waived if admitted to the hospital.

$90 copay; waived if admitted to the hospital. Coverage available in the United States and worldwide.

$50 copay; waived if admitted to the hospital. Coverage available in the United States and worldwide.

Medicare-covered Diagnostic Radiology Services

$30 copay (diagnostic x-rays- mammogram, ultrasound)$250copayfordiagnostic radiology (MRI andCT)

$30 copay (diagnostic x-rays- mammogram, ultrasound)$250copayfordiagnostic radiology (MRI andCT)

$10 copay (diagnosticx-rays- mammogram,ultrasound)$100copayfordiagnostic radiology (MRI andCT)

Ambulance Services

$240 copay per one-way emergency and non-emergency; copay not waived if admitted to the hospital

$240 copay per one-way emergency and non-emergency; copay not waived if admitted to the hospital

$100 copay (ground)$225 copay (air)

Ambulatory Surgical Centers $240 copay $240 copay $50 copay

Diabetic Supplies 0% coinsurance 0% coinsurance 0% coinsurance

KidneyDiseaseEducation $15 copay $10 copay $10 copay

Acupuncture Not covered $200 annual allowance $300 annual allowance

Routine Hearing Exams $0 copay for one routine hearing exam per year$0 copay for one routine hearing exam per year

$0 copay for one routine hearing exam per year

Hearing Aids Through TruHearing,$699 or $999 (depending onmodel)

Through TruHearing,$699 or $999 (depending onmodel)

Through TruHearing,$399 or $699 (depending onmodel)

Eyewear(Non- Medicare covered) Not Covered

$150 allowance every two years to beused on eyewear, includinglenses,frames,and contact lenses.

$300 allowance every two years to beused on eyewear, includinglenses,frames,and contact lenses

Advantage MD PPO Advantage MD PPO Plus

Advantage MD PPO Premier*

Comprehensive Dental (non-Medicare covered) Not Covered Not Covered

0% to 50% coinsurance

Routine Podiatry Services 20% coinsurance (6 per year) 20% coinsurance (6 per year)

$10 copay (up to 12 visits per calendar year

Routine Chiropractic Visits Not Covered $20 copay (12 per year)

$10 copay (up to 12 visitsper calendar year)

2020 Advantage MD PPO Benefits Comparison Chart (cont.)

Advantage MD PPO 2020 Group Benefits• Advantage MD GroupThe Group plan is available to eligible Johns Hopkins Health System retired employees and families who reside in Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, and Virginia.

• Plan Overview- Low monthly premium ($175)- Low in-network maximum out-of-pocket ($300)- Worldwide emergency and urgently needed services coverage ($50,000 combined limit annually)- Visitor/Traveler benefit (ability to reside outside of the service area for less than 12 months, remain in plan and receive in-network cost sharing anywhere in the United States)- Comprehensive dental coverage

- Routine podiatry and chiropractic services- Acupuncture allowance

Advantage MD HMO Member ID Card

2020 Advantage MD HMO Benefits ChartBenefit Cost Sharing

Primary Care Visits $5 copay

Specialist Care Visits $50 copay

Retail Prescription Drugs: Five Tiers

30 days:$0/$10/$47/$100/33% 60 days:$0/$15/$94/$200/NA

Mail Order Benefit 90-day supply at two times retail copay, excluding Specialty Drugs (Tier 5)

Acute Inpatient Hospital Services Days 1-5:$310 copay per day.

Outpatient Hospital Surgery $300 copay

Urgent Care $40 copay

Emergency Room Visits

$90 copay; waived if admitted to the hospital within 24 hours

Diagnostic/Radiology Services

$20 copay (Diagnostic X-ray – mammography, ultrasound, etc.) $175 copay (Diagnostic Radiology – MRI and CT) 20% coinsurance (Therapeutic Radiology and Nuclear Medicine, lab services)

Benefit

Cost Sharing

Primary Care Visits

$5 copay

Specialist Care Visits

$50 copay


30 days:$0/$10/$47/$100/33%

60 days:$0/$15/$94/$200/NA

Mail Order Benefit

90-day supply at two times retail copay, excluding Specialty Drugs (Tier 5)

Acute Inpatient Hospital Services

Days 1-5:$310 copay per day.

Outpatient Hospital Surgery

$300 copay

Urgent Care

$40 copay


$90 copay; waived if admitted to the hospital within 24 hours


$20 copay (Diagnostic X-ray – mammography, ultrasound, etc.)

$175 copay (Diagnostic Radiology – MRI and CT) 20% coinsurance (Therapeutic Radiology and Nuclear Medicine, lab services)

Benefit

Cost Sharing

Primary Care Visits

$5 copay

Specialist Care Visits

$50 copay


30

days:$0/$10/$47/$100/33%

60

days:$0/$15/$94/$200/NA

Mail Order Benefit

90

-

day

supply

at

two

times

retail

copay,

excluding

Specialty

Drugs

(Tier

5)


Days

1

-

5:

$310

copay

per

day.

Outpatient

Hospital

Surgery

$300 copay

Urgent

Care

$40 copay


$90

copay;

waived

if

admitted

to

the

hospital

within

24

hours

Diagnostic/

Radiology

Services

$20

copay

(Diagnostic

X

-

ray

–

mammography,

ultrasound,

etc.)

$175

copay

(Diagnostic

Radiology

–

MRI

and

CT)

20%

coinsurance (Therapeutic Radiology and

Nuclear

Medicine

, lab services

)

Benefit Cost Sharing

Primary Care Visits $5 copay

Specialist Care Visits $50 copay


30 days:$0/$10/$47/$100/33%

60 days:$0/$15/$94/$200/NA

Mail Order Benefit

90-day supply at two times retail copay, excluding

Specialty Drugs (Tier 5)


Days 1-5:$310 copay per day.

Outpatient Hospital Surgery $300 copay

Urgent Care $40 copay


$90 copay; waived if admitted to the hospital within 24

hours


$20 copay (Diagnostic X-ray – mammography,

ultrasound, etc.)

$175 copay (Diagnostic Radiology – MRI and CT)

20% coinsurance (Therapeutic Radiology and

Nuclear Medicine, lab services)

2020 Advantage MD HMO Benefits Chart (cont.)

Routine Vision Exams $0 copay - one exam annually

Ambulance Services

$240 copay per one-way emergency and nonemergency, under certain conditions; copay not waived if admitted to the hospital

Ambulatory Surgical Centers $250 copay

Diabetic Supplies 0% coinsurance

Kidney Disease Education $0 copay

Routine Hearing Exams

$0 copay (one routine hearing exam per year)

Hearing Aid

Through TruHearing, $699 or $999 (depending on model) per hearing aid per year to include:

• Advanced or Premium hearing aids • Three provider visits within first year of hearing

aid purchase • 45 day trial period • Three year extended warranty • 48 batteries per aid (retail or online)

Eyewear Allowance (Non Medicare-covered) $150 allowance every two years

Post-Discharge Meals (Skilled Nursing and Inpatient discharges only) Three meals a day for five days (four times per year)

Routine Podiatry Services (Non Medicare-covered) 20% coinsurance ( eight per calendar year)

Routine Chiropractic Visits (Non Medicare-covered) Not covered

HMO Referral Requirements• Referrals are required for specialty services only.• Referrals should be to in-network specialty providers only –

there is no out-of-network coverage for HMO members.• PCPs should complete referrals in Health LINK and provide

the member with a copy. Or, complete the Maryland Uniform Consultation Referral Form, provide member a copy, and fax to JHHC at 410-424-4036.

https://www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physicians/healthlink/

CY2020 Product Overview (Note: Please use the Evidence of Coverage (EOC) released in October for benefits and coverage)

HMO PPO PPO Plus PPO Premier* PPO Group

Premium $0 or $25 $75 $105 $350 $175

MOOP $6,700 $6,700 / $10,000 $6700 / $10,000 $1,500 / $5,000 $3,000 / $10.000

Service Area HMO 001 – All, but Baltimore City

HMO 002 – Baltimore City Only

All, but Montgomery County

All, but Montgomery County

Montgomery County only DC, VA, GA, MD, NC, SC, PA, DE, FL

MedicalDeductible

None None None None $100

Inpatient $310 days 1-5 $310 days 1-6 $310 days 1-6 $200 per stay $250 days 1-7

PCP $5 $10 $5 $0 $5

Specialist $50 $50 $50 $10 $30

OutpatientHospital

$300 (Outpatient)$250 (ASC)





ER $90 $90 $90 $50 $75

Urgent Care $40 $40 $40 $20 $40

Supplemental Benefits (not all inclusive)

PodiatryPreventive Dental

Hearing Vision

Post-Discharge Meals

Podiatry Preventive Dental

Hearing Vision

PodiatryChiropracticAcupuncture

Preventive Dental Hearing Vision

Silver&Fit

PodiatryChiropracticAcupunctureFull Dental

Hearing Vision

Silver&FitVisitor / Traveler

PodiatryChiropracticAcupunctureFull Dental

Hearing Vision

Silver&FitVisitor / Traveler

RX $0/$10/$47/$100/33%No Deductible

$7/$15/$47/$100/26% $350 Deductible

$4/$12/$47/$100/26%$350 Deductible

$3/$10/$40/$90/33%No Deductible

$4/$12/$42/$92/33%No Deductible

OptionalSupplemental Benefits

Comp Dental / Fitness$30 monthly premium

No Waiting Period

Comp Dental / Fitness$30 monthly premium

No Waiting Period

Comp Dental $28 monthly premium

No Waiting Period

N/A N/A

Johns Hopkins Employer Health Programs (EHP) Product Overview

Johns Hopkins Employer Health Programs (EHP)

As a third-party administrator, Johns Hopkins Employer Health Programs (EHP) provides benefits administration to Johns Hopkins Medicine employers and other strategic partners, serving more than 60,000 members.

With 20,000 health care providers and 30 hospitals in Maryland and Southern Pennsylvania, and a nationwide network of nearly 691,000 providers and 3,500 hospitals, EHP self-funded plans are designed to meet the needs of all its members.

• EHP offers programs and services to help members better manage their health. EHP offers the EHP Benefits Explorer, an interactive tool designed to help EHP members quickly and easily find coverage information related to specific services. For detailed information on what each individual employer offers, visit benefits.ehp.org or see the schedule of benefits.

http://benefits.ehp.org/https://www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physicians/our_plans/ehp/plan_benefits/schedule_of_benefits.html

As EHP members, your patients can take advantage of the following:• Prescription coverage: Prescription drug benefits vary among

EHP employer groups. The EHP pharmacy and formulary can be viewed here.

• Dental care: The EHP dental benefit, offered by some EHP plans, is administered by Delta Dental. Members can call Delta Dental customer service at 800-932-0783.

• Visits to urgent care: Members can find urgent care centers by accessing the Provider directory or calling EHP customer service at 800-261-2393.

https://www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physicians/our_plans/ehp/pharmacy_formulary/index.htmlhttps://ehp.healthtrioconnect.com/public-app/consumer/provdir/entry.page

• One-on-one health coaching: This gives members in most plans (excluding Broadway Services and Anne Arundel Medical Center) the opportunity to work one-on-one with a personal health coach and create an individualized action plan to help them meet their health goals. Members can call 800-957-9760 for more information.

• Care management program: Members are placed in one of three levels and, depending on their level, are given a variety of support, tools, and services that are specifically designed to help them better understand and manage their medical conditions. Members can call 800-557-6916 for more information.

https://www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physicians/health_programs_for_members/education_coaching.htmlhttps://www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physicians/health_programs_for_members/index.html

• Pregnancy resources: Various programs for expectant moms, including Partners with Mom, a high-risk prenatal case management program, and health coaching.

• Members can call 800-261-2396 Ext. 5355 for more information.

• HealthLink@Hopkins: This is the secure web portal for members' personal health information. Members can login and register at ehp.org.

• National medical coverage outside the state of Marylandthrough MultiPlan PHCS Healthy Directions Network: Members can visit www.multiplan.com for more information.


Member ID cards

New for 2020Benefit and plan changes effective January 1, 2020 include:• JHU has added Dermatological Screening as a covered

Preventive Service.NOTE: Refer to the Preventative/Well Child/ Adult Care guideline and Preventative Services section of the SOBs for additional information.

New for 2020Effective Jan. 1, 2020 all JHHS (Johns Hopkins Health Systems) groups will merge into one PPO plan structure. The EPO options will remain separated.The following are part of the JHHS groups:• Johns Hopkins Hospital• Johns Hopkins Health System Corporation• JH Bayview Medical Center• Howard County General Hospital• Sibley Memorial Hospital (Sibley does not have an EPO option)• Suburban Hospital

New for 2020 (continued)• Pharmacy - Suburban transitioned to the prescription

benefits manager Caremark for processing.• Direct Primary Care (PCP) will remain as an available PCP

option for selection during open enrollment. (This is for the EPO and PPO plans.)

Additional 2020 EHP Plan ChangesInfertility-The lifetime maximum increased to $60,000 for both Medical and Pharmacy related coverage.

– $30,000 for Medical coverage– $30,000 for Pharmacy coverage

• Infertility treatment expanded to coverage at Shady Grove Infertility center.

• The lifetime maximum and expansion to Shady Grove is for both EPO and PPO plans.

Additional 2020 EHP Plan ChangesHopkins Preferred Providers and Facilities• Hopkins Preferred Providers and facility

selections are the same for all JHHS PPO options.• Howard County and Suburban will also include

Hopkins Preferred Providers with the EPO option.

Additional 2020 EHP Plan ChangesVision Benefit• Vision benefits are now offered separately during the

enrollment process. Members can elect to either have coverage through EHP or not. NOTE: A separate premium is paid towards this coverage.

• The cost EHP pays towards materials increased. The member’s schedule of benefits reflects the increased amount.

Empl

Priority Partners Product Overview

EmplPriority Partners Overview

• HealthChoice is a health care program of the Maryland Department of Health and Mental Hygiene.

• The HealthChoice plan provided through Priority Partners includes coverage for Medical Assistance for Families and the Maryland Children’s Health Plan for pregnant women and children.

• Eligibility is based on family size, income levels, or special medical circumstances.

• Priority Partners offers special needs and outreach programs to assist provider’s offices in improving no-show rates by helping members get into care and partnering with them to provide special programs for diabetics, pregnant women and members with chronic diseases.

Empl• Priority Partners offers programs and services to help members better

manage their health. As Priority Partners HealthChoice members, your patients can take advantage of no and low cost services that include:

• Low-cost prescription drugs and over-the-counter medication. See the Priority Partners pharmacy and formulary for more information.

• Visits to urgent care centers• Emergency department facility services• Dental care: Dental care for pregnant women and children is directly

provided by the Maryland Healthy Smiles Dental Program. Members can contact DentaQuest directly at 888-696-9596. For adults 21 and over, dental care is provided by Priority Partners through DentaQuest. Members can contact DentaQuest at 800-698-9611.

https://www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physicians/our_plans/priority_partners/pharmacy.html

Empl• Vision care: Vision care is provided by Superior Vision. Members

can contact Superior Vision at 800-428-8789.• HealthLink@hopkins: 24/7 secure online access to personal

health information. Members can login or register at ppmco.org.• Transportation to doctor and medical appointments:

Members can call 800-654-9728 for transportation scheduling.• Assistance in finding the appropriate health care services, as

well as help with making doctor's appointments: Members can call 800-654-9728 for assistance and appointment scheduling.


Empl• Care management: Priority Partners is committed to becoming the

leader in care management population health solutions. Our care management model promotes prevention skills, performs health risk identification, and manages member compliance to avoid costly treatments. We not only outreach to the sickest members to stabilize and manage conditions, we guide healthy members further along the prevention path. Through our four main service areas of Preventive, Transitional, Complex, and Maternal/Child, we catch members wherever they are on the health continuum.

• Health education: Priority Partners has a team of health educators that teach different programs to help members better manage their health. Members can call 800-957-9760 to sign up for a program or contact a health educator.

https://www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physicians/health_programs_for_members/index.htmlhttps://www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physicians/health_programs_for_members/education_coaching.html

EmplMember ID Card

Empl

New for 2020

EmplNew for 2020

Diabetes Prevention Program • Members are eligible to participate in an evidence-based

diabetes prevention program established by the Centers for Disease Control and Prevention if they: - Are 18 to 64 years old - Overweight or obese - Have an elevated blood glucose level or a history of

gestational diabetes mellitus - Have never been diagnosed with diabetes- Are not currently pregnant.

EmplNew for 2020 (cont.)

• AIDS/HIV Prescription Drug Benefit Coverage Moves to Priority Partners. Effective January 1, 2020, AIDS/HIV prescription drug benefit coverage will be available under Priority Partners. The 2020 Formulary will be available soon, and will include a listing of preferred products in the HIV therapeutic class.

• Substance Abuse Drugs and Behavioral Health Drugs. The Maryland Department of Health is responsible for formulary management of drugs used for substance use disorder (SUD) and most drugs used for behavioral health. Please refer to the Maryland Medicaid Mental Health Formulary and the Maryland DHMH Clinical Criteria for Substance Use Disorders (SUD) Medications for more specific information. This list may also be viewed at the Maryland Department of Health Medicaid Pharmacy Program website.


• Specialty Medications - Pharmacy Benefit: Are self-administered and processed through the member’s pharmacy benefit. These medications are available at a local retail or specialty pharmacy and may require prior authorization. You may find a list of these self-administered specialty medications and their specific authorization requirements on the Priority Partners formulary. Use the Prior Authorization form to request prior authorization for self-administered specialty medications.

https://www.ppmco.org/wp-content/uploads/2018/12/ppmco_formulary.pdfhttps://www.hopkinsmedicine.org/johns_hopkins_healthcare/downloads/ppmco/pp_prior_authorization_form.pdf


• Specialty Medications – Medical Benefit: Are administered by a provider or under supervision of a provider and processed through the member’s medical benefit. Providers may supply these medications and bill the health plan for the medication and related administration using HCPCS Codes or J codes.

• View the HCPCS Codes that require prior authorization for medical necessity and site-of-service.

• To request prior authorization, submit the Medical Injectable Prior Authorization form along with clinical supporting documentation via fax to 410-424-2801.

https://www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physicians/our_plans/priority_partners/specialty-medications.htmlhttps://www.hopkinsmedicine.org/johns_hopkins_healthcare/downloads/ppmco/medical_review_prior_authorization.pdf


• ePREP Promotion. New federal rules require that MCO providers enroll with the state’s Medicaid agency (42 CFR Part 438, Subpart H). To continue to provide Medicaid reimbursable services, you must be enrolled with the Maryland Medical Assistance Program (Medicaid) by December 1, 2019, even if your practice will be providing services only to HealthChoice participants. Enrolling with Medicaid does not mean that you must provide services to Fee-for-Service (FFS) participants.

• The Maryland Department of Health (MDH) is the state agency for Medicaid, and the tool that providers use to enroll is a self-service, online portal called electronic Provider Revalidation and Enrollment Portal (ePREP), which can be accessed here: eprep.health.maryland.gov

https://eprep.health.maryland.gov/

Required Cultural Competency Training for Priority Partners Providers

• Cultural competency training is a requirement for participating providers in the Priority Partners network. JHHC has developed its own Cultural Competency Training, a free, online educational program designed for physicians, physician assistants, nurse practitioners and office staff to build the awareness, knowledge, and skills to better treat an increasingly diverse U.S. patient population.

• The mandatory training is in HealthLINK, JHHC’s secure, online web portal for Priority Partners members and their in-network providers. Your office manager can help you register for HealthLINK, if you already have not done so, and access the Cultural Competency Training.

https://www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physicians/healthlink/https://www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physicians/healthlink/

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USFHP Product Overview

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• Johns Hopkins US Family Health Plan (USFHP) is a health care choice for eligible beneficiaries under the Department of Defense’s TRICARE Prime program.

• Health care is provided to active duty family members, activated National Guard and Reserve family members, and retirees and their family members, including certain “grandfathered” beneficiaries who are age 65 and older.

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• For members who have coverage under both Johns Hopkins USFHP and Medicare:• Medicare cannot be billed for services that are covered by USFHP• Members filing Medicare claims or members that have claims filed on

their behalf are in violation of the conditions of participation for USFHP and are subject to disenrollment.

• Members who have coverage under both USFHP and Medicare may only use Medicare benefits for non-covered USFHP services, such as chiropractic care or end-stage renal disease.

• Members utilizing Medicare for benefits covered under USFHP are subject to disenrollment.

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• USFHP offers programs and services to help members better manage their health. As USFHP members, your patients can take advantage of the following:

• Prescription coverage: Johns Hopkins USFHP utilizes the TRICARE pharmacy formulary for prescription drug benefits. The USFHP pharmacy and formulary can be viewed here. Walgreens is the official pharmacy for USFHP members.

• Dental care: USFHP members take advantage of two free dental cleanings per year and dental discount benefits administered through United Concordia Companies, Inc. (UCCI) and its Concordia Advantage. Members can call UCCI customer service at 800-332-0366.

• The program also offers members a free yearly eye exam.

https://www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physicians/our_plans/usfhp/pharmacy.html

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• One-on-one health coaching: This gives members the opportunity to work one-on-one with a personal health coach to help them meet their health goals. Members can call 800-957-9760 for more information.

• Care management program: This program offers tools and ongoing support that members need to better understand and manage their health. Members can call 800-557-6916 for more information.

• Healthy Living for USFHP: Health and wellness programs for members ages 45+ to help them and their loved ones develop a healthier lifestyle through health education and the guidance of medical experts.

https://www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physicians/health_programs_for_members/education_coaching.htmlhttps://www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physicians/health_programs_for_members/index.html

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• Pregnancy resources: Various programs for expectant moms including care management and the Partners with Moms program. For additional information about these programs, members should call customer service at 800-808-7347.

• HealthLink@hopkins: This is the secure web portal for members' personal health information. Members can login and register at hopkinsmedicine.org/usfhp.


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• Vision care discounts including lenses, frames, and LASIK eye surgery performed by Johns Hopkins doctors.

• Discounts on selected cosmetic procedures performed by Johns Hopkins doctors.

• Discounts on selected fertility treatment servicesperformed by Johns Hopkins doctors.

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Member ID Cards

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New for 2020

Changes to Pharmacy Copays Prescription drug copays will change for many US Family Health Plan (USFHP) members beginning January 1, 2020. The new copay increases are listed below:

• Mail-Order Pharmacy (Home Delivery) – 90-day supplyGeneric drug copay: increase from $7 to $10Brand-name drug copay: increase from $24 to $29Non-formulary* drugs: increase from $53 to $60

• Walgreens Pharmacy – 30-day supplyGeneric drug copay: increase from $11 to $13Brand-name copay: increase from $28 to $33Non-formulary copay: increase from $53 to $60

*Non-formulary means that the drug is not on TRICARE’s list of fully covered medications

2020 TRICARE Prime Out-of-

Pocket Expenses

**When TRICARE Prime enrollees self refer to specialty or non-emergent inpatient care without a referral from a network provider, the TRICARE Point of Service deductible and copayment applies in lieu of TRICARE Prime copayments.

**When TRICARE Prime enrollees self refer to specialty or non-emergent inpatient care without a referral from a network provider, the TRICARE Point of Service deductible and copayment applies in lieu of TRICARE Prime copayments.

2020 TRICARE Prime Out-of-

Pocket Expenses

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JHHC Customer Service• Advantage MD Customer Service/Benefits

Toll free: 877-293-5325 (PPO) or 877-293-4998 (HMO)https://www.hopkinsmedicare.com/plan-benefits

• Employer Health Programs (EHP) Customer Service410-424-4450 or [email protected]

• Priority Partners Customer Service410-424-4500 or [email protected]

• US Family Health Plan (USFHP) Customer Service410-424-4528 or [email protected]

• /Presented by: Johns Hopkins HealthCare Provider Relations Department

https://www.hopkinsmedicare.com/plan-benefits/mailto:[email protected]:[email protected]:[email protected]://www.hopkinsmedicare.com/plan-benefits/

1/3/20201/3/2020Presented by: Johns Hopkins HealthCare Provider Relations Department

Provider Relations: 888-895-4998

THANK YOU

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johns hopkins healthcare llc...comparison chart the chart below details the in-network benefits...

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