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Medicare Advantage Participating Provider Training2020 Changes and Updates

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November 2019

© 2019 Kaiser Foundation Health Plan | Confidential and Proprietary

Part A Part B Part C Part D

Also known as Hospital Insurance program, covers inpatient hospital, skilled nursing facility, some health visits and hospice care

The Supplementary Medical Insurance program, helps pay for physician, outpatient, some home health and preventive services

Also known as the Medicare Advantage program, allows beneficiaries to enroll in a private plan, such as a health maintenance organization (HMO) or preferred provider organization (PPO), as an alternative to traditional Medicare

The outpatient prescription drug benefit is a voluntary benefit delivered through private plans that contract with Medicare; enrollment in Part D is voluntary

– Private plans can be either stand-alone prescription drug plans (PDPs) or Medicare Advantage prescription drug plans (MA-PD)

The four parts that make up Medicare Program are;

Medicare Overview

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Medicare Plus (Cost) Medicare Advantage (Risk)

Network • Signature network (MAPMG providers) with some additional external physicians; access to out-of-network providers through Original Medicare

• Medicare Advantage Signature Network (MAPMG providers + contracted providers required to meet MA network standards); no access to out-of-network providers in most circumstances

• Select Network available to 5 grandfathered employer groups (Transit, City of Baltimore, Baltimore County Schools, CCBC, Harford County)

2020 Service Area • VA: Alexandria City, Arlington, Fairfax, Fairfax City, Falls Church City, Loudoun, Manassas City, Manassas Park City, Prince William

• MD: Calvert, Carroll, Frederick

• MD: Anne Arundel, Baltimore, Baltimore City, Harford, Howard, Montgomery, Prince Georges, Charles, Calvert, Carroll, Frederick

• DC• VA: Alexandria City, Arlington, Fairfax, Fairfax City, Falls Church City, Loudoun,

Manassas City, Manassas Park City, Prince William

CMS Payment/Reimbursement

• KP bills CMS for Medicare-covered services provided to Medicare members and is reimbursed for those services

• Providers should bill CMS as primary and KP as secondary

• CMS pays KP a monthly rate per member (based on county of residence and the member’s health status) to manage the total care of the member, regardless of services used

• Providers should bill KP as primary

Contract number H2150 H2172

Inpatient Hospitalization benefit

Copay per benefit period Copay for days 1-5; $0 unlimited thereafter (STAY)

Home health referrals Existing referrals will remain in effect and members may continue to receive care from their providers

New referrals will be authorized for 2020 services and members may continue to receive care from their providers

DME referrals Existing referrals will remain in effect and members may continue to receive supplies and equipment from their providers

New referrals will be authorized for 2020 services and some supplies will be provided by Apria

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Key Differences: Plus vs. Advantage Both Medicare Plus plans and Medicare Advantage plans are offered in our service area. This grid outlines the main differences between the two types of plans.


Medicare Advantage Conversion: A History

Jan 2018

Jun 2018

Dec2018

Jan 2019

May 2019

MA membership 1,600 3,200 5,500 52,300 53,000

Cost membership 73,100 72,100 71,800 26,500 26,600

Total 74,700 75,300 77,300 78,800 79,600

January 1, 2018: Medicare Advantage plans were introduced in Washington, DC and 7 counties in Maryland for new enrollments.

January 1, 2019:

All Cost members (DPA and group/FEHB) living in DC and those 7 Maryland counties were transitioned from Cost to Medicare Advantage. There are no longer any Cost members in that part of the service area.

Medicare Advantage introduced in Charles County for new enrollments. DPA Cost members in Charles County can remain in Cost through the end of 2019.

All group members in Charles County were transitioned to MA.

2019 Kaiser Permanente Mid-Atlantic States Medicare Service Areas

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Medicare Advantage Conversion: 2020By December 31, 2019 all Cost members in Charles County must actively enroll in the Medicare Advantage plan in order to have coverage with KP as of January 1, 2020. There are retention activities planned throughout 2019 to encourage members to actively re-enroll.

On January 1, 2020, Medicare Advantage will be introduced in Northern VA and in Calvert, Carroll, and Frederick counties in Maryland for new individual enrollees. There are retention activities planned throughout 2020 to encourage members to actively re-enroll in MA throughout the year.

At the end of 2019, all group and FEHB Cost members will be transitioned to Medicare Advantage. As of January 1, 2020 all group and FEHB members will be in Medicare Advantage.

2019 Kaiser Permanente Mid-Atlantic States Medicare Service Areas

Projected membership

2019 2020 2021

MA membership 55,500 83,500 96,000

Cost membership

27,500 5,000 0

Total 83,000 88,500 96,000

Looking Ahead…As of January 1, 2021, the region should be fully transitioned to Medicare Advantage

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Eligible Kaiser Permanente Medicare

Advantage members may receive PRIMARY and

SPECIALTY care services at any Kaiser Permanente location throughout the

entire Kaiser Permanente Mid-Atlantic service area, regardless of whether or not the location is in the

Medicare Advantage service area.

Kaiser Permanente Medicare Advantage

members may also see select Participating Primary and Specialty care providers within Kaiser Permanente’s

Medicare Advantage Network.

Kaiser Permanente Medical Facilities

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Medicare Advantage NetworkBecause a Medicare Advantage member can only utilize the network of the Medicare Advantage Organization (MAO), there are rigorous network adequacy guidelines (time and distance requirements) that all MAOs must meet. These vary by the population density of a given area as well as the type of provider.

How this differs from the Cost network Cost members can, at any time, choose to utilize their Original Medicare benefit to see any

Medicare provider. The 20% coinsurance for those services would be the responsibility of the member

The KP-MAS Medicare Advantage Network is its own unique network and is not the same as the Signature or Select networks used in the commercial line of business.

The Medicare Advantage network has all MAPMG providers at the core of the network. Where there are gaps in the network, these are filled by contracts with community providers until network adequacy is met.

All providers in the Medicare Advantage network required to meet network adequacy are listed in the provider directory.

Members may choose from any provider in the network, though referrals and prior authorization may apply.

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© 2019 Kaiser Foundation Health Plan | Confidential and Proprietary8

ID Cards

MA Signature MA Select Plans with No Part D

Card Color White Tan White

Provider Information included

No Yes No

Rx Info Included Yes Yes No

Members may have different ID cards depending on whether they are in a plan with the Medicare Advantage Signature network or the Medicare Advantage Select network and whether their plan includes Part D prescription drug benefit. The differences appear in the card color as well as the information included on the card.

The Medicare Advantage ID Card will look very similar to Cost but have a different contract number and product name.


Participating Providers enrolled with KP HealthConnect AffiliateLink may verify eligibility and benefit information online by logging on at: www.providers.kp.org/mas

Participating Providers or members may call Member Services at 1-855-249-5019 or for TTY 1-866-513-0008 regarding:• General enrollment questions• Clarification of eligibility verifications• Clarification of member benefits• Members terminated greater than 90 days• Members presenting with no Kaiser Permanente identification number• Clarification of claims issues

Enrollment and Eligibility

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http://www.providers.kp.org/mas


Medicare Group and FEHB Plan ChangesAs of December 31, 2019, all Medicare Group members, including FEHB members, who are in Medicare Cost plans will be transitioned to the Medicare Advantage contract. Starting January 1, 2020, no group members will be remaining in Medicare Cost plans.

2020 Goal: To maintain/achieve competitive position while also striving to keep benefit stability throughout this Cost to MA transition

2020 Benefit Changes/Additions: - Group Medicare Advantage Plans do not include State Mandated benefits (as contained the EOC

amendment for Cost Plans)- Compression Garments: as with the direct pay plans, a supplement to broaden the circumstances

under which a Medicare member can receive compression garments has been added to all group plans. This brings the Medicare prescribing guidelines in alignment with commercial plans.

- Non-emergency transportation: In order to ensure that Medicare members are able to get from their homes to their medical appointments and back, 24 one-way rides have been added to all group plans

- BrainHQ: In order to help our members retain and improve cognition as they age, all Medicare group members will have access to a $0 subscription to BrainHQ, which is an online brain training platform and application


Appointment and Access Standards

Per the Medicare Managed Care Manual, Chapter 4 - Benefits and Beneficiary Protections, Section 110.1.1 – Provider Network Standards Hours of operation are convenient to, and do not discriminate against, enrollees. When medically necessary, services are available 24 hours a day, 7 days a week Examples of reasonable standards for primary care services are:

– (1) urgently needed services or emergency - immediately; – (2) services that are not emergency or urgently needed, but in need of medical

attention - within one week; and – (3) routine and preventive care - within 30 days

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Continuity of Care

Member calls MSCC/NCSC, goes to Town

Hall/MIM

Member receives form

in mail or online and fills

out, gives to outside provider

Provider faxes completed

form to UMOC

UMOC will review the form and return a

determination to the

member

1/1/2020Member’s MA

coverage starts, and they can

receive CoCcare

Applying for Continuity of Care• All members moving from Medicare Cost to Medicare Advantage (even those actively re-enrolling) are eligible

to apply for continuity of care. • The same form and process will be used for these cases as for other Continuity of Care requests.

• This process aligns with existing Continuity of Care processes for new-to-KP members in the State of Maryland. • Through this process, a member will receive a prior auth through KP’s utilization management (UM) staff for their outside

care, and their provider will submit claims to our claims processing staff. • For any unanswered questions, contact UMOC or see the FAQ.

Existing Referrals• All other care for existing Medicare Cost members that is in a KP center will not change.• If a member has an existing referral to see an external provider (they should check to confirm this referral is

up to date), their care will not be impacted unless it is homecare or DME supplies:• For homecare, the member will get a letter describing the transition and a new referral that adds a number of visits. Their

homecare provider will not change. • For DME supplies (note: supplies only, not DME equipment), the member will get a letter describing the change and a

referral letter, which will switch their supplier from non-Apria vendor to Apria.


Outpatient Dialysis CoinsuranceStarting on January 1, 2020, there will be a 20% coinsurance added to all outpatient dialysis services, including peritoneal dialysis, hemodialysis, and home dialysis.

What does this mean for our members?: Medicare members who utilize outpatient dialysis services will experience an increase in cost as they move from paying $0 cost sharing to a 20% coinsurance. Certain items, such as kidney disease education, will remain at $0. The costs incurred will go toward the member’s Maximum Out of Pocket (MOOP), which is capped at $6,700 annually for Value and Standard plans and $5,500 annually for High plans

Which plans are impacted?: All Medicare Advantage and Medicare Cost plans for individuals. This does NOT impact Medicare group or Medicare FEHB plan members.

How are we communicating this change to members?: - Through the Annual Notice of Change (ANOC), which members will receive in late September- A letter outlining the benefit change sent to members in late September to coincide with the mailing of the ANOC- An outbound calling program to impacted members in October/November 2019

Is there financial assistance available to members?:Patient Financial Assistance can assist members with the cost of services received in Kaiser Permanente facilities. Nephrology social workers will also be working with members to find additional resources. No member will be denied dialysis services due to an inability to pay. No member will lose their Kaiser Permanente Medicare Advantage coverage due to an inability to pay

Why are we making this change?To align with the market and Medicare standard for cost sharing in this benefit category


Non-Emergency TransportationStarting January 1, 2020, Medicare Advantage members will have access to no cost non-emergency transportation to help our members get from their home to their medical appointments and back. These rides can be scheduled in advance or requested on-demand.

What do our members get?: 24 one-way rides between the member’s home and any KP-contracted provider or facility for medical appointments or procedures. Depending on the needs of the member, rides will be provided by a rideshare service (i.e. Lyft) or a wheelchair or gurney van.

Which plans include this benefit?:All Medicare Advantage plans, including Value plans, group plans and FEHB plans.

How do members access this benefit?:Members will call the Transportation Line, 571-386-3769 (currently the PTAP line) to speak to a representative and schedule or request a ride. Members can also call this line with ride changes and cancellations and to inquire about their ride balance. The first time a member calls, an intake will be done to confirm eligibility and identify the type of transportation needed.

Why do we want our members to have this benefit?: We want to ensure that our members are able to get the care that they need when they need it. For many of our members, transportation has been cited as a barrier to getting care. Additionally, this benefit will aid our partners in care delivery by increasing medical compliance and enabling care delivery partners to arrange for member transportation to and from our medical centers when necessary.


Compression GarmentsMedicare covers compression garments for patients only under a very limited set of circumstances. This benefit expands the circumstances under which a member can get custom-made compression garments covered by the health plan.

What do our members get?: Compression garments in alignment with the commercial MAS medical coverage policy, which covers compression bandages and garments in the following circumstances. Member cost sharing remains the same, which is 20% coinsurance.

A. Treatment of lymphedema, including:1. Primary edema from congenital defect (hereditary edema);2. Secondary edema, acquired and due to lymphatic obstruction or interruption;3. Cancer or cancer related treatment for breast cancer, surgery or radiation therapy;4. Post-mastectomy lymphedema syndrome and other lymphedema

B. Treatment of an open venous stasis ulcer;C. Treatment of chronic venous insufficiency with venous stasis ulcers;D. Hypertrophic scarring and joint contractures following burn injury or scarring from surgery; orE. Post amputation compression therapy, e.g. stump wraps, shrinkers, and shapers.

Which plans include this benefit?: All Medicare plans, including Medicare Cost plans, Medicare Advantage Value plans, Medicare group plans and Medicare FEHB plans.

How do members access this benefit?: If the member is in need of a compression garment and has one of the clinical indications above, the item will be approved and the member will be responsible for their contribution.

Why do we want our members to have this benefit?: To support care delivery partners as they design treatment plans for our members that will maintain and improve quality of life.


Referrals and Authorizations

Specialty Care Referrals

• Initial Consultation• Referral must be authorized by PCP or Specialist• Referral valid for 90 days (3 months), or as otherwise specified on the referral

• Additional Visits and Expired Referrals• After an approved initial consult you do not have to call the PCP to request

additional visits• Complete a Maryland Uniform Consultation Referral Form to initiate a new

request, fax to UMOC for processing• UMOC FAX Numbers: 1-800-660-2019 – Alternate Fax: 855-414-1693

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Referrals and Authorizations

Utilization Management Operations Center (UMOC)Referral Management Unit: 8:00am –4:30pm, weekdays

Concurrent Review Unit: 8:30am – 5:00pm, weekdays

Home Care/DME Unit: 8:30am – 5:00pm, weekdays

Emergency Care Center (ECC): 24/7, 365 days/year

Referrals, authorizations hospital observation & inpatient admissionsGeneral Number (listen for prompts): 1-800-810-4766

Fax Numbers• Specialty Care Referrals: 1-800-660-2019 or 855-414-1693• Homecare/DME (Please send clinical information): 855-414-1695• Rehab Re-Authorizations (Please send clinical information): 855-414-1698• DCSM Concurrent Review: 855-414-1704• NOVA Concurrent Review: 855-414-2659• Baltimore Concurrent Review: 855-414-1702• Emergency Care Center: 855-414-2634

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Claims & Billing Procedures

Billing Address:Mid-Atlantic Claims AdministrationKaiser PermanenteP.O. Box 371860Denver, CO 80237-9998

Clearinghouse Payor IDs for KP:ChangeHealthcare: 52095Office Ally: 52095Availity: 54294OptimumInsight/Ingenix: NG008Relay Health: RH010

Timely Filing: 180 days (6 months) from date of service

Timely appeals filing: 180 days (6 months) from date of denial

“Clean Claim”: Standard format/completed fields, attachments, current industry standard data coding

All patient services must be billed on CMS 1500 or UB04

Kaiser Permanente is the primary payor for Medicare Advantage. Claims should be sent to Kaiser Permanente, not CMS. However, the same billing requirements for CMS are applicable to all claims billed to Kaiser Permanente. Please verify the member’s plan to ensure that the claim is submitted to the correct payor.

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Provider Appeals

All provider appeals should be sent to:Mid-Atlantic Claims AdministrationKaiser PermanenteP.O. Box 371860Denver, CO 80237-9998

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