ADVANTAGE Health Solutions, Inc.

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ADVANTAGE Health Solutions, Inc.SM
ADVANTAGE Special Needs Plan

Provider Model of Care Training
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Advantage Mission

• Provide managed care solutions to improve
  outcomes, keep costs low and improve the health
  and wellness of the communities we serve

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MOC Provider Training Requirement

• Upon initial enrollment, DE-SNP PCPs will undergo
  a comprehensive face-to-face or, web-based
  training.
• All PCPs will receive general training that
  addresses all aspects of the health plan MOC, as
  well as the special needs of the SNP Population.
• All PCPs will be required to complete the MOC
  training upon initial enrollment, on an annual
  basis and as otherwise required by ADVANTAGE .
• DE-SNP participating PCPs must successfully
  complete the training before enrollment can be
  considered complete.

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What are Medicare Special Needs Plans (SNPs)

• Medicare SNPs are specially designed Medicare
  Advantage Plans, which have the following
  features
• Enrollment is limited to Dual Eligible (DE)
  Medicare/Medicaid populations
• Benefit plans are custom designed to meet the
  needs of this designated population
• SNP members typically have additional election
  periods to change their Medicare coverage

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Purposes of SNP

• The purposes of the Special Needs Plan are to
• Increase plan beneficiary participation in
  managed care
• Encourage access of special needs populations
• Provide better coordination of care between
  primary, acute, and long term care providers
• Reduce fragmentation
• Improve quality outcomes

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MEDICARE/MEDICAID COVERAGE

• If a members Medicaid status is Qualified
  Medicare Beneficiary (QMB) or Qualified Medicare
  Beneficiary Plus (QMB-Plus), he/she will pay 0
  for Medicare covered services as set forth in the
  ADVANTAGE Health Solutions Summary of Benefits.
• If a members Medicaid status is not QMB or
  QMB-Plus, he/she may have to pay some
  coinsurance, co-payments, and deductibles
  depending on their Medicaid coverage, even if
  he/she otherwise qualify for full Medicaid
  benefits.
• A members Medicaid benefits will vary based on
  income level and other Medicaid Standards.
  Medicaid benefits may also change during each
  year. Regardless, while a member of the ADVANTAGE
  Health Solutions Special Needs Plan, members will
  have access to this
• plans benefits even if their Medicaid status
  changes.

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SNP Approved Counties

• Hamilton, Hancock, Johnson, Marion, Morgan

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Categories of Dual Eligibility

• The categories of Dual Eligibility under the
  state Medicaid program are
• Qualified Medicare Beneficiary (QMB) Individuals
  whose Medicare Part A and Part B premiums, cost
  sharing, and deductibles are paid by Medicaid.
  This excludes Part D cost sharing.
• Qualified Medicare beneficiary with full Medicaid
  (QMB Plus) Individuals whose Medicare Part A and
  Part B premiums, cost sharing, and deductibles
  are paid by Medicaid and receive full Medicaid
  benefits. This excludes Part D cost sharing.
• Specified Low Income Medicare Beneficiary (SLMB)
  Medicare Part B premiums are paid by Medicaid.
• Specified Low Income Beneficiary with full
  Medicaid (SLMB Plus) Individuals whose Medicare
  Part B premiums are paid by Medicaid and receive
  full Medicaid benefits.
• Qualified Disabled Working Individual (QDWI)
  Individuals whose Medicare Part A premiums are
  paid by Medicaid.
• Qualifying Individual (QI) Individual whose
  Medicare Part B premiums are paid by Medicaid.
• Full Benefit Dual Eligible (FBDE) Individuals
  whose Medicare Part A premiums are paid by
  Medicaid, and in certain cases, Medicare Part B
  premiums. These individuals receive full Medicaid
  benefits.

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Member Eligibility for SNPs

• To join ADVANTAGEs Medicare SNP, individuals
  must
• Have Medicare Part A and Part B coverage
• Live in the county where the plan they wish to
  join is offered.
• Not have End Stage Renal Disease (ESRD)
• Be eligible for some level of Medicaid Coverage

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SNP Individualized Care Plan (ICP)

• SNP members have an Interdisciplinary Care Team
  that has clearly defined roles. The team
  provides the infrastructure necessary to
  coordinate the plan of care (POC) and to provide
  appropriate staff and program oversight.
• Interdisciplinary Care Team functions include
  developing/implementing individualized care
  plans, coordinating care and sharing information
  with providers, caregivers and the member.

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SNP Individualized Care Plan (ICP) (cont.)

• Bio-Psycho-Social (BPS) Model
• Bio-psycho-social systems focus on member health
  and well-being using the critical components of
  behavior change, relationship building and member
  systems engagement that can result in the member
  realizing resiliency and self-efficacy.

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SNP Individualized Care Plan (ICP) (cont.)

• Guiding Principles of the BPS model
• Moving from disease focus to member focus
• Identifying and employing the most effective
  intensity of evidence-based, plan-covered systems
  and services
• Behavior engagement for change
• Teaming with the member and care providers to
  enhance care outcomes
• Collaboration with plan sponsors to influence
  benefit design that supports our model

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Provider Network
ADVANTAGE Medicare HMO Network (SNP Counties) Indiana Medicaid Provider Participation Analysis ADVANTAGE Medicare HMO Network (SNP Counties) Indiana Medicaid Provider Participation Analysis
Provider Specialty Type of Participating Providers who also participate with Indiana Medicaid
Primary Care Physicians 89
Specialist Physicians 96
Ancillary Providers  90
BH Facilities 100
BH Providers (MD's, PhD's, PSYD's) 93
Skilled Nursing Facilities 88
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• Life of a Member

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Health Risk Assessment (HRA)

• Assessments are initially mailed to the member
  within 10 days of CMS confirmation of
  eligibility.
• The D-SNP Program will complete health screenings
  within 90 calendar days of members effective
  date and AT LEAST annually thereafter (within one
  year of the last HRA).
• Member or Care Giver is requested to complete the
  HRA and return to ADVANTAGE within 15 days (a
  self-addressed stamped envelope is provided).
• A health professional performs a telephonic
  outreach if HRA is not returned within 30 days of
  CMS confirmation.
• At least three attempts are made to have a
  successful contact. A successful contact is
  defined as
• assisting the member to complete the HRA
  telephonically
• getting care giver or members verbal commitment
  to complete and submit the HRA within ten days
  or establishing a more convenient date and time
  for member to take a follow-up call to complete
  the HRA or scheduling an appointment with
  Members PCP.

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Health Risk Assessment (HRA) cont.

• Once an assessment is received the results are
  entered into our system. This data is collated
  with claims encounter data and the member is
  stratified into their risk level (1 4).
• ADVANTAGE will produce monthly management reports
  on our completion rate and identify members who
  have not completed a health screen within 30, 60
  and 90 calendar days.

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Assignment and Stratification

• Within 10 days of completion of HRA, members will
  be assigned a dedicated Health Coach or Case
  Manager to assist the member in navigating the
  health care system in both the ambulatory and
  inpatient settings to ensure timely and
  appropriate access to needed services.
• Each member will have an assigned case manager or
  health coach who is the primary liaison to the
  member, providers, and health plan.
• A Health Coach for low level risk stratified
  members
• A Certified RN Case Manager for medium to high
  level stratified members.
• An Advanced Nurse Practitioner in the most
  complex cases

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Assignment and Stratification

• Each members health care professional acts as
  the liaison to the ICT and will assist the member
  and primary medical physician in the development
  of the members plan of care (POC) by providing
  all relevant information available
• Pharmacy and medical claims
• History of admissions and use of ER
• Review of primary medical record information if
  member at high risk
• Member and/or care giver/taker interviews
• HCC scores
• Clinical impressions gleaned from interviews and
  face to face visits.

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Interdisciplinary Care Plan (ICP)

• ADVANTAGE will develop and implement an
  individualized care plan (ICP) in consultation
  with the PCP and the beneficiary/caregiver for
  all beneficiaries.
• ADVANTAGE communicates this ICP to the PCP (via
  e-mail, fax, or written correspondence with the
  beneficiary/caregiver).
• ADVANTAGE conducts face-to-face or telephonic
  meetings with the provider, beneficiary/caregiver
  and/or disease manager/case manager or health
  coach.
• The care plan is reviewed
• at least every 6 months for members who are
  stratified at levels 1 and 2
• at least every 3 months for members stratified at
  levels 3 and 4.

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ICP cont.

• Care Manager will monitor member profile of care
  (claims and lab data) at least quarterly to
  identify gaps in care and will perform outreach
  to encourage member compliance according to goals
  of members Plan of Care and HEDIS measures for
  preventive services.
• The ICP will initiate the Transitional Care
  Program for all Members during the acute or
  sub-acute admission to ensure that appropriate
  resources are available and engaged across the
  continuum of care.
• All ICPs are HIPPA compliant and submitted to the
  PCP via a secure web-based provider portal or via
  secured encrypted email.

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Interdisciplinary Care Team (ICT)
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Interdisciplinary Care Team (ICT)

• ICT Care Conferences
•  ICT Case Conferences are an integral part of the
  ADVANTAGE DE-SNP Model of Care
• Focus on support of the Member through the review
  and modification of the Member's Individualized
  Care Plan (ICP) as health status requires or
  urgent/emergent events occur

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Interdisciplinary Care Team (ICT)

• Care plan ICT conferences will be held within the
  first 90 days of Member enrollment and
• at least annually for low and medium levels of
  risk
• at least every six months for high level of risk.
  
• Impromptu conferences can also be requested based
  on change in the patients condition or needs.
•  

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Interdisciplinary Care Team (ICT)

• ICT Care Conferences (PCP Participation)
• DE-SNP PCPs are strongly encouraged to
  participate at minimum on a quarterly basis
• PCPs are eligible to receive additional
  reimbursement for their time and participation
• Reimbursement Criteria
• Conference attended by the SNP members assigned
  PCP or PCPs Nurse Practitioner or Physician
  Assistant
• ADVANTAGE will initiate administrative payment
  and reimburse the PCP within 30 days of care
  conference completion

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Providers

• All current ADVANTAGE Medicare HMO network
  participating providers are able to provide
  services to DE-SNP members.
• ADVANTAGE Medicare HMO network PCPs are eligible
  for special enrollment in the DE-SNP and receive
  enhanced reimbursement
• PCPs in the field of General Practice, Family
  Practice, Pediatrics, Internal Medicine or OB/GYN
• Any specialty who agrees to the responsibilities
  and requirements of a DE-SNP PCP

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Providers

• Members will have the choice of access to at
  least two culturally appropriate primary medical
  homes located within 10 miles of his/her home.
• All SNP members will be linked to their preferred
  primary care physician within thirty days of
  enrollment.
• Utilizing the Monthly Provider Report Cards the
  Interdisciplinary care teams encourage referral
  to affiliated providers who demonstrate high
  rating of efficiency of care compared to their
  cohort group.

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Providers

• PCP Responsibilities
• Completion of MOC training
• Adhere to universally accepted standards
• Provide or arrange for the delivery of
• Routine comprehensive preventative services
• Medically necessary primary care treatment and
  urgent care services

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Providers

• PCP Responsibilities (Cont.)
• Coordinate or seek referrals for
• Specialty physician services
• Hospital inpatient and outpatient services
• Ancillary services (lab, radiology,
  orthotics/prosthetics DME)
• Provide PCP visit within 14 days of DE-SNP member
  discharge from acute or SNF facility

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Providers

• PCP Responsibilities (Cont.)
• Participate/Direct the Interdisciplinary Care
  Team
• Provide insight into the medical needs of the
  DE-SNP member
• Review DE-SNP members ICPs
• Assure ICP is supportive of the PCPs own plan of
  care for the member
• Communicate with ADVANTAGE ICT staff

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Providers

• PCP Incentives
• DE-SNP PCPs will receive (15) PMPM
  administration fee for each DE-SNP member
  assigned to his/her ADVANTAGE Medicare HMO panel
  roster
• ICT Case Conferences reimbursed at (40) for each
  DE-SNP member discussed
• Access to the ADVANTAGE provider portal for
  improved communication, member/provider report
  cards, panel rosters, and access to member ICP

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Provider Education and Outreach

• Interdisciplinary care teams encourage referral
  to affiliated providers who demonstrate high
  rating of efficiency of care compared to their
  cohort group.
• Once a member has been assessed and stratified,
  they are contacted by the ICT. After the initial
  contact, the practitioner will receive a letter
  notifying them of
• The program in which the member is enrolled
• The Clinical Practice Guidelines (CPG) on which
  the program is based
• The Disease Management Educator coaching the
  member
• Gaps in care (condition and prevention based)
  noted by claims or results needed from testing
  completed

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Provider Education and Outreach

• Once the initial letter is sent, based on
  stratification either every 3 months or every 6
  month the practitioner will receive a letter
  with
• Gaps in care (condition and prevention based)
  noted by claims or results needed from testing
  completed

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ADVANTAGE Provider Portal

• All DE-SNP PCPs who register online through the
  ADVANTAGE provider portal will have access to
  the personal health record of each assigned
  member
• PCPs will also find provider report cards that
  details valuable information on PCP performance.
• The provider portal will also allow the PCP to
  view their entire ADVANTAGE Medicare HMO roster
  of patients as well as contact information for
  the Care Manager assigned to the PCPs SNP
  members.
• The live Provider Portal will be available
  soon. The following slides are for training
  purposes only.

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http//www.advantageplan.com
Link to registration/login will be in this area
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Login for existing users, and first-time users
can register here
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Initial Login Screen
This area will be customized for each provider.
This will display your ENTIRE assigned member
panel, across ALL ADVANTAGE product lines.
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This is the patients homepage. All tabs above
can be accessed for patient information.
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Continuation of patients homepage. Again, the
content of this page can be customized.
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Each tab contains additional options to view/edit
health information about each patient.
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WEIGHT
11/04/2011
07/30/2011
01/15/2009
01/06/2010
01/04/2011
04/08/2011
06/16/2010
Providers will have the ability to choose a
timeframe to view
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Providers will have the ability to choose a
timeframe to view
This information will be auto-populated if the
providers office has access to EMR. If not, the
office can use this feature as an EMR Lite.
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Pharmacy Name
Medication Name
SIG
Days Supply
Quantity
Refills
Frequency
Dose
Patient Instructions
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Tool for ranking physicians within their
specialty based on the Total Cost Index.
Tool showing membership numbers by quarter
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Tool showing medical conditions of all patients
Tool showing admission rates
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Tool showing Quality Performance Summary
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Our Health Plan values the well-being of our
members!
Our goal is to serve the Medicare dual-eligible
populations of Indiana with value-added services
that enhance quality of care.
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Training Completion and Attestation

• Congratulations! You have completed the required
  SNP Provider training. Please click on the link
  below to download the attestation form. In order
  to validate your completion of this training, the
  attestation must be printed, signed, and returned
  to Lisa Poole, Provider Relations Specialist at
  ADVANTAGE Health Solutions, Inc., using one of
  the following methods

Mail 9045 River Road, Suite 200 Indianapolis,
IN 46240 Fax [phone] Email
lpoole_at_advantageplan.com
Attestation Form
Click here for the
(http//www.advantageplan.com/MAplans/pdfs/SNP_Tra
ining_Attestation.pdf)
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