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PrimeWest Health Special Needs BasicCare SNBC

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... pharmacy benefits ... B items can be processed on the pharmacy benefit, electronically. ... from providers located outside the United States and Canada. ... – PowerPoint PPT presentation

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Title: PrimeWest Health Special Needs BasicCare SNBC


1
PrimeWest Health Special Needs BasicCare (SNBC)
2
SNBC Stakeholders Group
  • Monthly meetings consist of
  • Disabled individuals
  • Guardians
  • Providers
  • PrimeWest Health staff
  • Public Health
  • Special Education teachers

3
What is SNBC?
  • State-defined program
  • Members have Medicaid coverage or combined
    Medicare and Medicaid coverage (If Medicare,
    enrolled members must have Medicare Parts A B)
  • PrimeWest Health is responsible for adjudicating
    claims
  • Includes pharmacy benefits

4
Eligibility
  • Age 18 - 64 or age 65. If enrolled when turning
    65, member can choose to remain on SNBC.
  • Eligible for Medical Assistance
  • Reside within PrimeWest Health counties
  • Certified as disabled or be a person with mental
    retardation or a related condition (also known as
    a developmental disability) as determined by the
    local agency or receive services under the
    Medicaid Waivers Community Alternatives for
    Disabled Individuals (CADI), Traumatic Brain
    Injury (TBI), Community Alternative Care (CAC),
    or Developmental Disabilities (DD)

5
Covered Services
  • Comprehensive preventive, diagnostic,
    therapeutic, and rehabilitative services as
    covered by MN Medicaid
  • Home Care Services except for personal care
    assistant services, private duty nursing
    services, and personal care qualified
    professional supervision services (PCA)
  • Medicare benefits as provided by Specialized
    Medicare Advantage (MA) plans for Special Needs
    enrollees, known as Special Needs Plans (SNPs)
  • 100 days of Nursing Facility benefit for any
    enrollee admitted to a NF from the community
  • All services must meet Medical Necessity standards

6
Benefits for Members Enrolled in SNBC
  • Total coordinated health care
  • Each member is assigned a Care Coordinator and a
    County Case Manager
  • Minimum yearly assessment of individual
  • 3-day qualifying hospital stay waived to access
    Medicare A benefits for SNF or home care

7
Added Benefits
  • PrimeFitness Program
  • PrimeFitness is a covered benefit that will be
    offered to all PrimeWest Health members starting
    mid 2008.
  • Each PrimeWest Health member who chooses to join
    will be involved in creating an individualized
    fitness plan
  • PrimeFitness is designed to facilitate behavioral
    and environmental adaptations that protect and
    improve health, prevent disease, modify and limit
    risks of existing disease, or minimize the
    disability that accompanies advanced stages
  • PrimeFitness will give members the opportunity
    to
  • Work with a trained fitness professional
  • Participate in fitness assessments
  • Receive fitness assistance and counseling
  • Work to improve health and vitality

8
Added Benefits
  • Unlimited wheelchair cushions if deemed
    medically necessary and on the care plan
  • Replacement and loaner communication devices
  • Transportation not limited to health care
    travel (e.g., support groups)
  • Extra pair of eyeglasses and protective coating
    on lens if deemed medically necessary and on the
    care plan

9
Added Benefits
  • Working with all vendors to ensure that all
    repairs and replacements are done in a timely
    manner
  • Porcelain crowns and up to 3,000 /year for
    bridge work
  • Prescriptions All Part D and a select number of
    Part B items can be processed on the pharmacy
    benefit, electronically. Notable Part B products
    are diabetic testing supplies, ostomy supplies,
    and medications used in conjunction with
    chemotherapy and transplantation. Vaccines
    eligible for Part B can also be billed
    electronically through eVaccine.

10
Customer Service
  • Dedicated phone line
  • Specialized friendly enrollment coordinators
  • Always willing to listen
  • Staff involvement in local community activities
  • Local community outreach (partnering with other
    resources)

11
Care Coordination
  • Health Risk Screenings, Comprehensive
    Assessments, and Care Plan
  • PrimeWest Health will provide a holistic care
    coordination model
  • Each member will have a health risk screening
    within 30 days of enrollment

12
Care Coordination
  • Based upon the health risk screening, each
    member will have a comprehensive assessment to
    determine the enrollees needs and potential
    service options
  • A holistic/preventive care plan will be
    developed for each SNBC enrollee integrating any
    current care plans that the enrollee may already
    have

13
Care Coordination
  • Case Managers
  • A Case Manager will be assigned to each of
    PrimeWest Healths SNBC members
  • Case Managers will be local county social
    workers and county registered nurses already
    trained on disability related issues and
    community and public resources/programs

14
Care Coordination
  • If there is an assessed need, the SNBC enrollee
    will be assigned a social worker and registered
    nurse as dual case managers for a
    collaborative/comprehensive approach
  • Our Case Managers will provide coordination of
    services
  • PrimeWest Healths services and Medicare and
    Medicaid covered services
  • Community services

15
Care Coordination
  • Our Case Managers will provide a respectful and
    caring team approach for all of our members
  • Our Case Managers will be available to attend
    doctor appointments
  • Our Case Managers will assist and advocate for
    our SNBC members to help them navigate the health
    care system to ensure their needs are met

16
Care Coordination
  • Additional Care Coordination
  • Dedicated disability program staff at PrimeWest
    Health consisting of a Disability Program Care
    Manager and two Disability Care Coordinators
    available to support our county case managers and
    our SNBC members

17
Care Coordination
  • PrimeWest Health also has Care Coordinators who
    specialize in coordinating and monitoring care
    and facilitating educational and preventive
    materials to our members who suffer from certain
    chronic health conditions such as
  • - Heart disease
  • - Diabetes
  • - Behavioral Health issues
  • - Depression
  • - Skin breakdown
  • - Urinary tract infections
  • Also included is Maternal/Child Health

18
Billing Medicare Covered Services
  • Bill using CMS guidelines
  • Check with PrimeWest Health for exceptions
  • All SNBC plans must waive the 3-day qualifying
    hospital stay prior to SNF or home care
  • Reimbursement based on CMS rates
  • Combined Medicare and Medicaid payment on one
    claim
  • Generally no deductibles/ coinsurance
  • Check your contract for payment rates.

19
Billing Medicare Non-Covered Service
  • Bill using DHS guidelines with few exceptions
    (e.g., RHCs submit itemized services on CMS-1500)
  • Reimbursement based on DHS rates
  • Generally based on MA rates
  • Check your contract for payment rates

20
Coordination of Benefits (COB)
  • When no secondary insurance
  • No need to submit multiple claims
  • Medicare/Medicaid payment combined into one claim
  • Supplemental policies
  • Since most Medicare supplement policies do not
    coordinate with Medicare replacement plans, our
    payment will include the Medicare and Medicaid
    (deductible) portion combined.
  • In situations where coordination may occur,
    PrimeWest Health will work directly with the
    supplement.

21
Checking Eligibility
  • Check eligibility on all MN Health Care Programs
    members each month
  • Verify eligibility through the Electronic
    Verification System (EVS) at (800) 657-3613,
    PrimeWest Health Contact Center at (866)
    431-0802) or through PrimeWest Healths Provider
    Portal
  • A members coverage will never be terminated in
    the middle of a month

22
Authorizations
  • If a member chooses, he/she may go to a
    non-contracted specialty provider. If you refer a
    member to a non-contracted specialty provider,
    please notify PrimeWest Health.

23
Services Not Covered by SNBC
  • Abortion Services
  • Circumcision (must be medically necessary)
  • Child Welfare Targeted Case Management
  • Developmental Disability Case Management (Rule
    185)
  • Mental Health Targeted Case Management (Rule
    79)
  • Personal Care Assistant Services
  • Quality Professional Supervision for Personal
    Care Assistant Services
  • Private Duty Nursing
  • ICF-MR services, including Day Training and
    Habilitation
  • Home and Community Based waiver services
  • Relocation Service Coordination

24
Services Not Covered by SNBC
  • Nursing Facility Per Diem Services
  • Nursing Facility per diem services are not
    covered, except as provided for in Section 4.25
    for 100-day Nursing Facility coverage
  • Cosmetic Procedures or Treatment
  • Cosmetic procedures or treatment are not
    covered, except that the following services are
    not considered cosmetic and therefore must be
    covered services necessary as the result of
    injury, illness or disease or for the treatment
    or repair of birth anomalies
  • Experimental or Investigative Services
  • Federal Institutions
  • All claims arising from services provided by
    institutions operated or owned by the federal
    government, unless the services are approved by
    the MCO

25
Services Not Covered by SNBC
  • State and Other Institutions
  • All claims arising from services provided by a
    State regional treatment center, a state-owned
    long term care facility, or an institution for
    mental disease (IMD), unless the services are
    approved by the MCO, the services are covered by
    Medicare, or unless the services are
    court-ordered pursuant to Minnesota Statutes,
    62Q.535, 253B.045, subd. 6, or 260C.201, subd.
    1.
  • Fertility Drugs and Procedures
  • Fertility drugs are not covered when
    specifically used to enhance fertility. The
    following procedures also are not covered in
    vitro fertilization, artificial insemination, and
    reversal of a voluntary sterilization.

26
Services Not Covered by SNBC
  • Sex Reassignment Surgery
  • Sex Reassignment Surgery is not covered.
  • IEP and IFSP Services
  • Medically Necessary Medical Assistance services
    that would otherwise be covered by this Contract
    that are provided by school districts or their
    contractors and are either (A) identified in an
    Enrollees Individual Education Plan (IEP) or (B)
    the Individual Family Service Plan (IFSP).

27
Services Not Covered by SNBC
  • Incidental Services. Incidental services,
    including but not limited to, rental of
    television, telephone, barber and beauty
    services, and guest services that are not
    Medically Necessary
  • Childrens Residential Mental Health Treatment
    Facility Services (Rule 5). Enrollees needing
    childrens residential mental health treatment
    facility services may obtain them from the Local
    Agency. The MCO shall be responsible for other
    medical costs while the Child resides in the
    childrens residential mental health treatment
    facility and remains in managed care.

28
Services Not Covered by SNBC
  • Out of Country Care
  • Emergency Care or other health care services
    received from providers located outside the
    United States and Canada. For the purpose of
    this section, United States includes the 50
    states, the District of Columbia, the
    Commonwealth of Puerto Rico, the Virgin Islands,
    Guam, American Samoa, and the Northern Mariana
    Islands.
  • Additional Exclusions
  • All other exclusions set forth in Minnesota
    Statutes, 256B.0625 and 256B.69 and Minnesota
    Rules, Parts 9505.0170 through 9505.0475, and
    Parts 9500.1450 through 9500.1464.

29
Prescriptions
  • Prescriptions.
  • Members with Medicare coverage will have all Part
    D eligible drugs paid for by the Medicare Part D
    benefit using the PrimeWest Part D formulary as a
    reference. Medications excluded from Part D
    (i.e. vitamins, OTCs, benzodiazepines,
    barbiturates) are covered under the Medicaid wrap
    around benefit. Members without Medicare
    coverage have full access to the Medicaid
    formulary similar to our other MA, GA, or MN Care
    Members. All formularies are listed on our web
    site.

30
Claim Submission
  • Members ID number for Part A, B, or D is their
    PrimeWest Health ID number
  • Claims for Covered Services rendered to SNBC
    members should be submitted to and received by
    PrimeWest Health no later than 180 days from the
    date of service.
  • Paper claims should be sent to PrimeWest Health
    at
  • P.O. Box 369
  • Alexandria, MN 56308
  • All paper claims should be sent to this address
    after 1/1/2008

31
Durable Medical Equipment (DME) Supplies
  • When ordering DME supplies for your residents,
    the vendor you ordered the supplies from may not
    be contracted with PrimeWest Health
  • To assure that this vendor will be reimbursed for
    these supplies, we encourage you to call Medical
    Administration for a Service Authorization for
    the item

32
Durable Medical Equipment (cont.)
  • Medical Administration at (866) 431-0803
  • Needs to be done each time an item/supply is
    ordered for the SNBC member
  • If the vendor is interested in contracting with
    PrimeWest Health please contact
  • Amanda Trinka, Credentialing/Network Specialist
    (320) 335-5245

33
Bad Debt Reconciliation
  • PrimeWest Health is not part of this process
  • We are not a fiscal intermediary
  • We are a public program that receives funds from
    the State and CMS to cover only the medical
    services of our members
  • We do not receive extra funds from CMS to
    reimburse this
  • Concerns regarding this need to be addressed
    directly with CMS

34
Other helpful information
  • PrimeWest Health website www.primewest.org -
    check it frequently for timely update
  • Administrative manual
  • PrimePointers
  • Pharmacy Link
  • Provider Insite
  • Credentialing
  • This presentation
  • Much more!

35
Contact Numbers
  • Provider Services
  • (866) 431-0802
  • Medical Admin-Service Auth
  • (866) 431-0803
  • Member Services
  • (866) 431-0801
  • SNBC Care Management
  • (888) 588-4420

36
Questions
Disability Linkage Line 1-866-333-2466
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