Johns Hopkins Advantage MD 2021 HMO and PPO Plans - Presented by: Johns Hopkins HealthCare Provider Relations Department
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Johns Hopkins Advantage MD 2021 HMO and PPO Plans Presented by: Johns Hopkins HealthCare Provider Relations Department 3/2/2021
Advantage MD Product Overview HMO,PPO, PPO Plus, PPO Premier & Group
Agenda
• Our Mission
• Advantage MD Overview
• Advantage MD - Service Area, Medical Benefit Overview
• Product Differentiation
• New for 2021
• Advantage MD Product Overview – PPO, PPO Plus, PPO Premier,
PPO Group
• Advantage MD Product Overview – HMO
• Advantage MD Dental and Vision Coverage
• Telemedicine
• Requirements, Processes and Important Information for all
Advantage MD Plans
• Health Care Performance Measures
• JHHC Website and Contact Info
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. • Additional details can be found in the Advantage MD Provider Manual at www.jhhc.com
Johns Hopkins Advantage MD Service Area
Service 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 County
NOTE: Advantage MD Group is available
in Delaware, District of Columbia,
Florida, Georgia, Maryland, North Carolina,
Pennsylvania, South Carolina and Virginia
Medical Benefit Overview
• Our 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, worldwide
emergency and urgent coverage.
• Our HMO, PPO and PPO Plus plans have dental and fitness
benefits.
• Our HMO plan offers post-discharge meal services to
members who have been discharged from an inpatient or
skilled nursing facility (SNF) stay, coordinated by Johns
Hopkins Health Services.Differences Between
HMO & PPO Plans
HMO
• Primary care physician (PCP) 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
HMO & PPO Plans
PPO, PPO Plus, PPO Premier & Group
• Flexibility in choosing physicians and specialists
• Monthly premium higher than HMO plans
• No referrals needed, but higher out-of-pocket costs than
HMOs
• Coverage outside of the plan network (cost sharing may be
higher)
• Robust supplemental benefits with premium productsAdvantage MD PPO 2021
Group Benefits
The 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 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 allowanceAdvantage MD PPO Member ID
Cards
Front Back
Note: The circled section will vary depending on selected plan.Advantage MD HMO Member ID Cards
Front BackJohns Hopkins Advantage MD Product Overview and New for 2021
New for 2021: End Stage Renal Disease (ESRD)
• Effective Jan. 1, 2021, ESRD individuals will have the ability to enroll in Advantage MD plans, placing
greater emphasis on managing this high-cost population
• Advantage MD is establishing an ESRD Model of Care and evaluating the current network of providers
(i.e. Fresenius, DaVita, etc.) to ensure cost effective services are provided
• To assist with expected added costs and network access issues, CMS proposed:
– Original Medicare will cover kidney acquisition costs for Advantage MD beneficiaries
– Potential changes to network adequacy requirements in 2022 to promote greater use of in-home
dialysis
• Removing outpatient dialysis from list of facility types subject to time and distance standards
• Allowing plans to attest to providing dialysis services in lieu of requiring plans to meet time
and distance standards
• Allowing exception to time and distance standards if a plan is instead covering home dialysis
• Customizing time and distance standards for all dialysis facilitiesNew for 2021: Acupuncture Benefit Changes Original Medicare • Covers chronic lower back pain • Up to 12 visits within 90 days under the following circumstances: • Lasting 12 weeks or longer • Nonspecific, has no identifiable cause • Not associated with surgery • Not associated with pregnancy • Cost share information: • HMO – 20% co-insurance • PPO – 20% co-insurance IN, 30% co-insurance OON Advantage MD Supplemental Benefit • No restrictions on type of injury or illness (excludes those covered by Original Medicare) • PPO Plus - $200 allowance • PPO Premier - $300 allowance • PPO Group (EGWP) - $300 allowance
New for 2021: Home Infusion Therapy (HIT) Changes
HIT is the administration of drugs or biologicals to an individual at home, outside of the hospital or clinic
setting.
a
Cost share information:
o HMO – 20%
o PPO Basic – 20% IN, 50% OON
o PPO Plus – 20% IN, 30% OON
o PPO Premier – 20% IN, 20% OON
o PPO EGWP (Group) – 20% IN, 45% OON
Source: CMS – Medicare Learning NetworkNew for 2021: Change to Inpatient Cost-Sharing – From Benefit Period to Per Stay, Per Admission • Member is responsible for copays each stay • Benefit period will apply to SNF only • Change applies to all plans • Lifetime reserve days still apply
New in 2021: Expanded Telehealth Services
Pre-COVID COVID
• Rural settings approved by CMS • Temporarily expanded coverage to offer
access from more places (including member’s
• For ESRD, renal dialysis facilities and at home home) and more communication tools
(including smart phones)
• Diagnosis, evaluation or treatment of
symptoms of an acute stroke regardless of • Virtual check-ins from anywhere for
location treatment of COVID
• Substance use disorder or a co-occurring • Common office visits
mental health disorder
• Mental health counseling
• Virtual check-ins and E-visits via:
▫ Phone • Preventive health screenings
▫ Audio/visit
▫ Secure text messages • Audio only visits allowed
▫ Email
▫ Use of a patient portalNew in 2021: Expanded Telehealth Services Eliminating geographical barriers Removing rural only requirement Expanding the location of care (e.g. includes member’s home) Partnering with national telehealth vendor to facilitate nationwide access to care Service 2020 2021 Physician Services (PCP, Specialist) * X X Individual/Group Sessions Mental Health Services X X Individual*/Group Sessions Psychiatric Services X X Individual/Group Sessions Outpatient Substance Abuse X X Other Health Care Professional X X 24/7 Urgently Needed Services * X Home Health Services X Note: * Indicates services that can be provided by telehealth vendor
New in 2021: Approved Telehealth Clinicians and Providers
Expanding the types of providers that can furnish telehealth services
Providers 2020 2021
Physician (PCP, Specialist) X X
Nurse Practitioner X X
Physician Assistant X X
Certified Nurse Midwives X X
Certified Nurse Anesthetists X X
Licensed Clinical Social Workers X X
Clinical Psychologists X X
Registered Dietitians or Nutrition Professionals X X
Registered Home Health Agencies X
Clinical Care Coordinator Management Professionals X
Source: CMS June 2020Enhancements for 2021: Telemedicine Beginning with the 2021 benefit year, Advantage MD members will have a new option for accessing care via telemedicine. Johns Hopkins OnDemand Virtual Care (powered by Teladoc) will give members access to an urgent care medical visit 24/7 from the comfort of their home, or anywhere they may travel in the United States. JHHC encourages members to utilize their primary care provider when possible, but Johns Hopkins OnDemand Virtual Care will be an alternative option to quickly access needed care.
Enhancements for 2021:
Telemedicine
The Johns Hopkins OnDemand Virtual Care service is as an
online telemedicine platform for both adult and pediatric
patients. It is available to members through mobile app,
computer or tablet.
• The service is intended for minor care concerns that
don’t require lab work, such as colds, rashes and
pinkeye.
• The service is not for medical emergencies. If a patient is
experiencing a medical emergency, they should call 911
or go to the nearest emergency room.Advantage MD Changes 2021
Product Design
HMO PPO PPO Plus PPO Premier
Changes
Premium $20, $40 $91 $121 $351
Maximum Out-of-
$7,550 $7,550/$11,300 $7,550/$11,300 $7,550/$11,300
Pocket (MOOP)
Ambulatory
$225 $225 $225
Surgery Center
Outpatient
substance abuse $20
therapy visit
Inpatient Hospital
$310 days 1 to 5 $310 days 1 to 6 $310 days 1 to 6 $200 IN/OON
(Mental Health)
Inpatient Hospital
OON 30%
Coverage
Health Education
Discontinued as a benefit during the transition to the new service.
(DECIDE/act 2)
Physical Therapy OON 50%
Medicare Part B
OON 50%
Drugs
Home Health Care OON 50%Advantage MD Changes 2021
Product Design Changes HMO PPO PPO Plus PPO Premier
Rehabilitation Services –
OON 50%
Cardiac
Rehabilitation Services –
OON 50%
Occupational
Physical/SpeechTherapy OON 50%
Preventive Care OON 30%
Emergency Care $90
Diagnostic Services / Lab / Tests
OON 30% $0 (Services and Lab)
/Radiology
Therapeutic Radiology OON 30%
Hearing OON 30%
Dental – Medicare covered
OON 30%
dental services
Dental – Oral Exam, Preventive
OON 30%
Cleanings and X-ray(s)
Acupuncture (Medicare
20% IN 20% IN/30% OON 20% IN/30% OON 20% IN/30% OON
Covered Benefit)
Home Infusion Therapy 20% IN 20%IN/50% OON 20%IN/30% OON 20%IN/20% OONAdvantage MD Product Overview
HMO PPO PPO Plus PPO Premier* PPO Group
Premium $20 and $40 $91 $121 $351 $175
MOOP $7,550 $7,550 / $11,300 $7,550 / $11,300 $7,550 / $11,300 $3,000 / $10,000
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
Outpatient $300 (Outpatient) $300 (Outpatient) $300 (Outpatient) $100 (Outpatient) $250 (Outpatient)
Hospital $225 (ASC) $225 (ASC) $225 (ASC) $50 (ASC) $200 (ASC)
ER $90 $90 $90 $90 $75
Urgent Care $40 $40 $40 $20 $40
Supplementa Podiatry Podiatry Podiatry Podiatry Podiatry
l Benefits Preventive Dental Preventive Dental Preventive Dental Chiropractic Chiropractic
Hearing Hearing Hearing Acupuncture Acupuncture
Vision Vision Vision Full Dental Full Dental
Post-Discharge Meals Expanded Telehealth Chiropractic Hearing Hearing
Expanded Telehealth Acupuncture Vision Vision
Expanded Telehealth Silver&Fit Silver&Fit
Visitor / Traveler Visitor / Traveler
Expanded Telehealth Expanded Telehealth
RX $0/$10/$47/$100/33% $7/$15/$47/$100/26 $4/$12/$47/$100/26 $3/$10/$40/$90/33 $4/$12/$42/$92/33%
No Deductible % % %
$350 Deductible $350 Deductible No Deductible
Optional Comp Dental / Fitness Comp Dental / Fitness Comp Dental
Rider $30 $30 $28
No Dental Waiting No Dental Waiting No Dental Waiting
Period Period PeriodAdvantage MD Product Differentiation
HMO PPO PPO Plus PPO Premier
•Premium $20 (Baltimore City •Premium $91 •Premium $121 •Premium $351
Only) and $40 •MOOP $7,550 IN /$11,300 OON •MOOP $7,550 IN /$11,300 OON •MOOP $7,550 IN /$11,300 OON
•MOOP $7,550 IN /$11,300 OON
•Residents of Anne Arundel, •Residents of Anne Arundel, •Residents of Montgomery
•Residents of Anne Arundel, Baltimore, Baltimore City, Baltimore, Baltimore City, County only
Baltimore, Baltimore City, Calvert, Carroll, Frederick , Calvert, Carroll, Frederick ,
Calvert, Carroll, Frederick , Howard, Somerset, Washington, Howard, Somerset, Washington,
Howard, Montgomery, Wicomico, Worcester Wicomico, Worcester
Somerset, Washington,
Wicomico, Worcester •IN lower than OON cost-sharing •IN lower than OON cost-sharing
•IN and OON cost-sharing the
•Reduced some copayments to •Reduced some copayments to same
•Low IN cost-sharing to reduce meet FFS schedule meet FFS schedule
barriers to care •No to low cost-sharing on all
benefits
•Reduced some copayments to
meet FFS schedule
•Supplemental Benefits •Supplemental Benefits
•Preventive Dental •Acupuncture •Supplemental Benefits
•Vision Exam •Chiropractic •Acupuncture
•Supplemental Benefits
•Hearing Exam and Aids •Preventive Dental •Chiropractic
•Preventive Dental
•Expanded Telehealth •Vision Exam and Eyewear •Full Preventive and
•Vision Exam and Eyewear
•Hearing Exam and Aids Comprehensive Dental
•Hearing Exam and Aids
•Silver&Fit •Enhanced Vision
•Post-Discharge Meals
•Worldwide ER and UC •Enhanced Hearing
•Expanded Telehealth
•Expanded Telehealth •Silver&Fit
•Worldwide ER and UC
•Visitor / Traveler Benefit
•Expanded TelehealthEnhancements for 2021: eviCore Johns Hopkins HealthCare LLC (JHHC) has partnered with eviCore healthcare to provide patients with access to high quality, medically appropriate care that is consistent with evidence-based treatment guidelines. • Beginning January 1, 2021, providers in the Johns Hopkins Advantage MD and Priority Partners networks will be required to use the JHHC-eviCore system to obtain prior authorization for High Tech Radiology and Cardiology Advanced Imaging services. • Other lines of business may be required to use the JHHC-eviCore preauthorization system process in 2021. • Additional services requiring preauthorization through the JHHC- eviCore system will be added quarterly in 2021.
Enhancements for 2021: eviCore • Providers will be able to access the JHHC-eviCore provider portal in HealthLINK 24/7 for prior authorization for High Tech Radiology and Cardiology Advanced Imagine. • Providers who already have an eviCore account can also access the JHHC-eviCore portal through their established account.
Enhancements for 2021: Site of Service • The JHHC Medical Policy Advisory Committee (MPAC) has approved changes and additions to the Johns Hopkins HealthCare LLC (JHHC) Site-of-Service Medical Policies for Priority Partners and Johns Hopkins US Family Health Plan (USFHP). JHHC is implementing this policy using a staged approach, targeting specific procedures with each phase. Effective date for changes: • Priority Partners: Dec. 1, 2020 • USFHP: Jan. 1, 2021.
Enhancements for 2021: Site of Service As of the dates mentioned in the previous slide, JHHC will require preauthorization to include a site-of-service review for certain Musculoskeletal and Gastrointestinal procedures when performed in an outpatient hospital setting. This requirement affects Priority Partners and USFHP members of all ages. These Musculoskeletal and Gastrointestinal procedures are in addition to the services already requiring site of service review and preauthorization when performed in an outpatient setting.
Enhancements for 2021: Site of Service The site-of-service policy specifies that members receive certain outpatient diagnostic or surgical procedures in an ambulatory surgery center (ASC) when clinically appropriate. A surgical procedure performed in a hospital setting will require preauthorization and must meet medical necessity criteria for the hospital setting. The outpatient hospital setting, classified by Place of Service 22, is also known as "regulated space" within the state of Maryland. Some procedures may also require medical necessity review using clinical review criteria specific to the procedure in ANY site of service (outpatient hospital setting, ambulatory surgery center or office). Please refer to Updates to CMS23.05 Site of Service – Outpatient Surgical Procedures for a summary of the criteria changes pertaining to the site-of-service medical policy, as well as a detailed listing of affected CPT codes.
Vision and Dental Provider Education 2021 Benefits Overview
Vision PPO Coverage Overview 2021
• Advantage MD PPO covers additional • You may electronically submit claims
vision benefits through Superior Vision. via the Superior website
• The in-network benefit is covered (www.superiorvision.com) or in the
only if the member visits a Superior ASC X12N 837 HIPAA standard
contracted provider. format, either directly to the Superior
• Providers who do not participate with or through its clearinghouse.You may
Superior can still see Advantage MD also utilize the CMS 1500 form for
PPO members when there is an out- submitting paper claims to Superior or
of-network benefit under the PPO mail them to:
products.
Claims Department
Superior Vision
939 Elkridge Landing Rd, Ste. 200
Linthicum, MD 21090
Please refer to the “Claim Submission Requirements”
section of the Provider Manual for further details on
submitting claims, as well as the Superior’s
reimbursement policies.VISION HMO and PPO
Coverage Overview (2021)
Service Advantage MD Advantage MD Advantage MD Advantage MD Advantage MD
HMO PPO PPO Plus PPO Premier Group
Routine Eye Exam IN: $0 member cost IN: $0 member cost IN: $0 member cost IN: $0 member cost IN: $0 member cost
OON: No coverage OON: 50% member OON: 45% member OON: $0 member OON: 45% member
coinsurance coinsurance cost coinsurance
Eyewear $150 towards Not Covered $150 towards $300 towards $300 towards
eyewear or contacts eyewear or contacts eyewear or contacts eyewear or contacts
lenses every two lenses every two lenses every two lenses every two
years from any years from any years from any years from any
source source source source
The routine eye exam and eyewear benefit is processed through Superior Vision.
For questions related to the benefits and claims process, please contact Superior at
866-819-4298.Dental HMO Coverage Overview 2021 • Advantage MD covers additional dental • For questions related to the benefits through DentaQuest. benefits, prior authorizations, • The in-network benefit is covered only if and claims, please contact the member visits a DentaQuest DentaQuest at 800-471-7140. contracted provider . • There is an optional supplemental package available to members in the Advantage MD HMO plan that offers comprehensive dental coverage (additional monthly premium) in- and out-of-network.
DENTAL Coverage Overview 2021
Service Advantage MD HMO Advantage MD PPO Advantage MD PPO Plus Advantage MD PPO Advantage MD Group
Premier
Preventive Dental (In-network IN: Cleaning (1 per year) $15 IN: Cleaning (1 per year) $15 IN: Cleaning (2 per year) $10 IN: Cleaning (2 per year) $0 IN: Cleaning (1 per year) $15
covered through DentaQuest copay copay copay copay copay
network) Dental X-Ray (frequency Dental X-Ray (frequency Dental X-Ray (frequency Dental X-Ray (frequency Dental X-Ray (frequency
depends on type of services) depends on type of services) depends on type of services) depends on type of services) depends on type of services)
$25 copay $25 copay $20 copay $0 copay $25 copay
Oral Exam (frequency depends Oral Exam (frequency depends Oral Exam (frequency depends Oral Exam (frequency depends Oral Exam (frequency depends
on type of services) $15 copay on type of services) $15 copay on type of services) $10 copay on type of services) $0 copay on type of services) $25 copay
Fluoride (2 per year) $0 copay
OON: No Coverage OON: 50% coinsurance OON: 45% coinsurance OON: $30 coinsurance OON: 45% coinsurance
Comprehensive Dental (In- Additional $30 a month Additional $30 a month Additional $30 a month Included at no extra monthly Included at no extra monthly
network covered through premium premium premium premium premium
DentaQuest network)
IN: $50 to $400 copay IN: $50 to $400 copay IN: $50 to $400 copay IN and OON: 0% to 50% IN: $50 to $400 copay
OON: 50% to 70% coinsurance OON: 50% to 70% coinsurance OON: 50% to 70% coinsurance OON: 50% to 70% coinsurance
Same cost IN or OON
Covers extractions, root Covers extractions, root Covers extractions, root Covers extractions, root
canals, crowns, oral surgery, canals, crowns, oral surgery, canals, crowns, oral surgery, Covers extractions, root canals, crowns, oral surgery,
dentures, and more dentures, and more dentures, and more canals, crowns, oral surgery, dentures, and more
dentures, palliative treatment,
Maximum plan coverage $1,200 Maximum plan coverage $1,200 Maximum plan coverage $1,200 tissue conditioning, protective Maximum plan coverage $1,200
annually annually annually restoration, consultations, and annually
more
Maximum plan coverage $1,500
annually
For questions related to the benefits, prior authorizations, and claims,
please contact DentaQuest at 800-471-7140.Johns Hopkins Advantage MD Requirements, Processes and Important Information for All Plans
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. • Primary care physicians (PCPs) should complete referrals in HealthLINK 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.
HMO Referral Process
HealthLINK Submitting a Referral
• Log into HealthLINK
• From the office management
menu select
Referrals/Authorization
• Select the Specialist tab
• Enter the patients information
and provider information
*(all required fields indicated by a
box)Maryland Uniform Referral Form
The Maryland Uniform
Referral Form can be faxed
to 410-424-4036.Prior Authorization
• Prior Authorization requirements apply uniformly to all
• Johns Hopkins Advantage MD products.
• Submit a request for Prior Authorization prior to rendering
services by calling:
– Medical Management at 844-560-2856
– Behavioral Health at 844-340-2217
• Submit clinical notes and treatment plan by fax:
– Medical Management at 855-704-5296
– Behavioral Health at 844-363-6772Diabetic Supplies • Advantage MD members will have 0% coinsurance for diabetic supplies (excluding insulin pumps) • Diabetic supplies include: – Blood sugar (glucose) test strips – Blood sugar testing monitors – Lancet devices and lancets – Glucose control solutions
Diabetic Supplies (cont.)
• Advantage MD members will have 0%
coinsurance for diabetic supplies (excluding
insulin pumps)
• In-network providers for diabetic supplies:
– Better Living Now, Inc.
• 800-854-5729
– Participating network pharmacies
• For a 2021 listing of participating pharmacies, please
visit www.hopkinsmedicare.comPrescription Drug Benefit (Part D)
Formulary Overview
• Advantage MD offers a comprehensive prescription drug
benefit with coverage in all therapeutic classes, as indicated
by the Medicare Part D rules and regulations.
– Drugs excluded by Medicare: drugs used for cosmetic
purposes, erectile dysfunction, cough and cold, vitamins
(except prenatal vitamins) and over-the-counter
medications.
• The lists of formulary drugs, coverage limit requirements,
and prior authorization forms are available on the plan’s
website www.hopkinsmedicare.comPrescription Drug Benefit (Part D)
Formulary Overview
• Drugs must be used for a “medically accepted indication,”
either:
• Approved by the FDA for the diagnosis or condition
for which it is being prescribed OR
• Supported by certain Medicare-recognized references
NOTE: For more details on prescription drug benefits, please see the
pharmacy section of the Advantage MD website.Prescription Drug Benefit – Mail Order • CVS/caremark, our mail order pharmacy, sends a 3-month supply of maintenance medications in one fill, making it easier for the patient by only having to fill four times a year. • In addition, a 3-month supply of maintenance medication is available through CVS/caremark mail order at a reduced copay. • This means your patient can fill a 90-day supply for only 2 times the retail copay—saving them an equivalent of four retail copays per year. • Doctors and staff can contact CVS/caremark at 877-293-5325 (option 2) for PPO or 877-293-4998 (option 2) for HMO, 24 hours a day, 7 days a week.
Prescription Drug Benefit – Mail Order Three easy ways for your Advantage MD members to register for mail order: • Online. Members can information to register on caremark.com. • On smartphone or tablet. Download the CVS/caremark mobile app from the App Store or Google play. • By phone. Members can call Customer Service (TTY: 711) number on the back of their Member ID card and select option 2. Our Customer Service will get them started with a personalized registration email or text. • The mail order form is available at https://www.hopkinsmedicare.com/wp-content/uploads/member- mail-service-order-form.pdf.
Added Advantages for
Advantage MD Providers
• 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.Care Management • Johns Hopkins Advantage MD 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.
Care Management
• To contact Care Management Please include:
please call: 800-557-6916. • Member Name
• To submit a referral to Care • Date of birth
Management, please send an email
to caremanagement@jhhc.com. • ID number
• Diagnosis
• Patient needs
• Responses will be
provided within two
business days.The Claims Process
Providers are encouraged to submit claims electronically:
• Medicare Advantage Payer ID # 66003
• For electronic remittance advices (835) and
electronic payments:
– Enroll online at changehealthcare.com
OR
– Download the enrollment form at
changehealthcare.com/epayment/enrollment and fax
completed form to 615-238-9615
• Timely filing – 180 days from date of service
• Clean claims processed within 30 daysThe Claims Process (cont.) • Mailing address for medical claims: -Johns Hopkins Advantage MD P.O. Box 3537, Scranton, PA 18505 For details on Medicare Secondary Payer & COB, as well as the Provider Payment Dispute Process, please see the Advantage MD Provider Manual and use the Participating Provider Post-Service Payment Dispute Form.
Johns Hopkins Advantage MD Healthcare Performance Measures
Center for Medicare & Medicaid Services (CMS) Five-Star Quality Rating System • The Center for Medicare & Medicaid Services (CMS) developed the Five-Star Quality Rating System to evaluate the quality and performance of Medicare Advantage (MA) plans and Prescription Drug Plans (PDPs). The Star Ratings measures change annually and include measures from Healthcare Effectiveness Data and Information Set (HEDIS®), Consumer Assessment of Healthcare Providers and Systems (CAHPS®), and Health Outcomes Survey (HOS). • As health plans and providers collaborate to give our members the best quality care, we can all look to the plan’s Star Ratings to see how well we are achieving this goal. The annually-updated Quality Measures Tip Sheet can guide all of our efforts to improve.
Healthcare Effectiveness Data and
Information Set (HEDIS®)
• HEDIS® is a widely used set of health care performance
measures that is developed and maintained by the National
Committee for Quality Assurance (NCQA). Examples of
HEDIS® measures are Comprehensive Diabetes Care, Breast
Cancer Screening, Controlling Blood Pressure, and Colorectal
Cancer Screening.
• For detailed information about HEDIS®, please go to the
NCQA website or view our Quality Measures Tip Sheet.Consumer Assessment of Healthcare
Providers (CAHPS®)
• CAHPS® is a member satisfaction survey in which the objective is to
capture information about consumer-reported experiences with
healthcare. The focus of the survey is to measure how well plans are
meeting member expectations, determine which areas of service have
the greatest effect on overall member satisfaction, and identify areas of
opportunity for improvement.
• Topics included in the survey are Getting Needed Care, Getting Care
Quickly, How Well Doctors Communicate, Customer Service,
Coordination of Care, Getting Needed Prescription Drugs, and the
Ratings of: Health Care, Personal Doctor, Specialist, and Health/Drug
Plan. The survey is conducted annually according to CMS protocol by a
CMS certified vendor.Health Outcomes Survey (HOS) • HOS is a member survey that assesses the physical and mental health of a patient over a two-year period. Topics included in the survey are: improving or maintaining physical and mental health, reducing the risk of falling, and improving bladder control. • Health Literacy • There are many reasons health plan members, patients and caregivers may struggle to understand health information. Johns Hopkins HealthCare (JHHC) has structured its goals to meet their mission to provide quality health care, develop new methods to improve the health of its patient community and set standards of excellence in patient care. By having an engaged patient and developing a better means of communication through health literacy initiatives, healthcare providers can treat their patients and achieve optimal health outcomes and favorable HEDIS® and CAHPS® results.
Johns Hopkins Advantage MD
For more information on Advantage MD’s
Healthcare Performance Measures, please
contact your designated Provider
Engagement Liaison at 888-895-4998.Recap: Important Information • PPO members can go in-network or out-of-network. • HMO members can only go to in-network providers. • The formularies for the PPO and HMO products are not the same. Please review the applicable formulary prior to prescribing. • Advantage MD members have a 0% coinsurance for in- network diabetic supplies. • Members can save money on medications by getting a long-term supply at either a retail pharmacy or through mail order. • Johns Hopkins Advantage MD offers Medication Therapy Management (MTM) services at no cost to members through CVS/caremark. • Some services and supplies will require prior authorization.
Johns Hopkins HealthCare Website
Provider website includes:
– Provider manuals
– Forms
– HealthLINK@Hopkins portal access
– Online provider directory
• Find participating providers on
http://www.hopkinsmedicare.com/
– Policies & procedures
– Compliance guidance
– Prior authorization updatesHealthLINK@Hopkins
Registered providers are able to access the
following information using HealthLINK:
• Eligibility
• Claims
• Authorizations & referrals
• PCP member rosters
• Care coordination reports
• Advantage MD HMO – referral submission
NOTE: Quick Reference Guide on HealthLINK@Hopkins at www.jhhc.com.Provider Resource: JPAL The Johns Hopkins Prior Authorization Lookup tool (JPAL) is a provider resource to check and verify preauthorization requirements for outpatient services and procedures. Located in the HealthLINK portal, JPAL offers a user- friendly way for providers to look up preauthorization requirements. • Providers can simply click on the JPAL link in HealthLINK under the “Administration” tab to access this tool.
JPAL (Continued) JPAL features: • Search by specific procedure code or procedure description. • Confirm the authorization requirements of all procedures before delivery of service. • Search results are organized by procedure code, modifiers, procedure description, and individual lines of business. • Clicking on the procedure code link or on any line of business link brings up specific details, such as the rules pertaining to preauthorization for each line of business and access to the applicable medical policy document. NOTE: JPAL is a resource to look up preauthorization requirements only. Authorization requests cannot be submitted through JPAL. Please follow JHHC’s current policies and procedures to request prior authorization, which are available on the JHHC website.
JPAL (Continued) JPAL tips: • Please remember to confirm the authorization requirements of all outpatient procedures via JPAL before delivery of service. • If preauthorization status is unclear, submit an authorization request to JHHC Utilization Management. • Authorizations are not a guarantee of payment. • Instructions on how to use the JPAL tool are available on the JHHC Provider Education webpage (scroll down to the “HealthLINK Job Aids” section) and within HealthLINK.
Updating Your Information You are required to notify JHHC’s Provider Relations department of any demographic changes to your practice. Provider Relations (For demographic changes, contract status and fee schedule questions): Email: ProviderChanges@jhhc.com W-9 requests should be directed to: W9requests@jhhc.com CMS requires the Health Plan to validate provider information on a quarterly basis.
Fraud, Waste and Abuse • JHHC’s Payment Integrity department wants to inform you of new information processes for reporting; Fraud Waste Abuse. • Complaints of possible Fraud, Waste, and Abuse can be reported to the Johns Hopkins HealthCare Payment Integrity Department - Fraud Waste and Abuse. • By Mail: Payment Integrity Department, Attention: FWA, 7231 Parkway Drive, Suite 100, Hanover, MD 21076 • Phone: 410-424-4971 • Fax: 410-424-2708 • Email: FWA@jhhc.com
Network Access Standards • JHCC complies with state regulations designed to help make sure our plans and providers can give members access to care in a timely manner. These state regulations require us to ensure members are offered appointments within the following time frames Service Appointment Wait time (not more than): PCP Routine/Preventive Care Thirty (30) calendar days PCP Non-Urgent (Symptomatic) Seven (7) calendar days PCP Urgent Care Immediate/Same Day PCP Emergency Services Immediate/Same Day Specialist Routine Thirty (30) calendar days Specialist Non-Urgent (Symptomatic) Seven (7) calendar days Office Wait Time Thirty (30) minutes Service Appointment Wait time (not more than): Behavioral Health Routine Initial Ten (10) business days Behavioral Health Routine Follow-up Thirty (30) calendar days Behavioral Health Urgent Forty-eight (48) hours Behavioral Health Emergency Six (6) hours
Important Contact Information
• To report concerns related to privacy, and/or non-
compliance please contact the Medicare Compliance
Department at:
• Local: 410-762-1575
• Toll Free: 844-697-4071
• Fax: 410-762-1502
• Email: MedicareCompliance@jhhc.com
• Or the 24/7 Compliance Hotline at 1-844-SPEAK2US
(1-844-773-2528)Important Contact Information • Provider Website: www.jhhc.com • Advantage MD Website: www.hopkinsmedicare.com • CMS: www.cms.gov
Important Contact Information • Provider Relations Department: 888-895-4998 (provider education, credentialing & contract inquiries) • Customer Service, PPO: 877-293-5325 (benefits & claims inquiries) • Customer Service, HMO: 877-293-4998 (benefits & claims inquiries) • Care Management Referrals: caremanagement@jhhc.com or 800-557-6916 *For additional information, please reference the JH Advantage MD Provider Manual.
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THANK YOU
For participating with
Advantage MD.
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