sr hmos scripps access training and development. what is a sr hmo? n a medicare contracted hmo n...
TRANSCRIPT
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SR HMOs
SCRIPPS
ACCESS TRAINING AND DEVELOPMENT
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WHAT IS A SR HMO?
A Medicare contracted HMO
Uses approved network of providers
PCP directs care
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WHO IS ELIGIBLE?
Must be enrolled in Medicare Parts A & B
Continue to pay Part B premiums
Not have ESRD
Not be receiving hospice care
Must live in plans’ service area
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WHY CHOOSE A Sr HMO?
Same Medicare benefits Lower OOP expenses Most offer additional benefits:
Preventive care Prescription drugs Dental care Eyeglasses Hearing aids
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AUTHORIZATIONS
PCP sends authorization request to UR for review
Required for: Inpatient visits Some outpatient services Specialists
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OUT OF NETWORK SERVICES
No POS option Need auth from PCP No auth, patient responsible for charges
POS option (tier 3) No auth required Higher OOP for out of network
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FORMS Still considered a Medicare beneficiary
An Important Message From Medicare About Your Rights
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ENROLLING & DISENROLLING
Between Nov & Dec Medicare beneficiaries can: Enroll in a Sr HMO Switch Sr HMOs Change medical groups Switch back to Medicare New coverage begins Jan 1st
Can also switch between Jan & March (but can’t add or change to a plan with prescription drug coverage unless they already have Medicare drug coverage)
Cannot use Sr HMO & M/C at same time
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VERIFYING ELIGIBILITY
Verify with each visit
Call insurance to verify Eligibility Benefits Authorization requirements
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WHAT IS NEEDED FOR A CLEAN CLAIM
Name of medical group Group number, if available Policy number Effective date Correct billing address Authorization number, if needed
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MCARE HIC# FIELD An extra step is required
On the Misc screen, in the Mcare HIC# field, enter the patient’s Medicare
claim #
Medicare will pay us additional money
To keep the registration process consistent, this extra step is a requirement at all sites.
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SUMMARY
Must be enrolled in Medicare Parts A & B
PCP directs care
Authorizations are required
Less OOP expenses for the patient
Verify eligibility with each visit
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?QUESTIONS?