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HomeMy WebLinkAboutC2011-447 - 11/15/2011 - NANew Case Document City of Corpus Christi (Effective Date 01/01/2012) 2011 -447 11/15/11 Humana edicare 0.7 Page 1 of 19 INDEXED $; - ire' °+`` a� _✓ 'p . - r' S.,y� ^ "airy A C `; _ ..7f r >� �`'- �'{ �" . i� - - r ,..r. ✓ - n .x , F NCD completed bL GigRottl talcs Account f?epresenta.tNe: Warn Account Inatallatipn Manager Dougl 11 f� Authorizes Humana to draft the Evidence of Coverage based an the NCD; acknoMedges that it is the Employer's responsibility to review and verify that the NCD and all document drafts are correct and if not correct to make necessary corrections in a timely manner; and select one of the following' This authorizes Humana to build product, plan benefits and process claims based upon this final approved NCD- This authorizes Humana to postpone product, plan benefit builds and postpone claim processing until the docurent is finalized and sign off has been received. This authorization and agreement is made and entered into by and Humana, effective 0110912012. Between the time successor drafts of the NCD are prepared and exchanged, any changes to the documents describing the Plan for these purposes must be in writing, state the effective date, and must be communicated to and accepted by l unnana claims administration in a timely fashion. ❑ New Client Effective date of flan Renewing Plan for Existing Client Effective date of Plan - - 01101/ _ New C95e D3cirnent Group Medicare u4.7 Page 2 of 1 The Client and Humana have caused this agreement to be executed by their respective officers or representatives as duly authorized. TABLE of CONTENTS 1. EMPLOYER / GROUP INFORMATION ............................................................. ..............................4 2. PRODUCT INFORMATION ................................................................................ ..............................5 3. ID CARD INFORMATION ................................................................................... ..............................6 4. ENROLLMENT INFORMATION ......................................................................... ..............................7 5. BILLING SET UP INFORMATION .................................................................... .............................10 6. RENEWALS ...................................................................................................... .............................13 7. ANNUAL MEMBER MAILINGS ......................................................................... .............................13 8. CLINICAL PROGRAM SUMMARY ................................................................... .............................13 9. VENDOR INFORMATION .................................................................................. .............................17 10. HUMANA UTILIZATION MANAGEMENT ....................................................... .............................18 11. HUMANA CLINICAL PROGRAMS ................................................................. .............................19 12. OUTSOURCED DISEASE MANAGEMENT .................................................... .............................19 New Case Document Group Medicare v1.7 Page 3 of 19 1. Legal Name of Employer: City of Corpus Christi 2. Employer DBA Name: Cit y of Corpus Christi 3. Common Name of Employer: Ci of Corpus Christi 4. Federal Tax ID Number: 74- 6000574 Name provided must match the tax !D number reported to the !RS 5. Location Address: (No PO Boxes) 1201 Leopard Street Corpus Christi, TX 78401 County: Nueces 6. Mailing Address: PO Box 9277 Corpus Christi, TX 78469 County: Nueces 7. Management Contact: ( Primary plan decision maker Joan McKaughan Title: Interim Human Resource Director Mailing Address: 1201 Leopard Street Corpus Christi, TX 78401 Telephone: 361 -826 -3306 Fax Number: 361 - 826 -4542 Email Address: joanm @cctexas.com 8. Administrative Contact: ( Day to day administrative contact Christina Canales Title: Benefits Analyst Mailing Address: 1201 Leopard Street Corpus Christi, TX 78401 Telephone: 361 - 826 -3678 Fax Number: Email Address: christinaca @cctexas.com 9. What type of group sponsor is this account? ® Employer ❑ Trustees of a Fund ❑ Union 10. What type of organization is the group? ❑ State Government ® Local Government ❑ Publicly Traded Corporation ❑ Privately Held Corporation ❑ Non- Profit Organization ❑ Church 1 Religious Order ❑ Other: New Case Document Group Medicare 0.7 Page 4 of 19 .... ._._.. ..... _........... TH 1. What is the effective date of the Plan(s)? 01/01/2012 2. Is this a calendar or non - calendar year plan? ® Calendar Year ❑ Non - Calendar Year 3. What is the Plan/Option and Prescription Rider being sold? Type of Plan Plan Number Option Number Rx Option Medical Benefit Slick Rx Benefit Grid LPPO 079 082 27 i t 1 % LPPO Plan 079 Option 082.pdf Rx Option 27.pdf LPPO 079 083 31 0% 1 LPPO Plan 079 Option 083.pdf Rx Option 31.pdf LPPO 079 084 30 % 4 1 LPPO Plan 079 Option 084.pdf Rx Option 30.pdf LPPO 079 085 31 LPPO Plan 079 Option 085.pdf Rx Option 31.pdf LPPO 079 086 28 i t t LPPO Plan 079 Option 086.pdf Rx Option 28.pdf RPPO 079 622 29 RPPO Plan 079 Option 622.pdf Rx Option 29.pdf RPPO 079 623 27 "' 1 6 % RPPO Plan 079 Option 623.pdf Rx Option 27.pdf 4. Will a benefit review be conducted with the group? ❑ Yes ® No Date of Benefit Review: N/A New Case Document Group Medicare A.7 Page 5 of 19 ... m_... -. .....m. _._ ._,.. _ 1. Indicate Product Type ❑ MA (Medical only) ® MAPD (Medical with RX rider) ❑ PDP (RX benefits only) 2. The benefits that are checked below will appear on the ID Cards. (Coinsurance$ do not display on the card — if all three are coinsurances, then there is no co-payment information listed.) ® Office Visit ® Specialist ® Hospital Emergency Customizations Customizations are limited to a select few items 3. Will the Group Name be displayed on the card? ® Yes ❑ No If yes, please indicate the group name as it will appear on the ID card: (26 characters; M and W count as 1.5) 0000�00�00000 ©�0 © a�0 ©00���� 4. Confirm if the group will have a standard card or Company Logo displayed on the card. (If Yes, the logo must be in the bottom left front corner only and must meet quality guidelines to ensure that it looks sharp and clean on the card). ❑ Yes ® No 5. Confirm customer service number? Please provide the phone number: 1 -866- 396 -8810 6. Any additional notes: (Any deviation requested from the standard card must be noted. if the group needs a sample ID card for a particular product, New Case Document Group Medicare 0.7 Page 6 of 19 A, �iT ENOIVIA rv�.,.,... 1. What is the total number of eligible enrollees? 400 2. What type of initial enrollment method will be used? ® Paper Applications (Fire Only) ❑ Telephonic Applications ❑ Electronic Spreadsheet (one time only) ® EDI File (Civilian &Public Safety) 3. What type of on -going enrollment method will be used? ® Paper Applications (Fire Only) ❑ Telephonic Applications ® EDI File (Civilian &Public Safety) 4. For paper applications, where should applications be sent? Note: If applications are not sent directly to Humana, the applications will need to be forwarded to Humana within seven business days of the member signature date. ® Humana ❑ Group's Office ❑ TPA Office 5. How often will enrollment changes be provided? ® As Needed ❑ Weekly ❑ Monthly ❑ Annually ❑ No Changes are allowed ❑ Other: 6. Will the retirees have other insurance options offered through the group? ❑ (Full Replacement) ❑ (Slice Business) ® (Voluntary) If this is slice business, what other carriers are available? Full Replacement— Humana is expected to carry at least 95% of the total eligible membership. There are no other Medicare Advantage carries, nor can the retirees remain on the group's active commercial plan. Contribution from the group is usually high for these plans, giving the retiree little reason to opt out of the Humana offering New Case Document Group Medicare v1.7 Page 7 of 19 Slice — This is also known as "personal choice ". Humana will see varying participation between groups. Humana is one option available to these retirees who may also have the choice of many other Medicare Advantage plans and commercial carrier offerings. The group typically contributes to the premium. Voluntary Participation — Humana could see a wide range of participation that will vary from group to group. This uncertainty is due to the fact that group is not contributing to the retirees premium, but we are the only Medicare Advantage offering and the retirees are not allowed to remain on the commercial plan. This description is similar to Full Replacement except that the group will not contribute to the premium, leading some retirees to choose Individual Medicare plans over the Group Medicare offering. 7. Will there be an initial open enrollment period? ❑ Yes ❑ No ® NIA Starting Date: NLA Ending Date: N/A 8. Is there an annual open enrollment period that differs from the initial enrollment period? ❑ Yes ® No Starting Date: N/A Ending Date: (V A 0 Comments: 10. Can we accept enrollments after the Open Enrollment period? (Other than retirees aging -in to Medicare) ® Yes ❑ No Comments: 12. Are there any additional options or potential consequences if a retiree terminates or opts out of coverage? (Does the retiree lose all coverage offered by the group such as Dental, Life or Vision ?) Comments: New Case Document Group Medicare 0.7 Page 8 of 19 Are Medicare Age -Ins allowed to enroll throughout the year, or will they have to wait until the next plan year or open enrollment period? ® Aging -in retirees can enroll at any time ❑ Aging -in retirees must wait until the next open enrollment period 11. If a retiree terminates their coverage from the plan, will they be allowed to elect back into the plan at a later date? ❑ Yes ® No 1 3. Will Medicare eligible spouses or dependents be able to enroll? ® Spouses ® Dependents ❑ N/A Comments: 15. If multiple plan options are offered and spouses and /or dependents may enroll, will a split of coverage on separate plans be allowed? ❑ Yes ® No ❑ N/A Comments: 16. Are surviving spouses allowed to join the plan at the time of implementation? ® Yes ❑ No ❑ N/A Comments: 17. If spouses and /or dependents may enroll and the retiree passes away, will the spouse or dependent have the option to remain on the plan? ® Yes ❑ No ❑ NIA Comments: Please note that if time limit is set that allows the spouse or dependent to remain on the plan, the group is responsible for informing Humana 45 days prior to the desired termination date. 18. Will Humana coordinate Eligibility /Enrollment with a Third Party Vendor? ® No ❑ Yes, Specify Administrator's Name: Address: Phone Number: Fax Number: Contact Name: Email Address: Administrator's Name: New Case Document Group Medicare v1.7 Page 9 of 19 14. If spouses and /or dependents may enroll, may they remain on the plan if the retiree terminates coverage? ❑ Yes ® No ❑ N/A Address: Phone Number: Fax Number: Contact Name: Email Address: Additional Group Specific Enrollment Notes: Medicare Advantage _Enrollment Notes: Note; ,enrollment effective date is always the Ist of the month, following the receipt date or a future effective month specified by the group. Terminations: Voluntary terminations are initiated by the member. Requests for terminations must be made by a signed and dated letter submitted by the member specifically requesting a termination date. Involuntary terminations are initiated by the employer group. These requests must be made in enough time for Humana to provide the member 30 days notice of termination. No terminations can be accepted within 30 days of the termination date per CMS regulation. LEI `', w:�m .... . ........... . .Trt -.. Bl1V SST IzP li<I 11�IA 10 .. _. mmmm,em..:��, W_...M... ......._..__.......__.._..... � .._r _..._. e....._.. 1. is the premium a blended rate or different for each market? ❑ Blended ® Market 2. If blended, what is the composite rate? Plan Typ Blended Rate N/A N/A 3. What is the level of Billing? ❑ Employer (E- Billed) ® Individual (I- Billed) 4. Will the group make a contribution to the premium? ❑ Yes ® No ❑ Split - Billed (certain criteria must be met) New Case Document Group Medicare v1.7 Page 10 of 19 5. What amount will the group contribute to the premium? 6. Can customer service provide premium information to the members? ® Yes ❑ No If no, is there a phone number that the members can be referred to? N/A 7. If the group is Employer- billed or Self - billed, will the group be Pay as billed or Self - billed? ❑ Pay as billed ❑ Self - billed ® NIA Pay as billed: Humana bills group monthly via invoice, group numbers will be combined unless requested otherwise. Self - billed: Group provides roster to Humana on a monthly basis B. Will the group receive a single invoice for all accounts and markets or a single invoice for each market? ❑ Single invoice for whole group ❑ Single invoice for each market ® NIA Note: Group will be set up a Super billed unless noted otherwise 9. If this group is self- billed, Humana will the reconcile account via an excel spreadsheet and report discrepancies. 10. How will you pay your bill? (Payment is due at the I of the month. Example: January premium is due January f s `) ❑ Check ❑ ACH through Employer Portal (Humana Website) ❑ Wire (push from group to Humana) ® NIA Note: Humana will include banking information at a later date. Name of Bank: Routing Number: Account Number: 11. Will there be a separate billing address for the invoices? ❑ Yes ❑ No ® NIA 11 a. If yes, who would be the contact and what is their contact information? Billing Contact: Mailing Address: Telephone: Fax Number: Email Address: 12. Does the group receive the Retiree Drug Subsidy (RDS) or do they have an Employer Group Waiver Plan (EGWP)? ❑ RDS ❑ EGWP ® Neither 13. Does the group offer another Prescription Drug Plan? New Case Document Group Medicare v1.7 Page 11 of 19 ❑ Yes ® No 13a. What is the name of the Prescription Drug Carrier? L 14. Is the group able to attest that all of the retirees enrolling in our plan(s) have had Creditable Prescription Drug Coverage prior to enrolling? Medicare requires continuous prescription drug coverage at or above the Original Medicare level since the member became Medicare Eligible. Continuous coverage means going no more than 63 days without coverage. ® Yes ❑ No ❑ NIA 15. Will the group be willing to pay for Late Enrollment Penalties, assessed by CMS for members that did not have Creditable Drug Coverage? ❑ Yes ® No ❑ NIA Please note that if the group does not pay for the members' late enrollment penalty, Humana will send the member a coupon booklet to pay for the LEP portion of their premium. New Case Document Group Medicare v1.7 Page 12 of 19 Each year we must conduct a renewal process for group Medicare plans. In the interest of protecting the member's coverage, we will automatically term the Medicare Advantage plan if the employer does not respond to their renewal prior to December 1, 2012. 1. Renewal Date for next plan year: 01101(2013 Coordination of Benefits (COB) Humana's standard is to obtain Coordination of Benefit information at time of enrollment, and then annually thereafter. This information is collected in compliance with the Medicare Secondary Payer Act to ensure that Medicare should be the primary payer for the member. Annual Notification of Change (ANOC) Information Renewing members will receive an ANOC informing members of changes to their plan from one year to the next. The members will receive this information during the fourth quarter of each year, provided that the group has chosen to renew their plan. Evidence of Coverage (EOC) All new members receive a detailed description of their specific benefits through the Evidence of Coverage, which will arrive within 30 days of the effective date. Renewing member will receive a copy of the upcoming year's EOC along with the ANOC. New Case Document Group Medicare 0.7 Page 13 of 19 SENT Clinical Messaging Automatically Messaging to improve the quality of care for i w Included patients with ongoing illnesses, Prevent medical errors and Reduce medical costs Technology analyzes a member's claims, pharmacy! information and lab data to evaluate gaps and care e. j and offer recommendations on a patient's care to e: e- members and providers:....... r a Bariatric Management ? Automatically Dedicated Bariatric RNs, provide Bariatric Case included Management to eligible members during the surgery process through 6 months after surgery. ' This includes inpatient and outpatient surgeries, discharge planning, coordination of care, including post surgery home health needs Senior Case Management E Automatically Assist members with short -term case management included needs following a hospitalization or health event i Prociram Comoonents: • Coordination of medical services such as home health • Assessment for unmet medical needs and E working with provider to address those concerns I • Educate member on medications, physician's 9 treatment plan, and care following a health event n • Referral to appropriate disease management and condition management programs as appropriate 3 Utilization Management (UM} Automatically Utilization Management is the series of processes r (Medical /Surgical included related to managing the authorization and Authorizations) notification requirements of our insurance products. This includes a clinical review of services that are prospective, concurrent, and retrospective. -10% reduction in admissions per thousand over i 3 traditional Medicare. i E Humana consistently refines its clinical review i processes to provide guidance around the appropriate use of providers who participate in the e network. Opportunities to positively impact cost through care delivery include authorization E requirements on high- volume or high -risk x procedures such as experimental or investigational treatments. ' Prior to a hospitalization or service, Humana's g E Clinical Intake Team completes a preauthorization t review for medical necessity and length of stay. This gives Humana an opportunity to impact care delivery through authorization requirements on ' a high- volume or high -risk procedures such as experimental treatments. Transplant Management Automatically The specialized Transplant Department provides I included effective ways to help members and their families ?. manage the complex and emotional process of organ and tissue transplants. These specialists 1 review coverage, coordinate benefits, facilitate i services, and follow the transplant recipient's progress from initial referral through treatment and E3 recovery. E New Case Document Group Medicare v1.7 Page 14 of 19 New Case document Group Medicare 0.7 Page 15 of 19 Humana s NTN reduces costs of transplant servic by nearly 50% on average Therapeutic Review Services Automatically w Services include an array of medical management, (Utilization Management of included claims, and administrative services. Physical Therapy, • Manage all physical, occupational, and speech Occupational Therapy, Speechl, therapy (PT, OT, and ST) requests provided in an Therapy, and Spinal Fusion outpatient setting andaChronic pain ? • Manage post -acute inpatient musculoskeletal care °management) (Acute Rehab, Skilled Nursing Facility, and Long- j 3n Term Acute Care) a • Review focused claims (based on provider) for variances and communicating claims adjustments to Humana for payment • Provide and administer an acute back pain case management program i i • Manage the pain management services listed on Humana's Commercial and Medicare Preauthorization and Notification Lists in an e outpatient and inpatient setting, including spinal r fusion RadConsult — Radiology Automatically Provides evaluation and consultation for providers Humana has a =Authorizations included ordering radiology services for members. Providers partnership with can request consultation via the telephone, fax, or HealthHelp, an Internet. expert vendor £ who offers guidance and ° programs to ensure patients j receive the appropriate outpatient advanced imaging I radiology tests and treatments. i HealthHelp's services improve the quality of care patients receive and also prevent illnesses caused by unnecessary E exposure to radiation ji Radiation Therapy E Automatically In an effort to control radiology expenses while also ; Humana has a included improving patient safety, this call center service partnership with offers convenient scheduling of imaging procedures i HealthHelp, an as well as peer -to -peer consultation. expert vendor Inappropriate and unnecessary imaging studies are who offers i E a significant source of expense and patient guidance and inconvenience. This program is designed to help i programs to a avoid those issues by educating ordering ensure patients physicians on imaging procedures and best receive the E practice guidelines before the procedure is appropriate scheduled. Physicians call a toll -free number to outpatient initiate the consultation. advanced imaging jand i radiology tests treatments. HeaithHelp's services improve New Case document Group Medicare 0.7 Page 15 of 19 the quality of care patients receive and also prevent illnesses caused by unnecessary exposure to radiation HumanaCares Chronic Automatically Condition Management and included Complex Care E iE i • Involves the assignment of complex - chronic E Members to one primary nurse who will become the Members primary contact • Builds long term relationships while actively managing their co- morbidities and coordinating access between internal/external programs • Supports the most fragile of our Members with a multidisciplinary team comprised of medical, behavioral, social work, pharmacy, and home visits • Applies evidence -based medicine to drive Member adherence to proven standards of care i • Comprised of a centralized management team to ensure consistency, performance, and flexibility • Member for life I Nurseline Package ; Automatically Members are provided an easy way to get (HumanaFirst) ;included information on health care questions by calling the HumanaFirst phone number. A staff of registered nurses listens to the caller's symptoms and helps direct the caller to the appropriate level of care based on the responses to physician - developed questions that assess specific medical complaints. umanaFirst is also able to provide information nique to the member's participating provider etwork; to make sure the member is directed to a articipating physician or facility. Thirty percent of ie callers are given self -care instructions and do of have to seek care elsewhere making umanaFirst a value -added service. Humana Active Outlook Automatically Humana Active Outlook (HAO) is a health and included wellness program that offers timely, interesting information on healthy living, invites members to ! members -only local classes and national health education events and brings them discounts and money- saving offers on products they use most. Elements of the program include: • HAO Magazine • Live It Up! Digest • www.HumanaActiveOutlook.com • Classes • Seminars • Personalized Health Programs • HAO Marketplace Up! Digest Member Assistance Program Automatically Personal, one -on -one phone and Web consultation (MAP) [Telephonic] included including: • Counseling on personal and emotional issues including stress and anxiety • Referrals to specific community services such as social activities or group counseling HumanaBecpinnings (Maternity iAutomatically :lProvides prenatal and Now Case Document Group Medicare 0.7 Page 16 of 19 Program) i included education and support to all eligible pregnant Humana members. HumanaBeginnings nurses work with all eligible pregnant members regardless of gestational age or pregnancy ri stat _ Telephonic Health Coaching Automatically These programs connect members to a personal and Tailored Web Program ;included health coach, who will schedule calls with members focused on changing behaviors. Members may call in to their health coach as often as needed. • Educate members about preventive care screenings and health practices to maintain good health • Identify appropriate candidates for clinical programs and initiatives • Provide education and guidance in maintaining good health and reducing risk factors that lead to illness Tailored web program that delivers: i • Written personalized action plan ! • Series of newsletter based on the individual 3 assessment Well Dine j Automatically Benefit Available on most HMO and Local PPO included plans after an overnight hospital stay. Program goal is to improve nutrition after a hospital i stay and connect Humana members to local home i food delivery programs.. ......... New Case Document Group Medicare v1.7 Page 17 of 19 Behavioral Health Automatically • Team approach to managing a member's i Management - included behavioral and medical needs since many people i Humana Achieve who suffer with a medical condition also develop behavioral conditions (eg: depression) and vice versa • Experienced medical case managers work closely n with behavioral case managers to identify all of the health concerns impacting a member E • Both case managers contact the member by l phone and develop care plans with health goals _... -._____._._..._._...... and plans for meeting those goals identified ___- _wtiw..w.....__,....... _.. w_...._.__ ................_ .....,.,....,w......w.M.._..... ,. i Wellness MyHumana ; Automatically Secure, personalized Humana web page included • Spending account information E • Assessments • Tracking tools • Recipes • Drug info • Discounts • Claims Data Segmented into Health centers that focus specifically on men, women, children, seniors New Case Document Group Medicare v1.7 Page 17 of 19 If any of the clinical programs has been outsourced, list the name of the organization below: Vendor #1 Vendor #2 Service Provided Company Name Address Telephone Number Point of Contact Hours of Operation Service Provided Company Name Address Telephone Number Point of Contact Hours of Operation iiim Ii ...., :,::e,e,. m........._.>:.:.:.:.._._,e,..e m, m:e f�o ::.�#lA.{FfA..t�T[�l;k'�`f±��+N T ...:.. Definition of Medical Necessity: Medically necessary or medical necessity means the extent of services required to diagnose or treat a bodily injury or sickness which is known to be safe and effective by the majority of qualified practitioners who are licensed to diagnose or treat that bodily injury or sickness. Such services must be: 1. Appropriate for and consistent with your symptoms or diagnosis of the sickness or bodily injury 2. Furnished for an appropriate duration and frequency in accordance with accepted medical 3. Substantiated by the records and documentation maintained by the provider of service 4. Achieves optimally efficient use of medical resources Humana MA HMO and PPO members will follow Humana Standard Preauthorization guidelines (found on Humana.com) for preauthorization. Referrals (HMO Products Only): Humana will receive and complete all referral requests for members with an HMO product. All of Humana's HMO markets require referrals, except for those listed below. No referral required. Preauthorization may be required. New Case Document Group Medicare 0.7 Page 18 of 19 Y nf. c l rafcal. if Ms Disease Management: Groups will be enrolled into all programs by default if they select Humana as their choice for Disease Management services unless otherwise specified. ...... .......... °°eve rt° °Itl 1i yy "IJi[ E as MAhl *r,�lEl�ll hlT Outsourcing to another Vendor: If the group is outsourcing Disease Management to another vendor, list the clinical conditions the outsourced vendor will follow: Clinical Conditions: (example Asthma, Diabetes New Case Document Group Medicare v1.7 Page 19 of 1 9