4 Definitions Centers for Medicare & Medicaid Services (CMS) Federal agency that administers the Medicare program.Department of Public Welfare (DPW)Pennsylvania State agency that administers the Pennsylvania Medicaid program.
5 DefinitionsMedicareA National Health Insurance Program for people age 65 or older, some disabled people under age 65, and people of all ages with End-Stage Renal Disease.What are the different parts of Medicare?Medicare Part A (Hospital Insurance)Medicare Part B (Medical Insurance)Medicare Part C (Medicare Advantage Plans offering Part A & Part B coverage)Medicare Part D (voluntary Medicare Prescription Drug Coverage)
6 DefinitionsMedicaidJoint Federal and State Program that helps pay medical costs for some people with limited income and resources.Operated by the State. In Pennsylvania, Medicaid is operated by Department of Public Welfare (DPW).
7 Definitions Medicare Advantage (MA) Special Needs Plans (SNPs) This specialized MA plan type was authorized in the Medicare Prescription Drug Improvement, and Modernization Act (MMA) of There are 3 types of SNPs:Dual Eligible: For individuals having both Medicare and Medicaid.Institutional: For individuals who reside in or are eligible to reside in an institutional setting for 90 days or longer.Chronic Condition: For individuals having a severe or disabling chronic condition(s).
8 DefinitionsMedicaid only (“Full Dual”)- Individual who is eligible for full Medicaid benefits. Medicaid does not pay out-of-pocket costs for Part D cost-share.QMB Only- Individual who is eligible for Medicaid payment of Medicare cost-share (i.e. Medicare Part A and/or Part B coinsurance, deductible, premium). Medicaid does not pay out-of-pocket costs for Part D cost-share.QMB plus- Individual eligible for full Medicaid benefits and Medicaid payment of Medicare cost-share (i.e. Medicare Part A and/or Part B coinsurance, deductible, premium). Medicaid does not pay for Part D cost-share.
10 Medicare Health Plan Type What type of plan is Medicare Assured®?HMO (Health Maintenance Organization)Generally, must use in-network providers*Generally, must use in-network pharmacies***members may obtain care at any emergency room if they reasonably believe emergency care is needed.**members should contact the Plan for assistance in locating a pharmacy.
11 Medicare Health Plan Type What type of HMO Medicare Plan is Medicare Assured®?Medicare Advantage-Prescription Drug (MA-PD) Dual Eligible Special Needs Plan (D-SNP).Enrollees must:Be eligible for Medicare Part ABe enrolled in Medicare Part BHave Full Medicaid, or Qualified Medicare Beneficiary (QMB/ QMB Plus) Medicaid eligibilityReside in Gateway Health Plan Medicare Assured® service areaNot have ESRD (End Stage Renal Disease) at time of enrollment
12 2012 Service AreaWhere does Medicare Assured® Operate?28 Counties in PA: Adams, Allegheny, Armstrong, Beaver, Berks, Blair, Butler, Cambria, Cumberland, Dauphin, Erie, Fayette, Indiana, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Mercer, Northampton, Northumberland, Perry, Philadelphia, Schuylkill, Somerset, Washington, Westmoreland, York
13 2012 BenefitsWhat are the Medicare Assured® 2012 Benefits?Gateway Health Plan Medicare Assured® provides Original Medicare benefits plus:Prescription BenefitsDental BenefitsHearing BenefitsVision BenefitsHealth & Wellness EducationFitness ProgramTransportation Benefit, andBathroom Safety Products
14 2012 BenefitsGateway utilizes delegated entities to administer some Plan benefitsPBM (Pharmacy Benefit Manager):Argus Health Systems, Inc. (Argus)DentalUnited Concordia Companies, Inc. (UCCI)VisionDavis Vision
15 2012 BenefitsGateway utilizes delegated entities to administer some Plan benefits (cont.)Transportation:Medical Transportation Management, Inc. (MTM)Fitness:American Healthways Services, Inc. (Healthways)Behavioral Health:Community Behavioral HealthCare Network of Pennsylvania (CBHNP)
16 Prescription Benefits Gateway uses a formularyGateway members may obtain medications at any pharmacy that accepts ArgusDrugs covered under Medicare Part B:$0 Deductible$0 Co-payment
17 Prescription Benefits – Cont’d Drugs covered under Medicare Part D:Nearly all Gateway members are eligible for the Low Income Subsidy (LIS)$0 DeductibleCo-Payments:Generic:$0 or $1.10 or $2.60 – depending on income levelBrand:$0 or $3.30 or $6.50 – depending on income level
18 Dental Benefits $0 co-payment for covered services All Medicare covered services, plus routine services:One oral exam every 6 monthsOne cleaning every 6 monthsOne dental x-ray every 6 monthsOne panoramic x-ray every 5 years
19 Dental Benefits – cont’d Comprehensive Services:Up to $500* every 2 years toward minor restorations (such as fillings)*Unused monies do not carry forwardDentures:1 set every 5 years (includes one upper and one lower)
20 Hearing Benefits $0 co-payment for covered services All Medicare covered services, plus:Diagnostic hearing examsRoutine hearing testFitting and evaluation for hearing aidsHearing Aids covered up to $1000 every 2 years
21 Vision Benefits $0 co-payment for covered services All Medicare covered services, plus:Outpatient physician eye care servicesUp to 4 routine eye exams per yearOne pair of eyeglasses every year*Up to $90 towards non-vendor framesOne pair standard contact lenses, or up to $150 toward specialty lenses, per year* $150 limit per calendar year for eyewear
22 Health and Wellness Education $0 co-payment for all Medicare coveredservices, plus:Heart Disease ProgramDiabetes ProgramAsthma ProgramSmoking CessationNewsletter
23 Fitness Program $0 co-payment for all covered services Must use participating fitness centerAccess to 1 fitness center per calendar monthStandard fitness center membership
24 Transportation Benefit $0 co-payment for all covered servicesNon-emergent, non-urgent transportationUp to 36 one-way trips to plan approved locations per calendar yearPlan approved locations include medical, dental, vision, hearing, pharmacy, fitness center and behavioral health servicesMust schedule at least 3 days in advance
25 Bathroom Safety Benefit $0 co-payment for all covered servicesUp to $100* per calendar year for bathroom safety products such as bath/ shower chairs, bathtub rails, bathtub stool or bench*unused amount may not be carried over toanother year
26 Special Needs Plan (SNP) Enrollment and Disenrollment
27 SNP Enrollment / Disenrollment Dual Eligible individuals may change plans monthlyEnrollment can be done:In person, with a Gateway marketing representativePhone, by calling GatewayPhone, by calling MEDICAREInternet (through Medicare website)
28 SNP Enrollment / Disenrollment Voluntary Disenrollment can be done:By calling Gateway. The disenrolling member will receive a disenrollment form that must be completed and returned.By calling MEDICARE.By enrolling in another Plan; the member will automatically disenroll from Gateway.
29 SNP Enrollment / Disenrollment Involuntary Disenrollment includes, but not limited to the following:Move out of Gateway’s Medicare Assured® service area.Loss of Medicaid coverageCovered on plan for 90 days (“deemed” period).
31 Commonly Used Terms Evidence of Coverage (EOC) book Contract between the Plan and member:Explains benefits and servicesExplains what the member has to payExplains rules and responsibilitiesExplains disenrollment processExplains appeals and grievances.Formulary bookList of covered drugs
32 Commonly Used Terms Summary of Benefits (SB) Primary pre-enrollment document used by Plans to inform potential members of Plan benefit packages.Compares Gateway Health Plan Medicare Assured® to Original Medicare.Explanation of Benefits (EOB)Notice sent to member explaining claims payment.Gateway members may receive multiple EOBsPharmacyMedicalDentalVision
34 Medicare Compliance Program Medicare Administration DepartmentGateway Health Plan’s Medicare Regulatory and Compliance DepartmentStaffMedicare Compliance OfficerMedicare Compliance SpecialistsGovernment Affairs SpecialistPrimary Liaison with CMSAll contact with regulatory agencies must be directed to Medicare Administration Department
35 Medicare Compliance Program Responsible for assuring compliance with CMS requirementsResponsible for oversight of Gateway’s Medicare Assured® product.Conducts joint investigations with Corporate Compliance when appropriate
36 Medicare Compliance Program CMS Medicare Compliance Program Requirements:Gateway has adopted and implemented an effective Medicare compliance program, which includes measures that prevent, detect, and correct noncompliance with CMS' program requirements as well as measures that prevent, detect, and correct fraud, waste, and abuse.
37 Medicare Compliance Program The compliance program, at a minimum, includes the following  core requirements:Written policies, procedures, and standards of conductCompliance Officer and Compliance CommitteeEffective training and educationEffective lines of communicationEnforcement of StandardsMonitoring and auditingProcedures and Systems for prompt Response to Compliance Issues
38 Medicare Compliance Program Medicare compliance issues must be reported to Medicare Compliance Officer or Gateway Health Plan Fraud & Abuse/Compliance hotline within 24 hours of becoming aware of the incident.
39 Medicare Compliance Program Reporting Medicare compliance issues:Send issue via to:ORCall Fraud & Abuse/Compliance Hotline or (Call can be anonymous).
40 Audits / Oversight CMS Compliance Actions CMS Compliance Actions include but not limited to the following:Executive Conference Call/MeetingNotice of Non-ComplianceWarning LetterVarious Suppressions and ExclusionsSuspend Marketing & Enrollment ActivitiesRequest for Corrective Action PlanNew Applications/Service Area Expansion (SAE) DenialsAudit SelectionEnforcement and Termination
42 Fraud, Waste and Abuse Overview of Training: The Fraud and Abuse policy for Gateway Health Plan®The laws and regulations related to fraud, waste and abuseThe types of fraud, waste and abuse that can occurThe process for reporting suspected fraud, waste and abuseThe protections for employees, and first tier, downstream and related entities, who report suspected fraud, waste and abuse
43 Fraud, Waste and AbuseThe Fraud and Abuse policy for Gateway Health Plan® can be obtained by logging onto and clicking on the Fraud and Abuse link located at the bottom of the page.
44 Fraud, Waste and Abuse Definition of Fraud, Waste and Abuse Fraud - An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law. (42 CFR 42 §455.2)Waste - Over-utilization of services, or other practices that result in unnecessary costs. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources.
45 Fraud, Waste and Abuse Definition of Fraud, Waste and Abuse (cont’d) Abuse - Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid, Medicare Advantage or Medicare Part D program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for healthcare. It also includes recipient practices that result in unnecessary cost to the Medicaid, Medicare Assured®, or Medicare Part D program. (42 CFR § 455.2)
46 Fraud, Waste and AbuseThe Laws and Regulations Related to Medicare Advantage and Part D Fraud, Waste and Abuse include, but not limited to, the following (see Handout for more detail):False Claims Act: Impacts any person or entity who submits a false or fraudulent claim for payment to the US Government. Violators must repay three times the amount of damages suffered plus civil penalty of $5500 to $11,000 per claim.Stark Law: Prohibits physicians’ referrals for the furnishing of any “designated health services” for which payment may be made under the Medicare Part B program (and to some extent, Medicaid) to any entity with which the referring physician (or immediate family member) has a “financial relationship.”Anti-Kickback Statute: Prohibits the offer or receipt of certain remunerations in return for referrals for, or recommending purchase of, supplies and services reimbursable under government health care programs.
47 Fraud, Waste and AbuseFraud, waste and abuse can come from many sources:MemberProvidersPharmacy Benefit Manager (PBM)PharmaciesAgents
48 Fraud, Waste and AbusePerson(s) responsible for Identifying Fraud and AbuseAll Gateway Health Plan® employees and Board of DirectorsAll Gateway Health Plan® First Tier, Downstream and Related Entities
49 Fraud, Waste and AbusePerson(s) responsible for monitoring and auditing fraud, waste and abuse at Gateway Health Plan®The (Special Investigations Unit) SIU performs the following activities to protect Gateway Health Plan® from potential fraud, waste and abuse:Perform monthly auditsPerform monthly reviews of State and Federal provider exclusion listsPerform peer review ranking reports to identify outlying activity of providers and membersPerform periodic reviews with an emphasis on the audits identified in the annual Office of Inspector General (OIG) work plan
50 Fraud, Waste and AbuseThe methods for reporting Fraud, Waste and Abuse include but are not limited to the following:Standardized Referral Process FormFraud and Abuse Hotline MethodCall the dedicated hotline to report suspected incidents of fraud, waste and abuse.Hotline Number: (412)(800) (Toll Free)Calls can be anonymous
51 Fraud, Waste and AbuseThe protections for individuals who report suspected fraud, waste and abuseWhistle blowers are offered certain protections against retaliation for bringing an action under the False Claims Act (31 U.S.C. 3729). Employees who are discharged, demoted, harassed, or otherwise confront discrimination in furtherance of such an action or as a consequence of whistle blowing activity are entitled to all relief necessary to make the employee whole.
52 Gateway Health Plan® Product Test Please click here to begin the required test. When you have completed the test, you must hit submit or your answers will not be recorded. A Gateway Agent Specialist will provide you with your score in approximately 2 weeks.