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TX HealthSpring Medicare Program Training January 1, 2014—Go Live.

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Presentation on theme: "TX HealthSpring Medicare Program Training January 1, 2014—Go Live."— Presentation transcript:

1 TX HealthSpring Medicare Program Training January 1, 2014—Go Live

2 Agenda  Overview of Plans  Medicare Plans & Benefits  Member ID Cards  Complaints and Appeals  Questions

3 Overview of Plans – High Level  Cigna-HealthSpring offers 13 Medicare Advantage dental plans that have been filed as part of their Texas market with CMS. HealthSpring categorizes the plans by Contract ID.  All Medicare plans are effective 1/1/2014  All Medicare plans operate on a calendar year  January 2014 – December 2014  Some of the Medicare plans have out-of-network benefits  Some of the Medicare plans have co-insurance  None of the Medicare plans require authorization or UM review

4 Overview of Plans What types of dental plans are offered?  HealthSpring’s Medicare Advantage dental plans are similar to commercial insurance plans. There are 4 different benefit sets that members can choose to buy based on where they live:  Preventive Plan  Preventive + Out-of-Network Plan  Preventive & Comprehensive Plan  Preventive & Comprehensive Optional Supplemental Plan

5 Overview of Plans  The plans with the same benefits are rolled up into the same exhibits in the ORM. The subgroup names are listed below by plan category:  Preventive Plans  TX HS Preferred Advantage Medicare  TX HS Preferred AR Medicare  Preventive + Out-of-Network Plan  TX HS Preferred Advantage Medicare (50% Co-Ins)  Preventive & Comprehensive Plan  TX HS Preferred TotalCare Medicare  Preventive & Comprehensive Optional Supplemental Plans  TX HS Preferred TX/AR Medicare (Opt Supp)  HS Preferred AR Medicare (Opt Supp)

6 Preventive Plan DentaQuest Subgroups: TX HS Preferred Advantage Medicare, TX HS Preferred AR Medicare Covered Plans and Counties:  H Cigna-HealthSpring Preferred (HMO) Service Area: Bexar, Collin, Dallas, Denton, Ellis, El Paso, Hood, Johnson, Parker, Rockwall, Tarrrant, Wise, TX  H Cigna-HealthSpring Preferred (HMO) Service Area: Cherokee, Grayson, Gregg, Hale, Henderson, Hockley, Lubbock, Rains, Rusk, Smith, Upshur, Van Zandt, Wood, TX  H Cigna-HealthSpring Advantage (HMO) Service Area: Angelina, Brazoria, Cameron, Chambers, Fort Bend, Galveston*, Hardin, Harris, Hidalgo, Jasper, Jefferson, Liberty, Montgomery, Nacogdoches, Newton, Orange, Polk, Sabine, San Augustine, San Jacinto, Shelby, Tyler, Walker, Waller, Willacy, Webb, TX  H Cigna-HealthSpring Advantage (HMO) Service Area: Bexar, Collin, Dallas, Denton, Ellis, El Paso, Hood, Johnson, Parker, Rockwall, Tarrrant, Wise, TX  H Cigna-HealthSpring Preferred (HMO) Service Area: Yell, Sebastian, Scott, Pope, Logan, Johnson, Franklin, Crawford, Conway, AR

7 Preventive Benefits Preventive Dental Benefits CodeDescriptionFrequencyCo-Pay Diagnostic D0120Periodic Oral Evaluationone every 6 months$0 D0140Limited Oral EvaluationOne per Calendar year(s) Per patient$0 D0150 Comprehensive Oral Evaluation - new or established One per Calendar year(s) per patient. One every 36 months per provider per tax id number $0 D0210 Intraoral - Complete Series (including bitewings) One of (D0210 or D0330) every 36 months$0 D0220Intraoral - Periapical first filmOne every Calendar Year$0 D0230Intraoral - Periapical each additional filmOne every Calendar Year$0 D0272Bitewing, two filmsOne every Calendar Year$0 D0274Bitewing, four filmsOne every Calendar Year$0 D0330Panoramic FilmOne of (D0210 or D0330) every 36 months$0 Preventive D1110Prophylaxis - Adultone every 6 months$0

8 Preventive + OON Benefits Plan DentaQuest Subgroup: TX HS Preferred Advantage Medicare (50% Co-Ins) Covered Plans and Counties:  H Cigna-HealthSpring Preferred (PPO) Service Area: Cherokee, Collin, Dallas, Denton, Grayson, Gregg, Hale, Henderson, Hockley, Johnson, Kaufman, Lubbock, Rockwall, Smith, Tarrant, Rains, Rusk, Upshur, Van Zandt, Wood  H Cigna-HealthSpring Advantage (PPO) Service Area: Cherokee, Collin, Dallas, Denton, Grayson, Gregg, Hale, Henderson, Hockley, Johnson, Kaufman, Lubbock, Rockwall, Smith, Tarrant, Rains, Rusk, Upshur, Van Zandt, Wood

9 Preventive + OON Benefits Preventive Dental Benefits CodeDescriptionFrequencyCo-Pay Diagnostic D0120Periodic Oral Evaluationone every 6 months$0 D0140Limited Oral EvaluationOne per Calendar year(s) Per patient$0 D0150 Comprehensive Oral Evaluation - new or established One per Calendar year(s) per patient. One every 36 months per provider per tax id number $0 D0210 Intraoral - Complete Series (including bitewings) One of (D0210 or D0330) every 36 months$0 D0220Intraoral - Periapical first filmOne every Calendar Year$0 D0230Intraoral - Periapical each additional filmOne every Calendar Year$0 D0272Bitewing, two filmsOne every Calendar Year$0 D0274Bitewing, four filmsOne every Calendar Year$0 D0330Panoramic FilmOne of (D0210 or D0330) every 36 months$0 Preventive D1110Prophylaxis - Adultone every 6 months$0 Members have the option of going Out-of-Network to receive the preventive services on this plan. If members receive services from a non-participating (Out-of-Network) dentist they will be responsible for 50% of the dentist’s charges for services (50% co-insurance).

10 Preventive & Comprehensive Plan DentaQuest Subgroup: TX HS Preferred TotalCare Medicare Covered Plan and Counties:  H Cigna-HealthSpring Preferred (HMO) Service Area: Angelina, Brazoria, Cameron, Chambers, Fort Bend, Galveston*, Hardin, Harris, Hidalgo, Jasper, Jefferson, Liberty, Montgomery, Nacogdoches, Newton, Orange, Polk, Sabine, San Augustine, San Jacinto, Shelby, Tyler, Walker, Waller, Willacy, Webb  H Cigna-HealthSpring TotalCare (HMO SNP) Service Area: Angelina, Brazoria, Cameron, Chambers, Fort Bend, Galveston*, Hardin, Harris, Hidalgo, Jasper, Jefferson, Liberty, Montgomery, Nacogdoches, Newton, Orange, Polk, Sabine, San Augustine, San Jacinto, Shelby, Tyler, Walker, Waller, Willacy, Webb  H Cigna-HealthSpring TotalCare (HMO SNP) Service Area: Bexar, Collin, Dallas, Denton, Ellis, El Paso, Hood, Johnson, Parker, Rockwall, Tarrrant, Wise  H Cigna-HealthSpring TotalCare (HMO SNP) Service Area: Cherokee, Grayson, Gregg, Hale, Henderson, Hockley, Lubbock, Rains, Rusk, Smith, Upshur, Van Zandt, Wood

11 Preventive & Comprehensive Plan Benefits Preventive Dental Benefits CodeDescriptionFrequencyCo-Pay Diagnostic D0120Periodic Oral Evaluationone every 6 months$0 D0140Limited Oral EvaluationOne per Calendar year(s) Per patient$0 D0150 Comprehensive Oral Evaluation - new or established One per Calendar year(s) per patient. One every 36 months per provider per tax id number $0 D0210 Intraoral - Complete Series (including bitewings) One of (D0210 or D0330) every 36 months$0 D0220Intraoral - Periapical first filmOne every Calendar Year$0 D0230Intraoral - Periapical each additional filmOne every Calendar Year$0 D0272Bitewing, two filmsOne every Calendar Year$0 D0274Bitewing, four filmsOne every Calendar Year$0 D0330Panoramic FilmOne of (D0210 or D0330) every 36 months$0 Preventive D1110Prophylaxis - Adultone every 6 months$0 Members are entitled to the covered preventive benefits above, plus a Calendar Year Maximum of $1,000 towards comprehensive services including: Restorative care Periodontics Prosthodontics Oral surgery Diagnostic and preventive services above do not count towards annual coverage limit. Full list of covered codes can be found in the ORM.

12 Optional Supplemental Benefits Plan: Preventive & Comprehensive DentaQuest Subgroups: TX HS Preferred TX/AR Medicare (Opt Supp), TX HS Preferred AR Medicare (Opt Supp) Covered Plan and Counties:  H Cigna-HealthSpring Preferred (PPO) Service Area: Bowie, Cass, Titus, TX and Miller, AR  H Cigna-HealthSpring Preferred (PPO) Service Area: Howard, AR

13 Optional Supplemental Benefits Preventive Dental Benefits CodeDescriptionFrequencyCo-Pay Diagnostic D0120Periodic Oral Evaluationone every 6 months$0 D0140Limited Oral EvaluationOne per Calendar year(s) Per patient$0 D0150 Comprehensive Oral Evaluation - new or established One per Calendar year(s) per patient. One every 36 months per provider per tax id number $0 D0210 Intraoral - Complete Series (including bitewings) One of (D0210 or D0330) every 36 months$0 D0220Intraoral - Periapical first filmOne every Calendar Year$0 D0230Intraoral - Periapical each additional filmOne every Calendar Year$0 D0272Bitewing, two filmsOne every Calendar Year$0 D0274Bitewing, four filmsOne every Calendar Year$0 D0330Panoramic FilmOne of (D0210 or D0330) every 36 months$0 Preventive D1110Prophylaxis - Adultone every 6 months$0 Members can decide to opt up to an enhanced dental benefit package at any time during the year. Members are entitled to the covered preventive benefits above, plus a Calendar Year Maximum of $800 towards comprehensive services including: Restorative care Periodontics Prosthodontics Oral surgery

14 Optional Supplemental Benefits Continued… Diagnostic and preventive services above do not count towards annual coverage limit. Full list of covered codes can be found in the ORM. Members have the option of going Out-of-Network to receive services on these plans. If members receive services from a non-participating (Out-of-Network) dentist they will be responsible for 50% of the dentist’s charges for services (50% co-insurance). Both in and out-of-network services apply to the annual maximum of $800.

15 ID Cards & Welcome Letters  The DentaQuest ID card will be printed at the bottom of the Member Welcome Letter.  The ID card will include the HealthSpring product name & the DentaQuest subgroup name. The purpose of this is to ensure that all parties know the name of the plans (member, provider, DQ staff, HS staff).  Example:  HealthSpring product name: H Cigna-HealthSpring TotalCare (HMO SNP)  DentaQuest subgroup name: TX HealthSpring Preferred TotalCare Medicare  If a member has been active < 89 days they are considered “reinstated”. Reinstated members will only receive a new ID card/welcome letter.  If lapse in coverage is > 90 days, they are treated as new members. New members receive an ID card/welcome letter, member handbook & EOC document.

16 Sample ID Cards

17  DentaQuest is Primary for Member Services  DentaQuest HealthSpring Medicare Member Services   For reference:  HealthSpring Medicare Member Services   DentaQuest is Primary for Provider Services  (Dedicated TX MCO Line) Member/Provider Services

18  DentaQuest will not handle HealthSpring Medicare member complaints.  HealthSpring members should contact HealthSpring member services to file a complaint.  DentaQuest will not handle HealthSpring Medicare member appeals.  HealthSpring members should contact HealthSpring member services to file an appeal. Member Complaints & Appeals

19 Provider Complaints & Appeals  DentaQuest will handle HealthSpring Medicare provider complaints and appeals.  Providers should follow the standard TX process to file complaints or appeals with DentaQuest.

20 Questions?


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