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MGMA November 18, 2014 Presented by: Mary Hoover VP Provider Services/Contracting.

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Presentation on theme: "MGMA November 18, 2014 Presented by: Mary Hoover VP Provider Services/Contracting."— Presentation transcript:

1 MGMA November 18, 2014 Presented by: Mary Hoover VP Provider Services/Contracting

2 Overview –Prominence Health Plan –Universal Health Services, Inc. (UHS) What else is new? 2015 Commercial Plans 2015 Medicare Advantage Plans Provider Tools Other “News” 2 AGENDA

3 3 Universal Health Services, Inc. (UHS) acquired Saint Mary’s Health Plans June 1, 2014 Renamed Prominence Health Plan with the goal of expanding products, services and geographic coverage. Prominence Health Plan includes the following: –Prominence HealthFirst – HMO and POS products in Nevada –Prominence Health Insurance Company –PPO products in Nevada –CDS Group Health – TPA services –Nevada Preferred Healthcare Providers – PPO rental network to health plans and self-funded employers Overview

4 4 UHS is a Fortune 500 for-profit hospital management company in operation for 35 years. Our Acute Care Division operates 25 facilities in California, Florida, Nevada, South Carolina, Texas and Washington, DC. We offer a comprehensive range of high quality services and programs in each hospital to meet the needs of the communities in which they are located. Community involvement is important to our Behavioral Health Division as well. The Behavioral Health Division of UHS operates 195 facilities in 37 states, Washington, DC, Puerto Rico and the U.S. Virgin Islands. Universal Health Services

5 5 Why would UHS, a hospital management company purchase a health plan? The days of fee for service are coming to an end to make way for better patient care and outcomes. Provider owned health plans have the ability to better manage and deliver coordinated patient –centered care which improves patient satisfaction and provider engagement. The belief that through close collaboration with our local providers, we will be able to deliver better care management while continuing our strong tradition of providing excellent customer service. Universal Health Services

6 6 Medical Home Model Primary Care Providers submitting appropriate referrals and providing specialists with sufficient medical history, clinical data, goals for consultation and participation in annual Health Risk Assessments. Specialists providing primary care practitioners with patient care course of treatment and follow-up care requirements. Hospitals and Urgent Care efficiently communicating with primary care providers when their patients are hospitalized, have visited the Emergency Department or Urgent Care and require follow-up care.

7 7 Prominence Health Plan has a Pay-for-Performance program (P4P) that rewards physicians who meet nationally-established benchmark goals in clinical quality practice. The P4P objective is to encourage, facilitate and recognize “Best Practice” clinical performance while adhering to the program design attributes of clear program objectives, ease of use/administration, and the promotion of performance improvement. The clinical focus is on diabetes care, preventive health screenings, and pharmacy/prescribing measures. We are currently undergoing a final revision to the P4P and expect to roll out the program first quarter 2015. Pay for Performance

8 PPOHMO Updated 7.1.14 WPA Medicare Advantage

9 9 HMO/POS membership – 21,009 PPO membership – 14,152 Exchange membership – 4,140 TPA membership – 30,256 Rental network members – 95,500 Membership summary

10 10 What else is new?


12 12 2015 Commercial Plans

13 13 Once again participating in the state/federal exchange –More than 4K new members during last season; appreciate your support –Plans offered to residents in same regions: Carson City and Washoe, Douglas, Lyon and Storey counties Introducing ChoicePlus plans –Historically all exchange plans featured the select “Premier” network with all contracted specialists and a select network of PCPs –ChoicePlus plans feature the complete Prominence HealthFirst HMO network 2015 Exchange – Individual & Family

14 14 Online renewal and direct enrollment opportunities through Softheon Marketplace and Connector Cloud –Available via beginning November –Features price and benefit comparison tool –Easier navigation, fewer clicks to enroll, premium payment processing Softheon is the technology platform used by the nation's first full-service state health benefit exchange (2008) –Broker and member one-stop shopping experience for exchange plan comparison, purchase and renewal –Provides invoicing services, premium payment processing, and full functionality for Qualified Life Events (QLE) –Supports brokers through a dedicated website solution 2015 Exchange – Individual & Family

15 15 Same plans featured in 2014 with minimal benefit changes – increase in OOPM to $6,600 on select plans; $6,450 OOPM limit on HD per federal IRS regulations Some HMO deductible plans now include CYD on inpatient hospital benefit Premier North plans – Available to groups on all HMO plans; includes the same specialists and many of the facilities with a select PCP panel 2015 Small Group Products

16 16 New AdvantagePlus HMO plans for Large Group –Easy to follow deductible and coinsurance level type plans –Fixed office visit copays at $30/$60 –Fixed OOPM at $6,600 Introducing Freedom Beyond Plans – Small and Large Group –PCP participation is strongly encouraged but NOT required –Offers members choice and flexibility of PPO with the cost savings of an HMO –Access to both HealthFirst HMO and First Health national PPO network –Available to groups in northern Nevada only 2015 Large Group Products

17 17 2015 Medicare Advantage

18 18 Expanding into Medicare Advantage effective 1/1/15 −Nevada areas include Carson City, Washoe, Douglas, Lyon and Storey counties −Texas counties include: Moore, Potter, Gray, Deaf Smith and Randall Starr, Hidalgo and Brooks Future expansion plans to potentially include Clark County in Nevada; additional Texas locations and further expansion into additional states where UHS has a strong presence. Medicare Advantage expansion plans

19 19 Service Areas Storey Carson City Douglas Lyon Service areas include: Washoe County −Prominence Plus HMO Carson City, Douglas, Storey & Lyon counties −Prominence Value HMO Medicare Advantage service areas and plans - NV

20 20 Medicare Advantage service areas - TX

21 21 Sample Member ID Card - Medicare 2015 Prominence Health Plan Rural Nevada Carson City, Douglas, Lyon & Storey Counties Sample ID Card

22 22 Medicare Advantage HMO with prescription drug coverage can include: −$0 premium plans w/ prescription coverage −NO medical and NO prescription deductibles −Monthly allowance for over-the-counter drugs −Mail-order prescription drug program −Coverage in the GAP −Fitness Center Reimbursement −Routine Vision and Prescription Eyewear Allowance −Hearing Aid Allowance MA plan summaries and offerings

23 23 Provider Tools

24 24 Provider Portal - Commercial

25 25 Eligibility Authorization Status Review Referral and Authorization Submission Claims Status Review Documentation Contact Health Plan Provider Portal – Medicare Advantage

26 26 Claims Submission MEDICARECOMMERCIAL EDI Submission Nevada Payer ID – 93082 Clearinghouse – EMDEON Mail Prominence Claims Department PO BOX 151987 Tampa, FL 33684-1987 EDI Submission Nevada Payer ID – 88029 Clearinghouse – EMDEON Mail Prominence Claims Department 1510 Meadow Wood Lane Reno, NV 89502

27 27 Prior Authorization MEDICARECOMMERCIAL Medicare Pre-Certification Request Form –Include Medical Records –Fax request to 813-513-7304 Provider Portal Submission –PHP Nevada Portal Login Link: Medicare Pre-Certification Request Form –Include Medical Records –Fax request to 775-770-9364 Provider Portal Submission –PHP Nevada Portal Login Link:

28 28 Vendor Network Partners MEDICARECOMMERCIAL Behavioral Health Pharmacy

29 29 Other “News”

30 30 New DME Provider

31 31 Lower Out-of-Pocket Imaging Costs Lower out-of-pocket costs when using Reno Diagnostic Centers (RDC) or Saint Mary’s Imaging at Galena. Comprehensive panel of imaging tests and technologies. Convenient scheduling, professional staff, and easy-to locate facilities.

32 32 Health Coaching Free to all Prominence Members A personal health coach Physician and self referrals are encouraged HIGHLIGHTS

33 33 Rate how Prominence is doing? Feedback

34 Questions?

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