1. Overview of Gateway Health Plan Medicare Assured® HMO SNP

2. Training Objectives
To provide training on Gateway Health Plan Medicare Assured®.
To provide training on Gateway’s Medicare Compliance Program.
To provide Fraud, Waste and Abuse training.

3. Definitions

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. Definitions
Medicare
A 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. Definitions
Medicaid
Joint 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. Definitions
Medicaid 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.

9. About Medicare Assured®

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 A
Be enrolled in Medicare Part B
Have Full Medicaid, or Qualified Medicare Beneficiary (QMB/ QMB Plus) Medicaid eligibility
Reside in Gateway Health Plan Medicare Assured® service area
Not have ESRD (End Stage Renal Disease) at time of enrollment

12. 2012 Service Area
Where 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 Benefits
What are the Medicare Assured® 2012 Benefits?
Gateway Health Plan Medicare Assured® provides Original Medicare benefits plus:
Prescription Benefits
Dental Benefits
Hearing Benefits
Vision Benefits
Health & Wellness Education
Fitness Program
Transportation Benefit, and
Bathroom Safety Products

14. 2012 Benefits
Gateway utilizes delegated entities to administer some Plan benefits
PBM (Pharmacy Benefit Manager):
Argus Health Systems, Inc. (Argus)
Dental
United Concordia Companies, Inc. (UCCI)
Vision
Davis Vision

15. 2012 Benefits
Gateway 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 formulary
Gateway members may obtain medications at any pharmacy that accepts Argus
Drugs 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 Deductible
Co-Payments:
Generic:
$0 or $1.10 or $2.60 – depending on income level
Brand:
$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 months
One cleaning every 6 months
One dental x-ray every 6 months
One 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 forward
Dentures:
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 exams
Routine hearing test
Fitting and evaluation for hearing aids
Hearing 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 services
Up to 4 routine eye exams per year
One pair of eyeglasses every year*
Up to $90 towards non-vendor frames
One 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 covered
services, plus:
Heart Disease Program
Diabetes Program
Asthma Program
Smoking Cessation
Newsletter

23. Fitness Program $0 co-payment for all covered services
Must use participating fitness center
Access to 1 fitness center per calendar month
Standard fitness center membership

24. Transportation Benefit
$0 co-payment for all covered services
Non-emergent, non-urgent transportation
Up to 36 one-way trips to plan approved locations per calendar year
Plan approved locations include medical, dental, vision, hearing, pharmacy, fitness center and behavioral health services
Must schedule at least 3 days in advance

25. Bathroom Safety Benefit
$0 co-payment for all covered services
Up 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 to
another year

26. Special Needs Plan (SNP) Enrollment and Disenrollment

27. SNP Enrollment / Disenrollment
Dual Eligible individuals may change plans monthly
Enrollment can be done:
In person, with a Gateway marketing representative
Phone, by calling Gateway
Phone, by calling MEDICARE
Internet (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 coverage
Covered on plan for 90 days (“deemed” period).

30. Member Materials

31. Commonly Used Terms Evidence of Coverage (EOC) book
Contract between the Plan and member:
Explains benefits and services
Explains what the member has to pay
Explains rules and responsibilities
Explains disenrollment process
Explains appeals and grievances.
Formulary book
List 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 EOBs
Pharmacy
Medical
Dental
Vision

33. Medicare Compliance Program

34. Medicare Compliance Program
Medicare Administration Department
Gateway Health Plan’s Medicare Regulatory and Compliance Department
Staff
Medicare Compliance Officer
Medicare Compliance Specialists
Government Affairs Specialist
Primary Liaison with CMS
All contact with regulatory agencies must be directed to Medicare Administration Department

35. Medicare Compliance Program
Responsible for assuring compliance with CMS requirements
Responsible 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 [7] core requirements:
Written policies, procedures, and standards of conduct
Compliance Officer and Compliance Committee
Effective training and education
Effective lines of communication
Enforcement of Standards
Monitoring and auditing
Procedures 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: OR
Call 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/Meeting
Notice of Non-Compliance
Warning Letter
Various Suppressions and Exclusions
Suspend Marketing & Enrollment Activities
Request for Corrective Action Plan
New Applications/Service Area Expansion (SAE) Denials
Audit Selection
Enforcement and Termination

41. Fraud, Waste and Abuse
Training

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 abuse
The types of fraud, waste and abuse that can occur
The process for reporting suspected fraud, waste and abuse
The protections for employees, and first tier, downstream and related entities, who report suspected fraud, waste and abuse

43. Fraud, Waste and Abuse
The 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 Abuse
The 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 Abuse
Fraud, waste and abuse can come from many sources:
Member
Providers
Pharmacy Benefit Manager (PBM)
Pharmacies
Agents

48. Fraud, Waste and Abuse
Person(s) responsible for Identifying Fraud and Abuse
All Gateway Health Plan® employees and Board of Directors
All Gateway Health Plan® First Tier, Downstream and Related Entities

49. Fraud, Waste and Abuse
Person(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 audits
Perform monthly reviews of State and Federal provider exclusion lists
Perform peer review ranking reports to identify outlying activity of providers and members
Perform periodic reviews with an emphasis on the audits identified in the annual Office of Inspector General (OIG) work plan

50. Fraud, Waste and Abuse
The methods for reporting Fraud, Waste and Abuse include but are not limited to the following:
Standardized Referral Process Form
Fraud and Abuse Hotline Method
Call 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 Abuse
The protections for individuals who report suspected fraud, waste and abuse
Whistle 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.