MedStar 2019 Health Plan Kick Off 2019 MedStar Select Overview NOTE: This document is for training purposes only. Do not distribute. MedStar Select PPO 2019 Employee Health Plan Overview MedStar Select is an Employee PPO Plan Built on the MedStar Select Provider Network, featuring MedStar Health and contracted physicians and hospitals, as well as key community clinical partners We are a local health plan owned by MedStar Health. Our responsibility includes ensuring that as members of our communities, our associates and their families receive the highest level of quality care focused on health and wellness. Currently, membership is >13,800, which includes associates and dependents. Members have In-and-Out-of-Network benefits Union plans exist for a small set of associates, specifically the NNU Nurse Union and SEIU Nurse Union MedStar Select PPO
2019 Employee Health Plan Overview MedStar Select PPO Network: MedStar Select PPO Local Network In-Network benefits through MedStar Select Provider Network including all MedStar Health facilities and associated providers, as well as closely aligned independent providers in the community. Out-of-Area Network PHCS/Multiplan national network for Out of Service Area coverage Out-of-Network Services A member can see any Out-of-Network provider, but will have Out-of-Network cost shares associated with these visits For discounts on Out-of-Network services, members can utilize the Multiplan network Multiplan Out-of-Network providers located within the MedStar service area
MedStar Select PPO 2019 Sample Identification Card MedStar Select and SEUI Plan No PCP requirement PCP office visit co-pay: $0 Specialist co-pay: $30 ER: $250 Urgent Care: $10 MedStar Select NNU Plan No PCP requirement PCP office visit co-pay: $0 Specialist co-pay: $20 ER: $100 Urgent Care: $10 MedStar Select PPO Service Area MedStar Select Local Service Area Includes: DC Maryland: Anne Arundel County, Baltimore County, Baltimore City, Calvert County,
Carroll County, Charles County, Frederick County, Harford County, Howard County, Montgomery County, Prince Georges County, St. Marys County Virginia: City of Alexandria, Arlington County, City of Fairfax, Fairfax County, City of Falls Church When accessing medical care within the MedStar Select Service area, MedStar Select providers must be utilized in order to receive benefits at IN-NETWORK benefit level. For questions about participating providers, please call member services. MedStar Select provider directory can be accessed at www.MedStarProviderNetwork.org MedStar Select Out-of-Network Benefit MedStar Select Plan is a PPO, allowing members the choice to see any provider at the Out-of-Network benefit level MedStar Select members have benefits out of the MedStar Select Network at a higher cost share. Anytime care is accessed by a member using a provider outside of the Select Network, regardless of if they are in or out of the service area, the member will be responsible for 40% coinsurance after their deductible, unless otherwise noted. For Discounted Out-of-Network Services Multiplan Out-Of-Network within the MedStar Select Service area
The National Service area is the area inside of the MedStar Select Network To obtain information regarding providers in the MultiPlan network, call member services at 855.242.4872 Emergency room visits are always covered at the in-network benefit level. MedStar Select Out-of-Network Exceptions There are specific circumstances under which out-of-network services are covered at the in-network benefit level: 1. Students, associates, and/or their dependents who reside outside of the service area can obtain in-network level benefit coverage for non-emergency Out-ofNetwork (OON) services when utilizing the PHCS network. 2. Traveling: While traveling out of the service area, your emergency room services will be covered at the in-network benefits level. Non-emergent care is covered at the OON benefit level while traveling. i. Emergency care while traveling internationally is covered at the same benefit level as if the member were in the US. Depending on where services are received, the member may have to pay up front for medical expenses at the time of care. When the member returns home, they will be able to submit for reimbursement. 3. Lack of Access to Care: In the event that the MedStar network does not have
adequate access to a specific provider type inside of the service area, a member or provider can request an authorization for an OON provider to be covered at the InNetwork benefit level. Pre-Authorization is required. In-Network Referrals All providers are expected to utilize participating providers when making referrals. Please refer to the online directory at MedStarProviderNetwork.org for a list of participating providers, or contact provider services at 855-222-1042 for assistance. Please refer laboratory services to the following in-network laboratories: Laboratories at MedStar Health facilities Quest (includes genetic testing services) LabCorp (includes genetic testing services) Please refer dialysis services to participating Dialysis centers: DaVita Prior Authorizations The provider or patient is responsible for contacting the plan to
obtain authorization before receiving select services. If a prior authorization is required and one is not obtained, no payment will be made by the plan. Please refer to the Quick Reference Guide at http:// www.medstarprovidernetwork.org/2019-select-quick-reference-gui de for a listing of common services requiring a prior authorization, or contact provider services at 855-222-1042 for assistance. Drug Prior Authorizations For drugs covered under the medical benefit, please refer to the following process: To request Prior Authorization for medications covered under the Medical Benefit, please visit the following website: http://www.medstarprovidernetwork.org/medstar-select/pharm acy-resources/pharmacy-prior-authorization-forms For a comprehensive list of drugs covered under the medical benefit, please reference the Provider Manual. Contact the MedStar Pharmacy UM Services Team at 855-266-0712 for additional assistance. To request Prior Authorization for medications covered under the Pharmacy Benefit, please contact CVS Caremark at 888.771.7282
Select Medical Benefits 2019 Benefit Calendar Year Deductible In-Network Out-of-Network $0 Individual $0 Family $2,000 Individual $4,000 Family $1,500 Individual $3,000 Family $1000 Individual and $2000 Family for NUU Plan $6,000 Individual $12,000 Family Coinsurance (Paid by Plan Participant, after deductible)
None, unless noted 40% Office Visit PCP Paid In Full 40% coins after ded Office Visit Specialist $30 copay $20 NUU Plan 40% coins after ded Preventive Care Services (per ACA) Paid in full 40% coins after ded Copays do not count toward deductible, however deductible counts towards outof-pocket maximum
Out-of-Pocket Maximum OOP includes deductible, copays and coinsurance amounts. It does not include pharmacy copays OOP Maximums for In- and Out-of-Network accumulate together. Copays for Outof-Network Emergency Care accumulate toward the OOP Max. Diagnostic Services Advanced Imaging (e.g. PET, MRI, CT) $30 copay 40% coins after ded Other Imaging (e.g. X-ray, Sonogram) $15 copay 40% coins after ded
Lab and other services Paid in full 40% coins after ded $250 copay $100 NUU Plan $250 copay $100 NUU Plan Emergency Care (copay waived only if admitted, Emergency services available out-of-network) Select Medical Benefits 2019-Continued Benefit Urgent Care In-Network Out-of-Network $10 copay
40% coins after ded Outpatient Surgery $50 copay per surgery 40% coins after ded Inpatient Hospitalization (pre auth required) $100 copay per admission 40% coins after ded Medical Rehab coverage (medically necessary care non custodial; limited to 30 days per illness or injury) Paid in Full 40% coins after ded Morbid Obesity (pre auth required; ONLY performed at MedStar Centers of Excellence: currently bariatric surgery at Franklin Square and WHC)
Paid in Full Not covered Hospital Physician Services (Inpatient and Outpatient) Paid in Full 40% coins after ded Allergy Services PCP: Paid in Full Specialist: $30 copay ($20 for NUU Plan) 40% coins after ded Paid In Full 40% coins after ded Maternity Care ($100 reimbursed into HRA account if you deliver at MedStar facility) Note that an authorization is required beyond 48 hours for vaginal delivery and 96 hours for cesarean section for both mother and baby.
$100 copay 40% coins after ded Infertility Services (pre auth required; benefits for AI and IVF are combined and limited to four attempts per year and six per lifetime. Includes injectable drugs only. Attempt defined by transfer of embryo. Available to same sex couples. Sterilization not covered.) 50% coins 50% coins after ded Hospital Facility/Surgical Procedures (including diagnostic testing and treatments such as injections and serums) Immunizations and Inoculations (for common communicable diseases, tests and serums) Reproductive Health Select Medical Benefits 2019-Continued Benefit
In-Network Out-of-Network Therapy Services Physical and Occupational (60 visits per year/combined); Speech Therapy (60 visits per year); Therapeutic manipulation (chiro: 30 visits per year; treatment plan required after 10 visits) and Acupuncture $30 copay $20 NUU Plan 40% coins after ded Cardiac and pulmonary rehab Paid in Full 40% coins after ded Medical Therapy Services (chemo, radiation, dialysis, infusion therapy) Paid in Full
40% coins after ded Mental Health/Substance Abuse Inpatient hospital/facility and professional services $100 copay per admission 40% coins after ded Office visits for mental health/substance abuse Paid in Full 40% coins after ded Home health care (60 visits per year, must be coordinated through care management) Paid in Full 40% coins after ded Private duty nursing (pre auth required)
10% coins 40% coins after ded Skilled nursing facility/SNF (pre auth required) $100 copay per admission 40% coins after ded Mental Health/Substance Abuse Home Health Care Services Select Medical Benefits 2019-Continued Benefit In-Network Out-of-Network Other Medical Services Hospice Care, Organ Transplants (pre auth required)
Paid in Full 40% coins after ded Dental services related to accidental injury 10% coins 40% coins after ded Diabetic equipment/education (supplies such as test strips, glucometers and insulin are covered under Rx plan); DME; orthotics, braces, and prosthetics (pre auth may be required and limitations may apply) Paid in Full 40% coins after ded Nutritional Counseling (12 visit per year max; subject to medical necessity) Paid in Full 40% coins after ded **Note this grid is for training purposes only, do NOT distribute to
members. If members wish to receive a copy of this, advise them to contact their corporate benefits department. MedStar Select Pharmacy Benefit Manager CVS Caremark CVS Caremark is MedStar Selects Pharmacy Benefit Manager If a member does not have a MedStar Select pharmacy located at their work location, they are encouraged to call 443.777.6201 to learn how they can take advantage of the discount Any questions regarding coverage must be directed to CVS Caremark at 888.771.7282 or visit www.Caremark.com Please contact MedStar Selects Pharmacy UM Team for assistance with drugs covered under the medical benefit. 855.266.0712 For a comprehensive list of drugs covered under the medical benefit, including prior authorization requirements, please refer to the Provider Manual. MedStar Select Behavioral Health Vendor - Magellan Magellan is the behavioral health vendor for MedStar Select. To access the MedStar Select provider network, go to the portal (
www.MedStarMyHealth.org) and click on Find a behavioral health vendor on the provider directory page Click on Behavioral Health Network for MedStar Select Plan This will open a new page onto the Magellan site Click Register or Enter as a Guest It will ask you enter a phone number: MedStar Select number is 800.327.7855 Click continue Scroll to bottom of page and click Enter as a Guest Wellness MedStar Employee Plan Wellness Programs MedStar MyHealth services include: MyHealth OnLine - www.MedStarMyHealth.org is a secure website with comprehensive wellness resources, health trackers, quizzes, programs etc. MyHealth Questionnaire (MHQ) online Health Assessment that provides a snapshot of overall wellness, complete with personalized results and interactive tools
If associates enrolled in MedStar Select complete the MHQ between the dates of 10/30/2018 - 11/29/2018, they will receive a $30 credit per month on their health insurance premiums for all of 2019 New hires are encouraged to participate within 60 days of eligibility to receive the credit for the remainder of the calendar year Wellness Programs and Campaigns incentives/prizes for participation TBD by entity - available throughout the year with MedStar Employee Plan Wellness Tobacco Surcharge Tobacco Surcharge: MedStar Select will require all members to attest to usage/non-usage every year during the annual enrollment process
During annual enrollment process (online), members will attest to tobacco usage or non-usage Tobacco users will be assessed a $50 per month surcharge stating on January 1, 2019 This surcharge is only applicable to MedStar associates enrolled in medical coverage Members have an option to enroll and complete a MedStar-approved tobacco cessation program during the year to stop the surcharge. One of those options is the tobacco cessation program on the portal in the OnLine LifeStyle Programs under Self-Service Quick Links. Materials distributed to associates during annual enrollment relating to the tobacco surcharge are provided for your reference For all questions regarding the tobacco surcharge, please refer all associates to their Corporate Benefits Office at 410.933.2929 MedStar Employee Plan MyHealth Maternity Program Available to MedStar Select members and dependents Program Requirements: $50 into HRA for completing initial assessment Must be completed and member must enroll during 1st trimester to qualify for this reward $50 into HRA for completing the program, including the postpartum assessment with your MyHealth Maternity Care Advisor Member must have completed the initial assessment and enrolled during 1st trimester to qualify for this reward
$100 into HRA for a member who delivers at a MedStar facility Does not require 1st trimester enrollment and is independent of assessments mentioned above For more information, members can call 888.959.4033 between 8:30am and 5:00pm Monday-Friday MedStar Employee Plan MyHealth Care Advising Available to MedStar Select members and dependents Program Requirements: This is a targeted outreach program, members are not eligible for financial incentives unless they are contacted for enrollment Members can enroll to work with Care Advisor voluntarily, however no financial reward will be given unless they are contacted via the targeted outreach $25 into HRA for initial contact with Care Advisor $100 into HRA for enrollment in program $100 into HRA for completion of program or 6 month engagement Members are eligible for financial incentive one time only For more information, members can call 888.959.4033 between 8:30am and 5:00pm Monday-Friday MedStar Employee Plan
HRA Accounts for Incentives Health Reimbursement Account (HRA): Members enrolled in MedStar Select who participate in the MedStar MyHealth Maternity or Care Advising programs will receive incentives funded into an HRA. HRA dollars can be used to offset out-of-pocket medical expenses such as copays and deductibles No action needed by the member, by participating the member will be automatically enrolled Once the account is established, the member will receive a welcome packet that includes their Healthcare Spending MasterCard or Benny card HRA is administered by Trion, the same company that manages MedStars FSA account as well If a member already has an FSA account, they can access both accounts from the same card For a complete listing of eligible medical expenses, go to www.irs.gov/pub/irs-pdf/p502.pdf For more information, members can call Trion at 800.580.6854 or via the web at www.EnrollOnline.com/MedStar MedStar Employee Plan MedStar eVisit MedStar offers an online acute care visit program for MedStar Select members All visits are online and are accessible 24 hours a day, 7 days a week, 365 days a year
eVisits are considered INN and are treated as PCP visits $0 copay for MedStar Select Can be conducted via web (computer) or mobile device (mobile app) Consultation, diagnosis, treatment, and prescriptions when appropriate for common illnesses Members must enroll to receive services by either Downloading the mobile app for iOS or Android MedStar eVisit Visiting www.MedStar-eVisit.com Contacting 1.844.VISIT.00 Provider Resources . Provider Website Provider Website Resources Certificate of Coverage Provider Manual Medical Policies & Payment Policies Utilization Management information including Prior Authorization requirements Pharmacy information including protocols and the formulary (and a list of drugs covered under the medical benefit)
Behavioral Health Resources Provider Directory Provider Newsletters Notice of Privacy Practices Quick Reference Guide (including contact information) Medical Management services and forms Provider OnLine for access to claim information Training Opportunities Provider OnLine Portal o Specifically designed for practitioners and providers affiliated with MedStar Select o The Portal allows quick and efficient access to claim, benefit, and eligibility information for our members. o In addition, providers can chat online with Provider Services by clicking the link at the bottom of the home page. Provider OnLine Portal 1. Direct Provider Services Communicating Save time by messaging or chatting online with Provider Services through the Provider OnLine Portal. Communications are sent directly to the appropriate service area by selecting applicable topic. Providers have the options to select topics such as, but not limited to, Eligibility, Authorization Inquiry, Claim Inquiry, or Batch Inquiry.
Register for the Provider OnLine Portal today! Sign up through https://secure.togetherforyourhealth.com/WebRequests/Requests/SecurityRe quest.aspx?CLIENT=000101&ID=000001&DIV=0001 For further information on the Provider OnLine Portal, please contact Provider Services as 855.242.1042. Provider OnLine Portal-Continued Providers are able to: 2. Check Eligibility & Benefits Member eligibility verification in ONE easy step. Simply enter the Member ID, Last name, and First name, then click search. Eligibility results for applicable dependents and subscribers display within seconds. The result details show the member's specific benefits and effective date of benefits. 3. Submit Claims Offers a CST (Claims Submission Tool) that provides a complete Internet Portal solution for services provided by Health plan. 4. Check Claim Status The Claim Inquiry search allows providers to search by member or claim information online to obtain real-time claim status.
Detailed HCFA and UB claim detail is supplied, including adjustment reasons by clicking on the applicable claim from the search results. Providers who have questions on claims can compose an email to Provider Services on the claim detail screen directly. Claims Submission 1. Direct Submission 2. 3. o Submit claims through Provider OnLine (provider portal) online on www.MedStarProviderNetwork.org o
Register online or through Provider Services at 855.222.1042 Clearinghouse EDI Submission (recommended) o Providers with existing relationships with clearinghouses such as Emdeon, Relay Health, Allscripts may continue submitting claims in the format used by their billing software. o Clearinghouses will reformat to meet HIPAA standards o Electronic Submission: Payer ID 251MS Paper Claims Submission Paper claims can be submitted to: Claims Processing Center P.O. BOX 1200 Pittsburgh, PA 15230-1200 Key Reminders Claims must be submitted within 180 days of date of service COB claims within 180 days of the primary EOP remittance *Applies to all transmission Options
Electronic Prior Authorization Submission The ability to submit prior authorization requests electronically is available. You will have the option to access this functionality through Provider OnLine through Single Sign On, or you can choose to access Identifi Practice directly. If you are interested in obtaining access to submission requests through Provider OnLine or through Identifi Practice, please notify [email protected] to request permission and indicate if you are interested in accessing through Provider OnLine or directly into Identifi Practice. If you are seeking access through Provider OnLine, you must be a registered user before the Electronic Authorization Submission functionality can be offered. If you are not currently registered with Provider OnLine, instructions are located at MedStarProviderNetwork.org. A registered Administrator to Provider OnLine within your practice can grant access to additional users. For technical issues related to Electronic Authorization submission, please contact [email protected] Provider Appeals and Grievances o Written appeal to MedStar Select must be submitted by provider within 180 (medical necessity) or 120 (administrative) business days of the denial notification o The QRG is updated frequently and is a good source of information: o http://medstarprovidernetwork.org/medicare-choice/quick-reference-guide o http://medstarprovidernetwork.org/medstar-select/quick-reference-guide-frequently -updated o Call Medical Management at 855.242.4875 to request an expedited review for an appeal. Clinical documentation is required.
Use these forms to assist with Appeals, Grievances and Provider Issues found on MedStarProviderPortal.org: Authorization Request Form Administrative Reconsideration Request Appeal and Grievance Request Claim Appeal Request Formal Appeal Request Provider Claim Project Assistance Request MedStar Health Verbal Consent MD, VA, and DC Regulations Verbal Consent to provide personal health information for an adult to another person is not permitted in MD, DC, or VA. Therefore, for MedStar, all consent must be in writing before any PHI can be released for an adult member. Members are required to fill out a release form which can be obtained from Member Services. It is in the process of being added to the
www.MedStarMyHealth.org and to www.MedStarProviderNetwork.org. MedStar Select Plan Vendor List Benefit Medical Prescription Drug Dental Vision Flexible Spending Accounts Employee Assistance Program Wellness Provider Phone Website MedStar Select Plan CareFirst PPO Plan Kaiser Permanente
855.242.4872 800.628.8549 800.777.7902 Kaiser HMO Plan 301.468.6000 (local) CVS Caremark 888.771.7282 800.777.7902 Caremark.com Kaiser Permanente 301.468.6000 (local) KaiserPermanente.org Delta Dental PPO Plus Premier Plan DeltaCare USA Plan
Group Vision Services 800-932-0783 MedStarMyHealth.org CareFirst.com KaiserPermanente.org deltadentalins.com 800-422-4234 866.265.4626 GVSmd.com Trion 800.580.6854 EnrollOnline.com/MedStar Business Health Services 866.765.3277
MedStar MyHealth 855.242.4871 BHSonline.com Username: medstar MedStarMyHealth.org Fraud, Waste & Abuse . Fraud Waste and Abuse Fraud is an intentional act of deception, misrepresentation, or concealment in order to gain something of value. Waste is over-utilization of services and the misuse of resources. Abuse is excessive or improper use of services or actions that are inconsistent with acceptable business or medical practice. Sanctions can include revocation of license and suspension of payments. Penalties can include fines and prison sentences. You have a responsibility to report any possible cases of fraud, waste and abuse. Calls can be placed anonymously. MedStar Health Integrity Hotline: Call 877.811.3411 If you identify or suspect fraudulent activities/behaviors, report
immediately! MedStar Health Compliance Program to Combat Fraud Waste and Abuse Fraud is an intentional act of deception, misrepresentation, or concealment in order to gain something of value. Waste is over-utilization of services and the misuse of resources. Abuse is excessive or improper use of services or actions that are inconsistent with acceptable business or medical practice. Sanctions can include revocation of license and suspension of payments. Penalties can include fines and prison sentences. You have a responsibility to report any possible cases of fraud, waste and abuse. Calls can be placed anonymously. MedStar Health Integrity Hotline: Call 877.811.3411 If you identify or suspect fraudulent activities/behaviors, report immediately!
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