MEDICARE ADVANTAGE PRESENTED BY: KRISTIN SCOTT - BLUECROSS BLUESHIELD OF SOUTH CAROLINA
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Medicare Advantage Presented By: Kristin Scott
Overview
Learn about our Medicare Advantage plans.
Web Resources
• ID Card Guide
• BlueCross TotalSM PPO Provider Office Administrative Manual
• BlueCross SecureSM HMO Provider Office Administrative Manual
• Medicare Advantage Prior Authorization List
Also Visit
• Education Center
• News Bulletins
• www.SCBluesMedAdvantage.com
• www.cms.gov
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.
2
Participating Provider Agreement
The Provider Agreement and the Medicare Advantage Office Administrative Manual
outline the contractual responsibilities of the network provider regarding the Centers
for Medicare & Medicaid Services (CMS) requirements to comply with all Medicare
laws, regulations and CMS instructions, federal and state laws, and applicable
authorities in the performance of delegated services.
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.
Participating Provider Agreement
Here is a general summary of the provider requirements:
• The provider will file claims to the plan.
• The provider will accept BlueCross’ payment plus any patient copays, coinsurance
and deductibles as full reimbursement.
• The preferred provider will not bill the patient for more than his or her applicable
patient liability amount not to exceed the fee allowance.
• The provider agrees to cooperate fully with the Utilization Review Procedures in the
Professional Agreement.
• The provider will use other network providers for a member’s care.
• The provider agrees to bill promptly and in a manner approved by BlueCross for all
services.
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.
MEDICARE ADVANTAGE PRODUCTS
AND BENEFITS
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.
BlueCross TotalSM
BlueCross Total
BlueCross Total is a Medicare Advantage PPO plan that allows members to go to any
network doctor, specialist or hospital for in-network benefits. A member can choose
an out-of-network provider, but he or she may have to pay more for services. This plan
is supported by the Medicare Advantage PPO network of providers.
• The prefix is ZHP.
• The suitcase on the front of the card indicates
the network.
• The plan name is located on the front of the card
in the upper right quadrant
• If a BlueCross Total member chooses to seek
out-of-network services when in-network
services are available, higher out-of-network
cost sharing will apply.
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.
BlueCross Total Service Area
Service Area 2020 2021
Anderson, Cherokee, Greenville, Anderson, Cherokee,
Total Upstate Oconee, Pickens, Spartanburg, Greenville, Oconee, Pickens,
York Spartanburg, York
Aiken, Calhoun, Fairfield, Aiken, Calhoun, Chesterfield,
Florence, Horry, Kershaw, Dillon, Fairfield, Florence,
Lexington, Orangeburg, Richland, Horry, Kershaw, Lexington,
Total Midlands/Coastal
Saluda, Sumter Marion, Marlboro,
Orangeburg, Richland, Saluda,
Sumter
Beaufort, Berkeley, Charleston, Beaufort, Berkeley,
Total Lowcountry Dorchester, Georgetown Charleston, Dorchester,
Georgetown
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.
BlueCross Total Service Area
Products are offered to eligible consumers
in these counties; however, the Medicare
Advantage PPO Network includes
participating providers across the state.
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.
BlueCross Total Monthly Plan Premium 2020 2021 Total Upstate $19 $19 Total Midlands/Coastal $15 $15 Total Lowcountry $29 $29 BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.
BlueCross Total
2020 2021
Deductible $0 $0
In-Network Maximum
$6,700 $6,900
Out-of-Pocket
Combined Maximum
Out-of-Pocket
(Costs for covered
medical services from INN
and OON count towards
$10,000 $10,000
combined maximum OOP.
Plan premium does not
count toward Maximum
OOP.)
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.BlueCross Total
2020 2021
Inpatient Hospital-Acute INN $400 per day for days 1-4 INN $450 per day for days 1-4
$0 for days 5-90 $0 for days 5-90
Inpatient Hospital- INN $440 per day for days 1-4 INN $465 per day for days 1-4
Psychiatric $0 for days 5-90 $0 for days 5-90
Skilled nursing facility INN $0 per day for days 1-20 INN $0 per day for days 1-20
(SNF) care $178 per day for $184 per day for
days 21-100 days 21-100
Urgently Needed Services INN and OON $45 copay per INN and OON $50 copay per visit
visit
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.BlueCross Total
2020 2021
Worldwide $250 copay once per calendar $250 service specific deductible and
Emergency/Urgent year, then 20% coinsurance then a 20% coinsurance for emergency
Coverage care outside of the United States
Ambulance Services INN and OON $275 per one-way INN and OON $295 per one-way trip
trip for ground ambulance for ground ambulance
Hearing Aids The copay range is based on The copay range is based on different types and
styles of hearing aids. The lower range is for the
different types and styles of Advanced hearing aid type and the higher range
hearing aids. The lower range is is for the Premium hearing aid type.
for the Advanced hearing aid Premium hearing aids are available in
type and the higher range is for rechargeable style options (for and additional
$50 per aid). Member must use TruHearing
the Premium hearing aid type provider for this benefit.
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.BlueCross Total
2020 2021
Preventive Dental Fluoride Treatment is Fluoride Treatment not covered
covered
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.BlueCross Total
Part D
Prescription 2020 2021
Drug Coverage
Deductible $70 deductible on Tier 3, 4, and 5 $100 deductible on Tier 3, 4, and 5
Stage medications (Tiers 1 and 2 excluded) medications (Tiers 1 and 2 excluded)
Tier 1-$5 copay, Tier 2-$15 copay Tier 1-$5 copay, Tier 2-$15 copay
Initial Coverage Tier 1-$5 copay, Tier 2-$15 copay, Tier 3- Tier 1-$5 copay, Tier 2-$15 copay, Tier 3-
Stage $37, Tier 4-45% of cost, Tier 5-31% of cost $37, Tier 4-45% of cost, Tier 5-31% of cost
Coverage Gap When total drug spend reaches $4,020 When total drug spend reaches $4,130
(a.k.a. Donut Tier 1-same cost as Initial Coverage Stage Tier 1-same cost as Initial Coverage Stage
Hole) or 25% of costs (whichever is lower) or 25% of costs (whichever is lower)
Generic drugs (not Tier 1)-25% of cost Generic drugs (not Tier 1)-25% of cost
Brand drugs-25% + part of dispensing fee Brand drugs-25% + part of dispensing fee
Catastrophic When True out-of-pocket reaches $6,350 When True out-of-pocket reaches $6,550
Coverage Stage Member pays greater of: Member pays greater of:
5% coinsurance or 5% coinsurance or
$3.60 for generic and $8.95 for all other $3.70 for generic and $9.20 for all other
drugs drugs
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.BlueCross SecureSM
BlueCross SecureSM
BlueCross Secure is a Medicare Advantage HMO. Members must go to a network
doctor, specialist or hospital for in-network benefits.
• The prefix is ZOH or ZOM.
• The plan name is located on the front of the
card in the upper-right quadrant.
• Beginning on January 1, 2020, BlueCross
Secure Greenville and BlueCross Secure
Richland use the same provider network as
our PPO plan. This large provider network
includes every hospital in SC except for
MUSC.
Out-of-network services are NOT covered.
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association. 15BlueCross Secure
BlueCross Secure
BlueCross Secure offers two plans with a huge provider network throughout the state
of South Carolina for residents in the following counties:
1. BlueCross Secure HMO Greenville (ZOH prefix)
2. BlueCross Secure HMO Richland (ZOM prefix)
• Beginning in January 1, 2020 BlueCross Secure HMO members have access to the
same provider network as Medicare Advantage PPO members.
• In 2021, BlueCross Secure HMO members will have the access to the same large
provider network as they do today. This encompasses all hospitals in South Carolina
except for MUSC and makes it easy for BlueCross Secure HMO members to find a
network provider.
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.BlueCross Secure Monthly Plan Premium 2020 2021 Secure Greenville HMO $0 $0 Secure Richland HMO $10 $10 BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.
BlueCross Secure
2020 2021
Deductible $0 $0
Maximum Out-of-
Pocket $6,700
(Costs for covered Once member has paid $6,700
medical services count OOP for covered Part A and
towards maximum OOP. Part B services, member pays
Plan premium and costs $6,700
nothing for covered Part A and
for prescription drugs to Part B services for remainder
not count toward of year
Maximum OOP.)
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.BlueCross Secure
2020 2021
Doctor office visits Primary Care visits: $15 per Primary Care visits: $15 per visit
visit Specialist Visit: $40 per visit
Specialist Visit: $40 per visit
Telehealth Services $5 for each Telehealth visit $5 for each PCP or urgent care
Telehealth visit
Inpatient hospital stays Days 1-4: $400 per day Days 1-4: $425 per day
Days 5-90: $0 per day Days 5-90: $0 per day
Worldwide $250 copay once per calendar There is a $250 service specific
Emergency/Urgent year, then 20% coinsurance deductible and then 20%
Coverage coinsurance for emergency care
outside of the United States
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.BlueCross Secure
Part D
Prescription 2020 2021
Drug Coverage
Deductible $70 deductible on Tier 3, 4, and 5 $70 deductible on Tier 3, 4, and 5
Stage medications (Tiers 1 and 2 excluded) medications (Tiers 1 and 2 excluded)
Tier 1-$5 copay, Tier 2-$15 copay Tier 1-$5 copay, Tier 2-$15 copay
Initial Coverage Tier 1-$5 copay, Tier 2-$15 copay, Tier 3- Tier 1-$5 copay, Tier 2-$15 copay, Tier 3-
Stage $37, Tier 4-45% of cost, Tier 5-31% of cost $37, Tier 4-45% of cost, Tier 5-31% of cost
Coverage Gap When total drug spend reaches $4,020 When total drug spend reaches $4,130
(a.k.a. Donut Tier 1-same cost as Initial Coverage Stage Tier 1-same cost as Initial Coverage Stage
Hole) or 25% of costs (whichever is lower) or 25% of costs (whichever is lower)
Generic drugs (not Tier 1)-25% of cost Generic drugs (not Tier 1)-25% of cost
Brand drugs-25% + part of dispensing fee Brand drugs-25% + part of dispensing fee
Catastrophic When True out-of-pocket reaches $6,350 When True out-of-pocket reaches $6,550
Coverage Stage Member pays greater of: Member pays greater of:
5% coinsurance or 5% coinsurance or
$3.60 for generic and $8.95 for all other $3.70 for generic and $9.20 for all other
drugs drugs
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.BlueCross TotalSM Value
BlueCross Total Value
BlueCross Total value is a new Medicare Advantage PPO $0 premium plan for 2021
that allows members to go to any network doctor, specialist or hospital for in-network
benefits. A member can choose an out-of-network provider, but he or she may have to
pay more for services. This plan is supported by the Medicare Advantage PPO network
of providers.
• The prefix is ZHP.
• The suitcase on the front of the card indicates
the network.
• The plan name is located on the front of the card
in the upper right quadrant
• If a BlueCross Total Value member chooses to
seek out-of-network services when in-network
services are available, higher out-of-network
cost sharing will apply.
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.BlueCross Total Value Service Area
Service Area
Anderson, Cherokee, Greenville, Oconee,
Total Value Upstate Pickens, Spartanburg, York
Aiken, Calhoun, Chesterfield, Dillon, Fairfield,
Florence, Horry, Kershaw, Lexington, Marion,
Total Value Midlands/Coastal
Marlboro, Orangeburg, Richland, Saluda,
Sumter
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.BlueCross Total Value Service Area
Products are offered to eligible consumers in these counties;
however, the Medicare Advantage PPO Network includes
participating providers across the state.
Upstate
Midlands/Coastal
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.BlueCross Total Value
Monthly Plan Premium 2021
$0
Total Value Upstate
$0
Total Value Midlands/Coastal
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.BlueCross Total Value
2021
$0
Deductible
In-Network Maximum Out-of- $7,550
Pocket
Combined Maximum Out-of-Pocket $11,300
(Costs for covered medical services
from INN and OON count towards
combined maximum OOP. Plan
premium does not count toward
Maximum OOP.)
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.BlueCross Total Value
2021
Inpatient Hospital-Acute INN $495 per day for days 1-4
$0 for days 5-90
Inpatient Hospital-Psychiatric INN $620 per day for days 1-3
$0 for days 4-90
Outpatient Hospital INN $0-395 copay per visit
Emergency Care INN $90 copay per visit
Urgent Care INN $65 copay per visit
Diagnostic tests and procedures INN $0-275 copay per visit
Lab Services INN $10 copay
Diagnostic radiology services (e.g., MRI) INN $0-150 copay per visit
Outpatient x-rays INN $10-20 copay
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.BlueCross Total Value
2021
Annual Physical Exam INN $0 copay for one physical exam per year. This is in
addition to the Medicare-covered annual wellness visit and
the “Welcome to Medicare” Preventive Visit.
Hearing Hearing exam: INN $45 copay
Hearing aids: INN $699-999 copay*
Preventive Dental Oral exam: INN $0 copay*
Cleaning: INN $0 copay*
Dental x-rays: INN $0 copay*
Vision Routine eye exam: INN $0 copay*
Contact lenses: INN $0 copay*
Eyeglasses (frames and lenses): INN $0 copay*
Eyeglass frames: INN $0 copay*
Eyeglass lenses: INN $0 copay*
*There may be limits on how much the plan will provide
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.BlueCross Total Value
2021
Mental Health Services Inpatient hospital-psychiatric: INN $620 per day for days 1-3;
$0 per day for days 4-90
Outpatient visit with a psychiatrist (Group and Individual
Therapy: INN $40 copay
Outpatient visit (Group and Individual Therapy): INN $40
Skilled Nursing Facility INN: $0 per day for days 1 through 20; $184 per day for days
21 through 100
Rehabilitation Services Occupational therapy visit: INN $40 copay
Physical therapy visit: INN $40 copay
Speech and language therapy visit: INN $40 copay
Ground Ambulance INN and OON: $310 copay
*There may be limits on how much the plan will provide
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.BlueCross Total Value
2021
Podiatry Services Foot exams and treatment: INN $50 copay
Medical Durable medical equipment: INN 20% coinsurance per item
Equipment/Supplies Prosthetics: INN 20% coinsurance per item
Diabetes supplies: INN 0-20% coinsurance per item
Medicare Part B Drugs Chemotherapy: INN 20% coinsurance
Other Part B Drugs: INN 20% coinsurance
Supplemental Benefits Fitness benefit through Silver&Fit; hearing aids though
TruHearing; vision services through the VSP Network; meal
program after discharge from an inpatient stay; OTC benefit
through Medline
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.BlueCross Total Value
Part D Prescription
2021
Drug Coverage
Deductible Stage $200 deductible on Tier 3, 4, and 5 medications
Tiers 1 and 2 excluded
Tier 1-$5 copay, Tier 2-$15 copay
Initial Coverage Stage Tier 1-$5 copay, Tier 2-$15 copay, Tier 3-$47, Tier 4-45% of
cost, Tier 5-29% of cost
Coverage Gap (a.k.a. When total drug spend reaches $4,130
Donut Hole) Tier 1-same cost share as Initial Coverage Stage or 25% of
costs (whichever is lower), Generic drugs (not Tier 1)-25% of
costs, Brand drugs-25% of costs + part of dispensing fee
Catastrophic Coverage When True out-of-pocket costs reach $6,550
Stage Member pays greater of:
5% coinsurance or
$3.70 for generic and $9.20 for all other drugs
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.Value-Added Benefits
For all Medicare Advantage Plans
Vision Services Through a VSP Advantage Network Provider: $0 Comprehensive
through VSP WellVision Exam, $0 for one pair of glasses to include frames and
Network lenses or one pair of contact lenses every 2 years
Hearing Aids $45 in-network routine exam, up to 2 hearing aids per year ($699-
through TruHearing 999 per aid) through TruHearing (rechargeable option for an
additional $50 per hearing aid)
Fitness Benefit $0 copay for basic membership to a Silver & Fit participating
through Silver&Fit fitness center; up to 2 home fitness kits per year; 1,500+ home
workout videos, daily workout classes via Facebook Live and
YouTube; 1 Stay Fit Kit per year (wearable fitness tracker kit, yoga
kit, or strength kit); healthy aging coaching via phone
Diabetic Supplies 0% coinsurance for diabetic supplies through OneTouch (e.g.,
through OneTouch OneTouch Verio Reflect meter, OneTouch Verio Flex meter)
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.Value-Added Benefits
For all Medicare Advantage Plans
Meal Program $0 copay upon discharge from and inpatient stay (Hospital,
SNF, or Rehab facility); provides 10 meals total (2 meals per
day for 5 days)
OTC Benefit through $0 copay for members to get up to $25 per quarter (up to
Medline $100 per year) for over-the-counter supplies through Medline.
Members can order online, by phone, or through the mail
Blue CareOnDemandSM $5 copay per telehealth visit using Blue CareOnDemand
for Telehealth provides members access to a convenient, in-home way to
video chat with a doctor
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.Featured Benefit
Physical and Wellness Exams
In addition to the Medicare covered Annual Wellness visit, BlueCross also covers an
extensive annual physical exam including any of the following:
• Medical history collection
• Vital signs
• Observation of general appearance
• Head and neck exam
• Heart and lung exam
• Abdominal exam
• Neurological exam
• Dermatological exam
• Extremities exam
• Lab work
• EKGs and any other Medicare-covered tests administered during the exam
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.Featured Benefit
Physical and Wellness Exams
Coverage of an annual physical is in addition to the Medicare Part B-covered wellness
exam and the “Welcome to Medicare” preventive visit using these codes:
Medicare Part B Annual Wellness CPT codes:
• G0402 (initial preventive physical examination; face-to-face visit, services limited
to new beneficiary during the first 12 months of Medicare enrollment)
• G0438 (once per lifetime)
• G0439 (annually) or G0468 (annually FQHC code)
Annual Physical CPT codes:
• 99381 – 99387 (new patient physical)
• 99391 – 99397 (established patient physical)
Note: The supplemental benefits annual physical exam includes any service performed
by the physician in conjunction with the annual physical such as labs, EKG, etc.
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.Benefits
CMS has established requirements applicable to BlueCross Medicare Advantage
benefit plans.
All BlueCross Medicare Advantage benefit plans will:
• Provide members with all Part A (except hospice care) and Part B benefits covered
under Original Medicare
• Not impose limitations, waiting periods or exclusions from coverage due to pre-
existing conditions that are not present in Original Medicare
• Cover ambulance services dispatched through 911 or a local equivalent
• Cover all Medicare preventive services performed at a network provider without
copay
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.Benefits
All BlueCross Medicare Advantage benefit plans will:
• Provide maintenance and post-stabilization care services.
– Benefits include covered services related to an emergency medical condition
and which are provided after the member is stabilized either to maintain the
member’s stabilized condition or, under certain circumstances, to improve or
resolve the member’s condition.
• Renal dialysis services for members temporarily outside of the plan’s service area
• Offer a network of providers that allows sufficient access to covered services,
according to CMS standards.
• Provide benefits in a manner consistent with professionally recognized standards
of health care.
• Make covered services available to members through office hours or telephone
service, 24 hours a day, seven days a week.
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.CMS Medicare Advantage Star Rating
Improved Health Outcomes
Higher Star Ratings = Positive Patient Experience
Increased Provider Incentive
CMS Star Ratings
• What is it? As part of the Medicare Advantage Star Ratings
program, health plans and providers are scored based on the care that
is completed (e.g., HEDIS quality measures), patient satisfaction
(e.g., CAHPS surveys) and other administrative elements.
• Why does it matter? Each year, CMS publishes Medicare Star Ratings to assist beneficiaries in
choosing a plan that produces the highest quality of care. As a result, a higher Star Rating provides
increased financial opportunity for physicians through incentive programs.
• How can providers increase ratings? Providers can improve Star ratings by addressing all health
services for which a member is due and promptly submit proper documentation (e.g. claims,
diagnosis code, medical charts). Including initiatives to increase patient satisfaction will also drive
star rating improvement.
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.
37Improve STAR Performance
The Provider’s role in CMS Star Ratings
• Schedule patients for Medicare Annual Wellness Exams annually
• Document all care in the patient’s medical record
• Code and bill appropriately for services rendered and conditions addressed
• Promote medication adherence
• Recommend formulary alternatives
• Recommend participation in disease management programs
• Respond to medical record requests (within five business days)
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.Provider Quality Incentive
Patient Assessment Reports CPTII Coding Incentive
• Patient assessment reports are member • Available for providers who submit
specific and prepopulated for the accurate CPTII codes for specific
provider. services that contribute to positive
health outcomes and close HEDIS
• Requires an in person or telehealth visit care gaps.
with member to address, make referrals,
and complete the quality and risk care • Providers can earn up to $50 for
gaps highlighted. each CPTII code appropriately
submitted on a claim.
Diabetic Eye Exam
• Requires submission of medical records –
– Diabetic A1C Values
with assessment. – Diabetic Nephropathy Testing
– Hypertensive blood pressure control
• Submitted forms are worth up to $150. – Medication Reconciliation Post Inpatient
Hospital Discharge
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.Quality Nurse Navigators
Our Medicare Advantage program has Quality Navigator nurses available to work 1-on-1 with
provider offices.
Our Quality Navigator nurse team can assist with:
• Taking action on patient lists and identifying open care gaps
• Reducing the administrative burden of your office by collecting medical record information
through available EMR systems
• Understanding proper risk assessment documentation and coding
• Tracking participation in Medicare Advantage provider incentive programs
• Tracking your quality performance by sharing score cards on a regular basis
• Monthly in-depth education on quality measures and documentation requirements
• Hosting a community health event at or near your office to assist with care gap closures and
increase patient engagement
• Assisting with referrals to care management teams
• Being a general liaison for questions or concerns with Medicare Advantage
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.Pharmacy Concierge
Medicare Advantage now offers pharmacy concierge services to
members and providers.
Providers can take advantage of the pharmacy concierge program
to help with:
– Formulary alternatives
– Assistance with prior authorizations for medications and step therapies
– General guidance on medication adherence
– Collaboration in office with Medicare Advantage members
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.CAHPS and HOS surveys
Consumer Assessment of Healthcare Health Outcomes Survey (HOS)
Providers and Systems (CAHPS)
CAHPS is an annual survey that measures patient experience • The Health Outcomes Survey assesses a Medicare
with the health plan and the care they receive from their Advantage plan’s ability to maintain or improve the
provider. The results from this survey make up the majority of physical and mental health of its beneficiaries
an MA plan’s Star Rating.
• Patients rate their own physical and mental health
over a period of 2 years
Tips to improve CAHPS
• Keep open time slots available to allow for Tips to improve HOS
same or next day scheduling
• Demonstrate active listening, make sure
patients don’t feel rushed Be sure to address these topics with your MA patients:
• Obtain and review records from labs,
hospitalizations and specialists to stay up to • Improving or Maintaining Physical Health
date about your patient’s care • Improving or Maintaining Mental Health
• Follow up in a timely manner to review test • Monitoring Physical Activity
results • Improving Bladder Control
• Provide clear explanations of treatments or • Reducing the Risk of Falling
procedures
• Discuss and review all medications
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.Prior Authorizations
Services that require prior authorization and/or notification:
• Non-standard wheelchairs and non-standard beds
• All inpatient admissions (rehab facility, long term acute care and skilled nursing
facilities)
• Dialysis treatment (notification for members initiating treatment)
• Non-emergent air ambulance and non-emergent water transportation
• Behavioral health services (inpatient, rehabilitation, residential treatment
centers)
Inpatient admissions require a review if a continued stay is necessary.
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.Prior Authorizations
Methods for Requesting Prior Authorization
You can request prior authorization for these services using any of these methods:
• Medical Forms Resource Center (MFRC) – A new, secure online tool available at
www.formsresource.center
• My Insurance Manager – The secure online provider portal available at
www.SouthCarolinaBlues.com
• Telephone – Call 1-855-843-2325
• Fax – Fax requests to 803-264-6552
Companion Benefit Alternatives (CBA)
• Online – www.CompanionBenefitAlternatives.com
• Telephone – Call 1-800-868-1032
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.Case Management Program
Bi-weekly and monthly calls to Chronic Conditions Coaching (CCC)
members based on their condition.
Monthly and quarterly calls to
For members with catastrophic illness members based on their condition.
who need high touch monitoring and
CCC is for members with certain
interventions.
chronic conditions at high risk for
• Cancer
serious complications:
• Transplant/Organ Failure
• Diabetes
• Acute Trauma
• COPD/Asthma
• Stroke/Head injury
• CHF/Heart Disease
• Chronic infection
• High Blood Pressure
– HIV, Hepatitis C, etc.
• High Cholesterol
• Acute instability of a chronic
• Metabolic Health
condition
• Migraine
– Multiple Sclerosis flair, acute on
chronic respiratory failure, etc.
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.My Insurance Manager Tool
• Providers have access to a tool called My Insurance Manager (MIM) that allows
providers to sign-in and check a member’s eligibility.
• This tool also allows providers to look up a member’s benefits.
• When looking up benefits for Medicare Advantage members, providers will:
– Enter the procedure code
– Enter the Medicare modifier that corresponds to the service they will be
providing
– The correct benefit will be returned for that service
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.Dedicated MA Provider Services Team
• Medicare Advantage continues to build out its dedicated provider call
center with its reps.
• Medicare Advantage has an average answer speed of less than 30 seconds
once a provider has opted to speak to a rep.
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.Reminders
• Check the member’s ID card to determine his/her plan.
• Refer members to in-network providers.
• Verify eligibility and benefits prior to rendering services.
• Follow Medicare guidelines for providing covered services.
• Review the Provider Manual for complete information on all Medicare Advantage
plans.
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.Questions?
If you have questions about the content we
discussed following today’s presentation, please
email us at:
Provider.Education@bcbssc.com.
Please include “Medicare Advantage” in the
subject field.
Thank you for joining us today!
BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.You can also read
