1. SR HMOs SCRIPPS ACCESS TRAINING AND DEVELOPMENT

2. WHAT IS A SR HMO? n A Medicare contracted HMO n Uses approved network of providers n PCP directs care

3. WHO IS ELIGIBLE? n Must be enrolled in Medicare Parts A & B n Continue to pay Part B premiums n Not have ESRD n Not be receiving hospice care n Must live in plans’ service area

4. WHY CHOOSE A Sr HMO? n Same Medicare benefits n Lower OOP expenses n Most offer additional benefits:  Preventive care  Prescription drugs  Dental care  Eyeglasses  Hearing aids

5. AUTHORIZATIONS PCP sends authorization request to UR for review n Required for:  Inpatient visits  Some outpatient services  Specialists

6. OUT OF NETWORK SERVICES n No POS option  Need auth from PCP  No auth, patient responsible for charges n POS option (tier 3)  No auth required  Higher OOP for out of network

7. FORMS Still considered a Medicare beneficiary n An Important Message From Medicare About Your Rights

8. ENROLLING & DISENROLLING n Between Nov & Dec Medicare beneficiaries can:  Enroll in a Sr HMO  Switch Sr HMOs  Change medical groups  Switch back to Medicare  New coverage begins Jan 1 st n Can also switch between Jan & March (but can’t add or change to a plan with prescription drug coverage unless they already have Medicare drug coverage) n Cannot use Sr HMO & M/C at same time

9. VERIFYING ELIGIBILITY n Verify with each visit n Call insurance to verify  Eligibility  Benefits  Authorization requirements

10. WHAT IS NEEDED FOR A CLEAN CLAIM n Name of medical group n Group number, if available n Policy number n Effective date n Correct billing address n Authorization number, if needed

11. MCARE HIC# FIELD n An extra step is required n On the Misc screen, in the Mcare HIC# field, enter the patient’s Medicare claim # n Medicare will pay us additional money To keep the registration process consistent, this extra step is a requirement at all sites.

13. SUMMARY n Must be enrolled in Medicare Parts A & B n PCP directs care n Authorizations are required n Less OOP expenses for the patient n Verify eligibility with each visit

14. ? QUESTIONS ?