About AlphaCare OUR MISSON AlphaCare of New York (ACNY) is a locally-based health plan dedicated to serving the needs of the chronically ill, elderly and disabled members of our community. Our mission is to offer person-centered, culturally sensitive care to our members in community-based settings. We offer a full range of programs in the New York Area (Bronx, Brooklyn, Queens, Manhattan and Westchester), including Medicaid Managed Long Term Care (MLTC) and Medicare Advantage Plans. Our programs engage the member, care givers, providers and families in the development of care plans to consider their unique needs, preferences and competencies and to provide a full continuum of supports to promote wellness and patient satisfaction. We look to our primary care providers to partner with us in serving our members by providing high quality and cost effective care. 2
Medicare Plans Offered Dual Eligible Beneficiaries (AlphaCare Total HMO SNP) Medicare beneficiaries with Parts A and B and New York State Medicaid who reside in the service area. This is a special needs plan for dual-eligible beneficiaries. Medicare Eligible Beneficiaries (AlphaCare Renew HMO) Medicare beneficiaries with Parts A and B who reside in our service area. Medicare Eligible Beneficiaries (AlphaCare Resilience HMO SNP) Medicare beneficiaries with Parts A and B who reside, long-term, in a contracted nursing home within the service area. This is a special needs plan for institutional beneficiaries. 3
Medicaid Plan AlphaCare MLTC designed for Medicaid beneficiaries who require long- term care and support services in the community for more than 120 days. 4
Service Area SERVICE AREA MLTC SERVICE AREA MAPD/ISNP/DSNP 5
AlphaCare Renew HMO MAPD 6
AlphaCare Renew HMO MAPD 7
AlphaCare Total HMO SNP 8
AlphaCare Total HMO SNP 9
AlphaCare Resilience HMO SNP 10
AlphaCare Resilience HMO SNP 11
AlphaCare MLTC BENEFITS Care Management and Consumer Nutrition Social Day Care Directed Personal Assistance Services Home Care, including Nursing, Medical Social Services Prostheses and Orthotics Home Health Aide, Occupational, Physical and Speech Therapies Optometry/Eyeglasses Personal Care (such as assistance Social/Environmental Supports with bathing, eating, dressing, etc.) (such as chore services or home modifications) Dental Services Podiatry Personal Emergency Response System Rehabilitation Therapies Non-emergency transportation to Adult Day Health Care receive medically necessary services Audiology/Hearing Aids Home Delivered and/or meals in a Nursing Home Care group setting (such as a day center) Respiratory Therapy Medical Equipment Optometry 12
Primary Care Physicians As a Primary Care Physicians (PCP), you play a key role in assisting and accessing all health care benefits and services through ACNY on behalf of our members. As a PCP you will be expected to: Provide health counseling and advice Perform baseline Health Risk Assessments and periodic examinations Serve as a key member of our interdisciplinary care team Diagnose and treat conditions not requiring the services of a specialist Arrange inpatient care, specialist consults, and other ancillary services when medically necessary such as laboratory and radiological services Maintain a current medical record for each patient which takes into consideration current and comprehensive medical records 13
Health Risk Assessments Health Risk Assessment (HRA) – Completed with New Members Within 90 Days to Identify Those with Ongoing Needs and Annually Thereafter You will be compensated $300.00 for each completed HRA The HRA is specially aimed at providing ACNY with each member ’ s needs regarding: General Health Care Preventative Care Social Services Supports (as applicable) Prescription Drug Coverage Needs The submission instructions are as follow: To qualify for compensation, please be sure to complete all sections and sign the HRA form. Submit the completed HRA and CMS 1500 form within 45 days of the assessment examination to: Provider Relations: HRA Unit AlphaCare of New York 335 Adams Street, Suite 2600 Brooklyn, NY 11201-9816 14
Acuity Adjustment Program CMS reimburses health plans based on the health status of health plan members. This methodology uses a Risk Adjustment Factor (RAF) Score for each individual member. The RAF score is dependent on how thoroughly physicians document all of a patient’s pertinent medical condition at least once a year during a face-to- face visit. The aggregate of your individual patients’ RAFs determines your practice RAF, which is the number used (along with your enrollment) to calculate your acuity payment. A Physician’s Practice average RAF must be at least 1.05 and have a panel of more than 50 members to participate in the acuity program. The payment rate is a per member amount that increases as the patient’s RAF increases(see attached sheet), to provide physicians with additional reimbursement for the acuity of illness of their patient population. The calculation is based on the RAF for 2014 dates of service as calculated quarterly. Example of acuity calculation : A physician who demonstrates an average RAF score of 1.20 would receive an acuity payment of $17.00 per member per month (PMPM) or $204.00 per member per year (PMPY). Therefore, if they had 100 members they would receive: RAF - $17.00 PMPM X 100 members $1,700 RAF - $204.00 PMPY X 100 members $20,400 Note: This acuity payment is an addition to either the PCP capitation or FFS contracted payment schedules. All payments are subject to the physician’s documentation passing a validation audit. Please contact Provider Relations at 1-855-OK- ALPHA to be scheduled for your training ASAP. The program applies to Dates of Service: Calendar Year 2014 Payments will be made Monthly beginning 4/1/2014 using a 90 day look back of claims experience. 15
Acuity Adjustment Program DOS 2013 DOS 2013 Avg RAF Avg RAF Score PMPM PMPY Score PMPM PMPY 1.05 $ 5.00 $ 60.00 1.46 $ 20.25 $ 243.00 1.06 $ 5.10 $ 61.20 1.48 $ 20.50 $ 246.00 1.07 $ 5.25 $ 63.00 1.50 $ 20.75 $ 249.00 1.08 $ 5.50 $ 66.00 1.52 $ 21.00 $ 252.00 1.09 $ 5.75 $ 69.00 1.54 $ 21.25 $ 255.00 1.10 $ 6.00 $ 72.00 1.56 $ 21.50 $ 258.00 1.12 $ 6.25 $ 75.00 1.58 $ 21.75 $ 261.00 1.14 $ 6.50 $ 78.00 1.60 $ 22.00 $ 264.00 1.16 $ 6.75 $ 81.00 1.62 $ 22.25 $ 267.00 1.18 $ 7.00 $ 84.00 1.64 $ 22.50 $ 270.00 1.20 $ 17.00 $ 204.00 1.66 $ 22.75 $ 273.00 1.22 $ 17.25 $ 207.00 1.68 $ 23.00 $ 276.00 1.24 $ 17.50 $ 210.00 1.70 $ 23.25 $ 279.00 1.26 $ 17.75 $ 213.00 1.72 $ 23.50 $ 282.00 1.28 $ 18.00 $ 216.00 1.74 $ 23.75 $ 285.00 1.30 $ 18.25 $ 219.00 1.76 $ 24.00 $ 288.00 1.32 $ 18.50 $ 222.00 1.78 $ 24.25 $ 291.00 1.34 $ 18.75 $ 225.00 1.80 $ 24.50 $ 294.00 1.36 $ 19.00 $ 228.00 1.82 $ 24.75 $ 297.00 1.38 $ 19.25 $ 231.00 1.84 $ 25.00 $ 300.00 1.40 $ 19.50 $ 234.00 1.86 $ 25.25 $ 303.00 1.42 $ 19.75 $ 237.00 1.88 $ 25.50 $ 306.00 1.44 $ 20.00 $ 240.00 1.90 $ 25.75 $ 309.00 16
Star Measure Quality Program CMS (Medicare) has developed a Star Rating Program for Medicare Advantage (MA) Plans based on a variety of measures. The Ratings go from 5 (Excellent) to 1 (Poor), with 4.0 being the desired average. We have selected 13 clinical measures that you, the physician, have the ability to specifically and measurably impact for your patient panel (see attached). We will provide you with the patients who need these specific measures done and ask that you work with us and your patients to accomplish these measures. We will then aggregate your performance into a single Star Measure score for your panel. Quality incentives will then be paid as follows: Physicain Aggregate PMPM PMPY Star Score 3.5-3.9 $ 5.00 $ 60.00 4.0-4.4 $ 10.00 $ 120.00 4.5-5.0 $ 15.00 $ 180.00 A physician’s practice must have a panel size of greater than 50 members to qualify for the Star Measure Program. By way of example, a physician with a panel of 50 patients who achieves a Star Rating of 4 would receive a quality payment of $6,000 based on the formula above (50 X $120). Please contact Provider Relations at 1-855-OK-ALPHA to be scheduled for your training ASAP. The program applies to Dates of Service: Calendar Year 2014 17 Payments will be made annually beginning 4/1/2015
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