About AlphaCare OUR MISSON AlphaCare of New York (ACNY) is a - - PowerPoint PPT Presentation

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.

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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.

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Medicaid Plan

AlphaCare MLTC designed for Medicaid beneficiaries who require long- term care and support services in the community for more than 120 days.

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Service Area

SERVICE AREA MLTC SERVICE AREA MAPD/ISNP/DSNP 5

AlphaCare Renew HMO MAPD

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AlphaCare Renew HMO MAPD

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AlphaCare Total HMO SNP

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AlphaCare Total HMO SNP

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AlphaCare Resilience HMO SNP

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AlphaCare Resilience HMO SNP

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AlphaCare MLTC

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BENEFITS Care Management and Consumer Directed Personal Assistance Services Nutrition Social Day Care Home Care, including Nursing, Home Health Aide, Occupational, Physical and Speech Therapies Medical Social Services Prostheses and Orthotics Optometry/Eyeglasses Personal Care (such as assistance with bathing, eating, dressing, etc.) Social/Environmental Supports (such as chore services or home modifications) Dental Services Podiatry Personal Emergency Response System Rehabilitation Therapies Non-emergency transportation to receive medically necessary services Adult Day Health Care Audiology/Hearing Aids Home Delivered and/or meals in a group setting (such as a day center) Nursing Home Care Respiratory Therapy Medical Equipment Optometry

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

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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

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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.

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Acuity Adjustment Program

DOS 2013 Avg RAF Score PMPM PMPY DOS 2013 Avg RAF 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 $

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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 Star Score PMPM PMPY 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 Payments will be made annually beginning 4/1/2015

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Star Measure Incentive Program

Measure Measure Description 3 Star PT 4 Star PT 5 Star PT 1 Breast Cancer Screening Percentage of female MA enrollees age 40-69 who had a mammogram during the measurement year or year prior to the measurement year ≥ 63 % - < 74% ≥74% - <81% ≥81% 2 Colorectal Cancer Screening Percentage of MA enrollees aged 50-75 who had an appropriate screening for colorectal cancer ≥ 49 % - < 58% ≥58% - <65% ≥65% 3 Cardiovascular Care – Cholesterol Screening Percentage of MA enrollees aged 18-75 with ischemic cardiovascular disease who had LDL-C test performed during the measurement year. ≥ 83% - < 85% ≥85% - <89% ≥89% 4 Diabetic Care – Cholesterol Percentage of MA enrollees aged 18-75 with diabetes who had LDL-C test performed during the measurement year ≥ 83 % - < 85% ≥85% - <93% ≥93% 5 Glaucoma Testing Percentage of MA enrollees aged 65+, without a prior diagnosis of glaucoma (or suspected Glaucoma) who received a glaucoma eye exam by an eye care professional during the measurement year ≥ 64 % - < 70% ≥70% - <77% ≥77% 6 BMI Percentage of MA enrollees age 18-74 who had an outpatient visit and who had their body mass index (BMI) documented during the measurement year or the year prior to the measurement year ≥ 68 % - < 77% ≥77% - <89% ≥89% 7 Osteoporosis Management in Women who had a Fracture Percentage of female MA enrollees aged 67+ who suffered a fracture during the measurement year and who subsequently had either a bone mineral density test or were prescribed a drug to treat or prevent osteoporosis in the 6 months after the fracture. ≥ 36 % - < 60% ≥60% - <70% ≥70% 8 Diabetes Care – Eye Exam Percentage of MA enrollees aged 18-75 with diabetes who had a retinal or dilated eye exam performed (by an eye care professional) during the measurement year. ≥ 53 % - < 64% ≥64% - <70% ≥70% 9 Diabetes Care – Kidney Disease Monitoring Percentage of MA enrollees aged 18-75 with diabetes who had medical attention for nephropathy during the measurement year ≥ 83 % - < 85% ≥85% - <89% ≥89% 10 Diabetes Care – Blood Sugar Controlled Percentage of MA enrollees age 18-75 with diabetes whose most recent Hemoglobin A1C test during the measurement year was ≤9% . ≥ 64 % - < 80% ≥80% - <84% ≥84% 11 Diabetes Care – Cholesterol Percentage of MA enrollees age 18-75 with diabetes whose most recent LDL-C level during the measurement year was ‹100. ≥ 44 % - < 53% ≥53% - <59% ≥59% 12 Controlling Blood Pressure Percentage of MA enrollees aged 18-85 with hypertension whose most recent blood pressure obtained during the measurement year was adequately controlled (<140/90) ≥ 49 % - < 63% ≥63% - <77% ≥77% 13 Rheumatoid Arthritis Management Percentage of MA enrollees with Rheumatoid arthritis during the measurement year who were dispensed at least one ambulatory prescription for a disease modifying anti-rheumatic drug (DMARD) ≥ 66 % - < 78% ≥78% - <83% ≥83%

18 PT = Performance Threshold

Prevention Quality Indicators (PQIs)

• The Prevention Quality Indicators

(PQIs) are a set of measures developed by the Federal Agency for Healthcare Research and Quality (AHRQ) for use in assessing the quality

• f outpatient care for “ambulatory care

sensitive conditions” (ACSCs). ACSCs are conditions for which good

• utpatient care can potentially prevent

the need for hospitalization, or for which early intervention can prevent complications or more severe disease.

• The PQIs are measured as rates of

admission to the hospital for these conditions in a given population.

• There are 12 PQIs that pertain to
• adults. They are the rates of admission

to the hospital for:

PQIs Category PMPY

Short-term complication of diabetes Diabetes 0 PQIs = $10 Long-term complication of diabetes Diabetes 0 PQIs = $10 Uncontrolled diabetes Diabetes 0 PQIs = $10 Lower-extremity amputation among diabetics Diabetes 0 PQIs = $10 Hypertension Circulatory 0 PQIs = $10 Congestive Heart Failure Circulatory 0 PQIs = $10 Angina Circulatory 0 PQIs = $10 Chronic obstructive pulmonary disease Respiratory 0 PQIs = $10 Asthma Respiratory 0 PQIs = $10 Dehydration Acute 0 PQIs = $10 Bacterial pneumonia Acute 0 PQIs = $10 Urinary tract infection Acute 0 PQIs = $10

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Working with AlphaCare Sales & Marketing Agents and Staff

AlphaCare has multiple agents in the community assigning new members to your practice by:

Community Events & Activities Contracted Sites Field RVs and Mobile Office Locations Physician Office Placements Direct Mail Local Advertising

AlphaCare has other new member enrollment initiatives that will increase your member panel by:

Call 1-855-OK-ALPHA to schedule your custom marketing campaign

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Physician Office Placements

Call 1-855-OK-ALPHA to schedule your Compliant Marketing Campaign

Our licensed sales & marketing agents can work in your

• ffice in a compliant manner. This means the following

areas are restricted for marketing activities :

Working with AlphaCare Sales & Marketing Agents and Staff

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No patient treatment rooms No waiting areas No pharmacy counters

For an evaluation of a suitable compliant marketing area, please contact our agents to identify the appropriate space within your office.

Referral & Authorization Process

For specific details on the AlphaCare referral and authorization process, please consult our website. Self Referral The self referral process allows members to “self refer” to in-network providers for services designated by the DOH, CMS, and/or the member’s benefit plan to be “self referred”

• services. Examples of self referral services

when provided by a participating in-network provider:

• Annual GYN Well Woman visits including

pap smear

• Annual Mammogram Screening
• Influenza Vaccinations

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Prior Authorizations

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The follow services require prior authorization:

• Services rendered in hospital outpatient services
• Outpatient substance abuse services
• Inpatient confinements including: elective inpatient,skilled nursing facility,

select behavioral health (including partial hospital), rehabilitation and long- term/sub-acute care services

• Advanced radiological, diagnostic cardiac, musculoskeletal (pain

management) and diagnostic sleep services

• Chiropractic services after 2 visits
• Cosmetic procedures
• Select durable medical equipment (DME) items
• Home health care services
• Select pharmaceuticals
• Skilled therapy: occupational, physical and speech therapy services
• Transplant services

For more information, visit www.alphacare.com.

Member Eligibility

It is important that the member’s eligibility is checked at the time of each visit. A member’s eligibility can change at any time for a number of reasons, including change

• f PCP or change to a different health plan.

When a member presents their ACNY card in your

• ffice, we encourage you to make a photocopy of the

front and back of the card for your file. The member’s card will identify their plan, the selected PCP and any applicable co-pay amount. Please remember that the ID card does not guarantee eligibility. Check eligibility by contacting: ACNY Customer Service 1-(855)-OK-ALPHA

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Claims Submission

ACNY accepts claims processing and payment for services.

Submit Paper Claims or Encounter Data to: Relay Health 1564 Northeast Expressway Mailstop: HQ-261-AlphaCare Atlanta, GA 30329-2010 Electronic Claim Submission Electronic Payor ID#: ALPHA Providers MUST include their NPI number and ACNY ID on all claims submissions. For claims inquires ACNY Customer Service 1-(855) MD-ALPHA

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Member Grievance & Appeal Procedure

Medical (Member Issues)

• ACNY Medical Director is solely responsible for denying reimbursement or coverage of

services and or procedures related to medical necessity.

• ACNY Medical Director is available for peer-to-peer discussion before issuing a denial.
• Additional information may be requested to further understand the medical necessity.
• Member has the right to appeal decision to deny, reduce or terminate services.

If a provider appeals on behalf of a member, the provider must complete the Appointment

• f Representative form located at:

http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf Send the appeal to: AlphaCare of New York Appeals and Grievance Department 335 Adams Street, Suite 2600 Brooklyn, N.Y. 11201-9816

• Physicians may provide documentation in support of an appeal
• 72-hour expedited appeals are available in urgent cases

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Provider Appeals

• Appeal: If you disagree with the determination made by ACNY, your appeal may be

submitted for:

• Lack of medical necessity
• Preauthorization issues
• Late submission
• Requests for provider appeal must be submitted within 45 days of the decision.
• Appeals must be submitted in writing with all pertinent documentation substantiating the

request.

• Appeal determinations will be final and binding and in keeping with the provisions of

your contract with ACNY.

• Mail appeals to :

AlphaCare of New York Appeals and Grievance Department 335 Adams Street, Suite 2600 Brooklyn, N.Y. 11201

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Key Contacts

ACNY Customer Service 1-(855) OK-ALPHA

ACNY Website:

http://www.alphacare.com

Contact for:

• Member Eligibility
• Member Complaints and Grievances
• General Benefit Inquiries
• Participating Providers Listing/ Search
• Referral and Authorization Status
• Claims Status or Resolution
• Provider Contract Inquires
• Provider Appeals

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Questions?

Thank you for your participation in AlphaCare of New York

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