What is a Medicare Advantage Plan?
A Medicare Advantage Plan is a type of Medicare health plan offered by a private company that contracts with Medicare to provide all Part A and Part B benefits. There are many different kinds of Medicare Advantage plans, including HMO, PPO, Special Needs Plan (SNP) and some others. Posted 07/10/2014
What is a Special Needs Plan (SNP)?
A Medicare Advantage plan designed for Medicare beneficiaries with unique special needs. There are different types of Special Needs Plans; we offer a “Dual Eligible” Special Needs Plan called BlueCare Plus. Posted 07/10/2014
What is a Dual Eligible Special Needs Plan (DSNP)?
DSNP is a Special Needs, Medicare Advantage Plan serving the unique individual needs of the chronically ill dual eligible Medicaid and Medicare population. Posted 07/10/2014
What is BlueCare Plus (HMO DSNP)SM?
BlueCare Plus is an HMO dual eligible special needs plan that operates as the individual’s point of contact for both Medicare and Medicaid, closing gaps in coverage and care.
Dual Eligible members have a Special Election Period (SEP) which allows them to enroll in BlueCare Plus and change plans every month if they choose, so our benefits are structured to keep the members’ needs in mind. (Enrollment for members will be made effective the first of the following month)
What are the CMS Requirements for DSNP?
A Model of Care (MOC) that must be approved by National Committee of Quality Assurance (NCQA) for Centers for Medicare and Medicaid Services (CMS).
Building on a strong foundation of managed care experience, our Model of Care coordinates Medicare and Medicaid benefits in a seamless continuum of care that is focused on the member and his/her needs. A care coordinator (nurse) is assigned to every member. Requirements include:
What is the MIPPA agreement with the Bureau of TennCare?
The MIPPA requires DSNP’s and Medicaid MCO’s to work together in an accountable manner to coordinate the delivery of Medicare and Medicaid covered services to beneficiaries.
“TennCare is not responsible for payment for these benefits, except for appropriate cost sharing amounts. TennCare is not responsible for guaranteeing the availability or quality of these benefits.” Posted 07/10/2014
We need additional information about enrolling in BlueCare Plus?
To find out more information about BlueCare Plus:
What is a Special Election Period (SEP)?
Dual Eligible members have a Special Election Period (SEP) which allows them to enroll in BlueCare Plus and change plans every month if they choose, so our benefits are structured to keep the members’ needs in mind. (Enrollment for members will be made effective the first of the following month) Posted 07/10/2014
What does BlueCare Plus Cover?
BlueCare Plus covers all of the services that Original Medicare covers except hospice coverage. Original Medicare covers hospice care even if the member is enrolled in BlueCare Plus.
Medicare coverage and payment is contingent upon a determination that:
The criteria above are codified through rulemaking in the Code of Federal Regulations (CFR) and are applied through coverage determinations. National Coverage Determinations (NCDs) are published on the CMS Website. Posted 07/10/2014
What is a Care Coordinator in BlueCare Plus?
A Care Coordinator is a nurse that helps members’ access community resources and coordinates their different Medicare and Medicaid services. A Care Coordinator is assigned to every member in BlueCare Plus. Posted 07/10/2014
What is an Interdisciplinary Care Team (ICT)?
The BlueCare Plus Model of Care necessitates a new level of communication with primary care physicians (PCPs) and other members of the “medical neighborhood”. The team is a group of health care professionals from diverse fields who work together toward a common goal for the patient. In BlueCare Plus the Care Coordinator works to develop an Individualized Care Plan (ICP) and create the ICT to assist the PCP in implementing the PCP’s plan of care and to compliment the PCPs plan of care for the patient, the information is shared with the ICT. The role of the ICT is to provide care management through analysis, collaboration and participation in team meetings and provision of appropriate healthcare services. Posted 07/10/2014
Who is responsible for the overall care of the BlueCare Plus member?
The Primary Care Physician (PCP) serves as the entry point for all of the patient’s medical and health care needs. The BlueCare Plus member’s PCP will always be the primary driver of the patient’s care and BlueCare Plus will serve as a conduit to assist in coordinating the member’s Medicare and Medicaid services. The Care Coordinators serve as an extension for the PCP by talking with members frequently and reinforce what the PCP has implemented for the member’s care. As an example, BlueCare Plus offers telemonitoring for our diabetic patients. If BlueCare Plus identifies an abnormal blood sugar result the PCP is contacted for appropriate action. Additionally, our Care Coordinators have access to our members drug claims payment database to assist PCPs in monitoring the patient’s medication adherence and refill patterns. Posted 07/10/2014
What is an Individualized Care Plan (ICP)?
The BlueCare Plus Care Coordinators develop an individualized care plan (ICP) through the Health Needs Assessment (HNA) and discussions with the member. The ICP is a draft plan to combine with the PCPs plan of care (POC). This process assists our PCPs in implementing the patient’s POC. The ICP creates a framework for designing and evaluating care that recognizes the patient’s health status, comorbidities, and psychosocial, cognitive and long-term needs. BlueCare Plus adds the personalized side of the care plan taking into consideration issues that can impact the member’s health and well-being including barriers that may prevent the patient from receiving needed services. Development and updates to the plan of care are accomplished by the ICT through analysis of a member’s health risk assessment, clinical data evaluation, PCP and other treating providers’ recommendations and input from the ICT. Posted 07/10/2014
How much time will the ICT teleconference call take?
BlueCare Plus is mindful of the PCPs schedule and will schedule the teleconference at the PCPs convenience. In some cases the teleconference can be conducted during the patient’s visit and generally last no more than 30 minutes.
BlueCare Plus provides a bonus to PCPs for ICT teleconferences to complete some core functions that are required of Medicare Advantage Dual Special Needs plans. The function of the ICT is to consistently collaborate to meet a member’s healthcare needs.
The codes that should be used for your participation in the ICTs are as follows:
Any PCP participating in the ICTs will be reimbursed $54 when they bill codes 99366, 99367 and 99368. Posted 07/10/2014
Medicare defines the definition of practitioners and physicians in the Internet Only Manuals (IOM) Publication 100-1 Chapter 5 Definitions. Physicians, nurse practitioners and physician assistants are included in the PCP bonus payment.
How do we file a claim to BlueCare Plus?
You will follow the same process as you do filing a claim to BlueCross BlueShield of TN claim. The member ID, which begins with ZEU will drive the claim to the correct tables.
To enroll in electronic claims filing, to add a provider to an existing electronic practice or make any changes in your electronic filing process you must complete an Electronic Provider Profile Form. Posted 07/10/2014Electronic Provider Profile Form for all Providers
How do we determine eligibility for BlueCare Plus members?
There are several ways to verify eligibility for our BlueCare Plus members:
How do we bill member liability?
BlueCare Plus (HMO SNP)SM is an HMO DSNP with a Medicare contract and a contract with the Bureau of TennCare which is responsible for any copayment, coinsurance and/or deductible amounts resulting in one claim being submitted to BlueCare PlusSM for dual eligible members. A dual eligible member is a Medicare enrollee who is eligible for TennCare and for whom TennCare has a responsibility for payment of the Medicare Cost Sharing Obligations under the State Plan.
The BlueCare Plus Remittance Advice will show the copay, coinsurance and deductible as member liability. However, the amount indicated under member liability is crossed over to the Bureau of TennCare for the processing of the member cost sharing.
BlueCare Plus submits all data relevant to the adjudication and payment of claims as defined by TennCare. TennCare uses this information to fulfill its crossover claims payment function for member cost sharing. As a result of the Medicare Improvements for Patients and Providers Act (MIPPA) agreement with the Bureau of TennCare, providers will not bill BlueCare Plus members for coinsurance, copayments or deductibles.
If you are a provider who has not received payment from the Bureau of TennCare for the copayment, coinsurance and/or deductible within sixty (60) days of the remittance date, please contact BlueCare Plus Provider Line at 1-800-299-1407. Posted 07/10/2014
This page was updated on October 1, 2018