Alan Wheatley

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Humana Inc.
North Carolina Medical Society
Alan Wheatley President East Region Humana Inc.
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Humana Highlights

• Founded in 1961 headquartered in Louisville, KY
• Fortune 200 company
• 7 million health plan members
• 2 million Medicare members
• Ranked number six among all U.S. companies in all
  sectors for technology leadership, according to
  Forrester Research
• Full spectrum of innovative products
• 20 years working with the Medicare Advantage
  Program

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Humanas Medicare Footprint
ME
WA
ND
MT
VT
NH
MN
MA
NY
OR
WI
SD
CT
MI
ID
RI
Milwaukee
NJ
WY
PA
Cleveland
Chicago
IA
Columbus
OH
NE
DE
Salt Lake City
Dayton
IN
MD
IL
NV
Cincinnati
Boulder
WV
UT
Indianapolis
DC
VA
Denver
Kansas City
Louisville
CO
MO
KS
Lexington
KY
St. George
CA
Raleigh
NC
Nashville
TN
AZ
Memphis
SC
OK
AR
NM
Atlanta
AL
Phoenix
GA
Dallas
MS
Shreveport
LA
TX
Jacksonville
Austin
Baton Rouge
Daytona Beach
San Antonio
Orlando
Houston
New Orleans
FL
AK
Tampa
Treasure Coast
Ft. Myers
South Florida
Corpus Christi
HI
PUERTO RICO
PFFS HMO Markets only
PDP States
Medicare Advantage/PDP
Local Markets
Feb 25, 2005 v3
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Medicares History
1965
1972 1977

1997 2003
Medicare Medicaid Eligibility extended to
HCFA created BBA creates
MC MMA established people with
disabilities program
passed
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Medicare Beneficiary Coverage Options
For a Medicare beneficiary, there are several
different health plan options available today
including

• Original Medicare
• Original Medicare, plus a Medicare Supplement (or
  MediGap policy)
• A Medicare Advantage plan choices include HMO,
  PPO and PFFS plan designs (depending on the
  service area)
• Prescription Drug Plan

No matter which option is chosen, the
beneficiary is still in the Medicare program.
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Medicare Advantage Plan Options

• Private Fee-for-Service (PFFS)
• Preferred Provider Organization (PPO)
• Health Maintenance Organization (HMO)
• Prescription Drug Plans (PDP)

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What Is Medicare Private Fee-for-Service?

• Created by the Balanced Budget Act of 1997
• Medicare Advantage design that works like
• Original Medicare, but with enhanced benefits
• Providers can accept members on a patient-by-
• patient basis
• Humana began offering PFFS plans in 2002
• Individual plans in 34 states and Puerto Rico
• Group plans in 50 states and Puerto Rico

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What Is Medicare Private Fee-for-Service?

• Defined by the Centers for Medicare and Medicaid
  Services (CMS)
• as a plan that
• Reimburses providers on a fee-for-service basis
• Does not place providers at risk
• Does not vary payment rates based on utilization
• Does not restrict provider selection among those
  
• who agree to accept the plans payment terms
• and conditions

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Private Fee-for-Service (PFFS)

• Members can seek care from any Medicare-approved
  provider that is willing to provide care and
  accepts the plans terms and conditions
• Plan benefits must include all services covered
  by Medicare Parts A and B
• Extra benefits may be offered by the plan
• A premium, in addition to the monthly Part B
  premium, may be required.
• Follows Medicare medical policies and guidelines
• Referrals and authorizations are not required
• Provider payments follow Medicare reimbursement
  methodologies
• Medical care is available outside of the plans
  service area

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Why Seniors Choose Humanas Medicare Advantage
Plans
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SilverSneakers and Silver Steps

• SilverSneakers Reside within 15 miles of a
  metropolitan statistical area (MSA), free
  membership to a network of fitness centers at no
  additional cost
• Staff trained in senior needs
• Specialized classes for seniors
• Motivational incentives
• SilverSneakers Steps Reside more than 15 miles
  from a MSA, self-directed walking program
• Online, telephone and mail support
• Prize incentives
• Offers social, as well as health, benefits to
  seniors

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Member Cost Share Impact
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Understanding benefits- PFFS

• Sales associate are required to articulate the
  product specifics
• Closely monitored. Constant reinforcement
• In bound and outbound verification calls
• Expanded hours of operation
• Expanded questionnaire
• Pre enrollment kits explaining benefits
• Welcome Calls
• Describing Health Management Programs
• Health Risk Assessment
• Explaining Benefits
• Provider education

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Why Medicare PFFS?

• Medicare Advantage Plan
• Same patients
• Patient receive better benefits
• Same reimbursement
• Same medical policies and guidelines
• No additional credentialing
• Medicare certified Humana certified
• No authorizations or referrals required
• No secondary billing in many cases
• Less bad debt

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Primary Care Provider

• Original Medicare
• Primary Care w/procedure
• (Office visit 99212 procedures)
• Billed charges 532.00
• Medicare allowable 332.12
• Patient coinsurance (20) 66.42
• Medicare pays (80) 265.70
• Total to Provider 332.12

Humana Gold Choice Primary Care
w/procedure (Office visit 99212
procedures) Billed charges
532.00 Medicare allowable
332.12 Patient copay
15.00 Humana pays 317.12 Total to
Provider 332.12
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Hospital Examples
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Preferred Provider Organization (PPO)

• Most common and popular type health plan for
  Americans
• Available on both a regional and local level
• Members may seek care from any provider that
  accepts Medicare
• Member out-of-pocket costs are lower when
  receiving care from network providers
• Referrals are not required for specialty care
• Plan benefits must include all services covered
  by Medicare Parts A and B
• Extra benefits may be offered by the plan

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CMS PPO Regions
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Health Maintenance Organization (HMO)

• Members choose a Primary Care Physician when they
  join the plan
• Referrals are required for specialty care or for
  certain services
• Members receive most care from network providers
• Only emergency and urgent care is covered outside
  of the service area
• Provider payments are based on their contract
  with the health plan
• Plan benefits must include all services covered
  by Medicare Parts A and B
• Extra benefits may be offered by the plan

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Prescription Drug Plans

• Part D is a voluntary program
• It is designed to provide coverage for outpatient
  prescription medications
• Part D will replace Medicare-approved drug
  discount cards, which will phase out by 5/15/06
• Available as
• Stand-alone prescription drug plans (PDPs)
• Medicare Advantage prescription drug (MA-PD)
  plans
• If MA members enroll in a PDP, they will lose
  their MA membership

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PDP Regions
ME
WA
ND
MT
VT
NH
MN
NY
OR
MA
WI
SD
ID
CT
MI
RI
WY
NJ
PA
IA
OH
DE
NE
IN
MD
IL
NV
UT
WV
DC
VA
CO
MO
KS
KY
CA
NC
TN
SC
OK
AR
NM
AZ
AL
GA
MS
LA
TX
AK
FL
HI
Note Each territory is its own PDP region.
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PDP Enrollment

• To receive Medicare prescription drug coverage,
  beneficiaries must
• Have Medicare Part A and/or be enrolled in Part B
• AND
• Enroll in a Medicare-approved prescription drug
  plan offered by a Medicare-approved organization
• OR
• Enroll in a Part D benefit offered by
  employers/unions responsible for retiree benefits
• OR
• Enroll in a fully insured MA plan with PD
  coverage offered by a Medicare-approved health
  benefits company

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PDP Enrollment

• Members eligible for both Medicare and Medicaid
• Will be automatically enrolled in a PDP plan if
  they do not enroll on their own
• If automatically enrolled in one plan, the member
  can switch to another plan at any time
• Will no longer receive prescription drug coverage
  from Medicaid
• No new supplements with prescription drug
  coverage will be sold after January 1, 2006

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Filling Prescriptions

• Humana members can have their prescriptions
  filled at more than 50,000 retail pharmacies
  nationwide
• Including Wal-Mart, Sams Club and Neighborhood
  Store pharmacies
• Members may also use mail order program for
  maintenance medications

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