Needs Review Not Apprvd
May 2018, Issue 30
Introducing Your New Retiree Health Plan Advisory Board
We are pleased to introduce you to your new Retiree Health Plan Advisory Board (RHPAB) board! This board was created by the Governor under Administrative Order 288 to give retirees in the Public Employees, Teachers, and Judicial Retirement Systems (PERS/TRS/JRS) a voice in the administration of the retiree health care plans. The board members are:
- Judy Salo (Board Chair)
Judy is a past president of NEA/Alaska and served on the Board of Directors of the National Education Association. She is a retired teacher and a former State Senator who represented the Northern Kenai and south Anchorage. Judy now lives with her husband in Big Lake.
- Cammy Taylor (Board Vice-Chair)
Cammy Oechsli Taylor, of Anchorage, is a retired lawyer who worked in various state departments including the Department of Law, Department of Natural Resources, and the Oil and Gas Conservation Commission. Since retiring, she has worked as a volunteer with retiree groups on various retiree benefits issues.
- Mark Foster
Mark Foster is a management consultant who has provided financial and economic analysis of health care markets in Alaska for a variety of clients. His work includes an analysis of the impact of the Affordable Care Act on Alaska for the Alaska Health Care Commission and an analysis of the potential value of consolidation Alaska public employee health plans and medical service procurement.
- Joelle Hall
Joelle Hall is the Director of Operations of the Alaska AFL-CIO. She has a Bachelor’ degree in Foreign Language and lives in Peters Creek with her husband and two children.
- Gayle Harbo
Alaska Retirement Management Board (ARMB); TRS retiree
Gayle Harbo, of Fairbanks, is retired and currently serves on the Alaska Retirement Management Board representing TRS. She holds a BS in Math and an MA in teaching, and has served on the ARMB since its inception in 2005.
- Dallas Hargrave
Human Resources Official
Dallas Hargrave, of Douglas, is the Human Resource/ Risk Management Director for the City and Borough of Juneau, where he oversees the city’s health benefits plan and other benefits. He holds a Master’s of Public Administration from the University of Alaska Southeast and a Juris Doctorate from the University of Denver.
- Mauri Long
Mauri Long, of Anchorage, is a lawyer whose practice has been dedicated to trial and litigation, specializing in cases involving medical care. She is knowledgeable about the provision of medical care, insurance, and dispute resolution.
The board will meet quarterly. Additional information, including meeting dates and how you can attend and participate in these public board meetings, is available on the AlaskaCare RHPAB webpage.
If you do not have access to a computer, you can request information through the Division of Retirement and Benefits toll-free at (800) 821-2251, or in Juneau at (907) 465-4460. For more information about the AlaskaCare Retiree Health Plan, see the plan booklet webpage.
New Medicare Cards Coming April 2018
The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 requires the Centers for Medicare and Medicaid Services (CMS) to remove Social Security numbers (SSN) from all Medicare cards by April 2019. A new Medicare Beneficiary Identifier (MBI) will replace the SSN-based Health Insurance Claim Number (HICN) on the new Medicare cards for Medicare transactions like billing, eligibility status, and claim status.
Under the current system, for each person enrolled in Medicare, CMS currently uses an SSN-based HICN to identify people with Medicare and to administer the program. CMS used the HICN with their business partners:
- The Social Security Administration (SSA)
- The United States Railroad Retirement Board (RRB)
- State Medicaid Agencies
- Health care providers
- Health plans
Under the new system, for each person enrolled in Medicare, CMS will:
- Assign a new MBI
- Mail a new Medicare card
The MBI, like the SSN, is confidential and should be protected as Personally Identifiable Information (PII).
Why are the new Medicare cards important?
The biggest reason CMS is removing the SSN from Medicare cards is to fight medical identity theft for people with Medicare. By replacing the SSN-based HICN on all Medicare cards, CMS can better protect:
- Private health care and financial information.
- Federal health care benefit and service payments.
What’s the timeline for the new Medicare cards and what does it mean for me?Getting Started
Beginning in April 2018, CMS will start mailing the new Medicare cards with the MBI to all people with Medicare in phases by geographic location.Transition Period
CMS plans to have a transition period where you can use either the HICN or the MBI to exchange data with them. The transition period will begin no earlier than April 1, 2018 and run through December 31, 2019.
Incoming premium payments: People with Medicare who don’t get SSA or RRB benefits and submit premium payments should use the MBI on incoming premium remittances. However, CMS will accept the HICN on incoming premium remittances after the transition period (Part A and Part B premiums, Part D income related monthly adjustment amounts, etc.)
How will the MBI look?
The MBI will be:
- Clearly different than the HICN and RRB number
- 11 characters in length
- Made up only of numbers and uppercase letters (no special characters); if you use lowercase letters, the CMS system will convert them to uppercase letters
Each MBI is unique, randomly generated, and the characters are “non-intelligent,” which means they don’t have any hidden or special meaning.
What do the new Medicare cards mean for people with Medicare?
The MBI won’t change Medicare benefits. People with Medicare may start using their new Medicare cards and MBIs as soon as they get them. The effective date of the new cards, like the old cards, is the date each beneficiary was or is eligible for Medicare.
Where can I get more information about the new Medicare cards?
MyMedicare.gov Personalizes Information
MyMedicare.gov is an innovative web portal—a free, secure online service for accessing personalized information regarding your Medicare benefits and services. Only people with Medicare who register as portal users, or trusted individuals they choose, will be able to view their information using a unique password. This tool is available in English and Spanish. You can use MyMedicare.gov to do the following:
- View claim status (excluding Part D prescription claims). Order a duplicate Medicare Summary Notice (MSN) or replacement Medicare card.
- View eligibility, entitlement, and preventive services information.
- View enrollment information, including prescription drug plans.
- View or modify your drug list and pharmacy information.
- View your address of record and Part B deductible status.
- Access Centers for Medicare and Medicaid (CMS) online forms, publications, messages.
To get started, have your red, white, and blue Medicare card handy and register at MyMedicare.gov for a password. You can then take a tour and use the website.
It’s important to review the Medicare Summary Notices that you receive by mail or view them online to be sure you received the services for which Medicare was billed. If you don’t have a convenient way to track your healthcare services, feel free to ask for a Personal Health Care Journal from Alaska’s Medicare Information Office. Call toll-free at (800) 478-6065 or in Anchorage at (907) 269-3680.
Coalition Health Centers in Anchorage and Fairbanks Welcome Alaskacare Employee Health Plan Members
The Coalition Health Centers, sponsors of the annual fall health fairs, are now welcoming AlaskaCare Employee Health Plan eligible members and dependents in Anchorage and Fairbanks. The Centers offer wellness and preventive care, as well as walk-ins for acute care (unexpected illness or injury.) Appointments are required for wellness and preventive care.
Services received at Coalition Health Centers are not subject to your plan’s annual deductible; you will only be charged a $25 co-pay for the office visit. Do not submit claims for these services. Coordination of benefits does not apply. See the AlaskaCare Employee Health Plan amendment effective March 1, 2018 for additional information.
Payment for sevices at the Centers is as follows:
- Acute/Unexpected Illness/Injury: Co-Pay $25/Office Visit
- Wellness & Preventive Care: Preventive $0/Office Visit
Coalition Health Center schedule:
Monday through Friday
7:30 a.m. – 6:30 p.m. (By appointment)
8:30 a.m. – 4:30 p.m. (Walk-ins welcome for acute care)
Coalition Health Center locations:
- Anchorage Coalition Health Center
Ages 5 and up
Alaska Regional Hospital
2741 Debarr Rd., Suite C210
- Fairbanks Coalition Health Center
Ages 2 and up
Ridgeview Business Park
575 Riverstone Way, Unit #1
Outpatient Rehabilitative Care Coverage in the AlaskaCare Retiree Health Plan
This article does not apply to the AlaskaCare Employee Health Plan. For details about coverage in the Employee Plan, see the plan document at AlaskaCare.gov.
Outpatient rehabilitative services such as chiropractic care, physical therapy, massage therapy, and occupational therapy are commonly obtained following joint replacement surgery or after suffering an injury to your back, knee, shoulder, or other joints. If you are planning an upcoming surgery or are currently under care for this type of condition, it is important to understand your rehabilitative care benefits under the AlaskaCare plan.
What coverage for rehabilitative services does the AlaskaCare Retiree Health Plan offer?
The Medical plan covers outpatient rehabilitative care designed to restore and improve bodily functions lost due to injury or illness. This care is considered medically necessary only if significant improvement in body function is occurring and is expected to continue. Care (excluding speech therapy) aimed at slowing deterioration of body functions caused by neurological disease is also covered.
How does the plan determine if the services are medically necessary?
The AlaskaCare claims administrator (currently Aetna) is required to verify that services are medically necessary per the guidelines listed in the AlaskaCare plan document. In order to do so, they will request copies of your treatment records from your provider. Generally medical review is not needed for these services if the course of treatment does not exceed 25 visits. Under Aetna, clinical records are requested from your provider when the claim for the 20th visit for a condition is received.
What information does my provider need to supply?
Your provider will need to supply clinical records that contain information on the initial evaluation, the most recent therapy re-evaluation with an updated plan of care, the last five daily therapy and progress notes, and documentation supporting the need for ongoing supervised rehabilitative care including dates of surgery, invasive procedures or a change of diagnosis. The goal of therapies and treatment should be to rehabilitate the patient to a point where he/she can function adequately in his/her normal daily activities. There must be reasonable expectations that the therapy/ treatment will produce significant improvement in the patient’s condition within a reasonable period of time. The AlaskaCare plan does not cover “maintenance” care, that is, services to keep the patient in his/her “rehabilitated” state. Maintenance is not considered a “medically necessary service”.
What happens if my provider does not submit my records after the 20th visit?
The AlaskaCare claims administrator will continue to process claims until the claim for the 25th visit is received. At that point all claims in excess of the 25th visit will be pended awaiting clinical records that support medical necessity. If no records are received within 45 days, the claims will be denied. (If you live in North Carolina or Texas the timeline may vary, please contact the Aetna Concierge at (855) 784-8646 for additional information.)
What if the AlaskaCare claims administrator determines the clinical records do not support the treatment as medically necessary?
It is essential that AlaskaCare members understand that “medical necessity” in this instance requires continued significant clinically documented improvement. You may want to direct your provider to Aetna’s Clinical Policy Bulletin in advance of your 25th visit. (The bulletins are numbered as follows: 0243 for speech therapy, 0325 for physical therapy and 0107 for chiropractic services.) This will allow your provider to see additional detail on what services and procedures are considered medically necessary. If it is determined by the AlaskaCare claims administrator that the treatment is not medically necessary, all claims after the 25th visit for that condition will be denied.
Is the need to verify medical necessity a change with this administrator?
No, the requirement for treatment to be medically necessary is a provision of the AlaskaCare retiree health plan. Previous claims administrators were also required to make medical necessity determinations per the guidelines listed in the AlaskaCare plan document.
What can I do if my rehabilitative care is denied?
You have the right to appeal a denial. You should work with your provider to ensure all clinical records supporting that the services were medically necessary are supplied to AlaskaCare Claims Administrator with your level I appeal. The Member Complaint and Appeal form is available on the AlaskaCare website’s Retiree Forms Index page.
If your appeal is denied, you may apply for an external review. At this level an independent review organization (IRO) will consider the AlaskaCare plan provisions, your clinical information, your provider’s recommendation, Aetna’s recommendation, and other applicable information, such as appropriate practice guidelines, etc. Should the IRO find that the denied claims were medically necessary, Aetna will process the denied claims upon receipt of the IRO’s determination. If the IRO upholds Aetna’s denial, you can advance your appeal to the Alaska Office of Administrative Hearings.
What should I do if I am approaching the 25th visit?
Claims for services after the 25th visit may be denied. In advance of the 25th visit, you should consult with your provider to ensure that the “medical necessity” requirements of the AlaskaCare plan have been met. Direct your provider to Aetna’s Clinical Policy Bulletin for additional information.
If treatment after the 25th visit is determined to be medically necessary, will I be asked to provide clinical records again for the same condition?
If treatment after the 25th visit is considered medically necessary, based on a person’s individual clinical situation, Aetna may at some later date(s) request treatment records to verify that services continue to be medically necessary.
What if I have a new injury or condition after I have reached maximum benefit from another series of rehabilitative services?
Your provider should submit the proper diagnosis codes for the course of treatment designed to restore and improve bodily function lost due to the new injury or illness.
New! Aetna In Touch Care Program Offers Case Management and Disease Management
Effective April 1, 2018, the AlaskaCare Employee Health Plan transitioned from Active Health Disease Management program to Aetna’s In Touch Care Program for both Case Management and Disease Management services. Historically, members facing chronic or acute health challenges would be assigned to either Active Health’s Disease Management team or Aetna’s Case Management team. As part of our streamlined, more focused approach to wellness, both services are now provided by Aetna’s Health Care Deliveries Division of Medical Professionals, through the InTouch Care Program. Through the adoption of a new holistic approach that provides connected one-on-one nurse support for urgent circumstances and/or 24/7 virtual care using online tools for chronic cases, we can anticipate an improved member experience.
We will keep Active Health’s member engagement platform, My Active Health, for member-driven access to health risk assessment data, digital coaching, and wellness-related resources. In addition, we will be coordinating efforts with the State of Alaska Department of Health and Social Services (DHSS) to take advantage of their educational materials, programs, and resources for diabetes prevention, control of high blood pressure, and smoking cessation.
Vitamin D and You
Alaska’s northerly latitude results in a lack of the quality sunshine our bodies need to produce Vitamin D naturally. Because of this, Alaskans are especially prone to Vitamin D deficiency, which can affect our health and wellness. You can supplement with foods high in Vitamin D, including salmon, fortified milk and cereal, and even sun-exposed mushrooms. It’s spring and days are getting longer, but you still need your Vitamin D! Learn more on the National Institutes of Health’s Vitamin D webpage.
Headed into Allergy Season
Alaskans start celebrating the great outdoors when the ice breaks up, lawns green up, and your eyes well up with tears. It’s not just because you’re overly emotional—welcome to allergy season! It’s right around the corner. Allergy sufferers, you can find relief for your runny noses, sore throats, tearing eyes, coughing, sneezing, sometimes wheezing, at your local drug store.
The Food and Drug Administration (FDA) has approved the allergy drug ZYRTEC® as an over-the-counter (OTC) medication. It’s available without a prescription in its original prescription strength. This drug is used for the relief of symptoms such as sneezing, runny nose, and watery eyes due to hay fever or other upper respiratory allergies. ZYRTEC-D® has the added benefit of relieving nasal congestion but may be kept behind the pharmacy counter because it contains a decongestant. Although your AlaskaCare health plan does not cover OTC medications, the cost of ZYRTEC® can be reimbursed through your Health Flexible Spending Account (Health FSA for active employees only).
Scam Alert! What to Know and Do About Scams
Criminals use clever schemes to defraud millions of people every year. They often combine sophisticated technology with age-old tricks to get people to send money or give out personal information. They add new twists to old ploys and pressure people to make important decisions on the spot. One thing that never changes: they follow the headlines—and the money. The advertisement of Medicare’s new card roll-out is a prime opportunity for criminals to practice their trade. Protect yourself against unethical practices of scammers.
Stay a step ahead with the latest information and practical tips from the nation’s consumer protection agency, the Federal Trade Commission (FTC) at FTC.gov. Browse FTC scam alerts by topic or by most recent.
Here’s some tips to deal with government imposters:
- Don’t give the caller your information. Never give out or confirm sensitive information—such as your bank account, credit card, or Social Security number—unless you know who you’re dealing with. If someone has contacted you, you can’t be sure who they are.
- Don’t trust a name or number. Con artists use official-sounding names to make you trust them. To make their call seem legitimate, scammers use internet technology to “spoof” the area code—so although it may seem they are calling from Washington D.C., they could be calling from anywhere in the world.
Check with the Centers for Medicare and Medicaid Services (CMS) directly. Contact Medicare at (800) 633-4227) and ask to speak with the Medicare Beneficiary Ombudsman (MBO). Contact Medicare by mail at:
Medicare Contact Center
P.O. Box 1270
Lawrence, Kansas 66044
Diabetes—Are You At Risk?
If you have prediabetes, you may be at risk. To find out, take the test on the Do I Have Prediabetes website.
Prediabetes is real. It’s common. And most importantly, it’s reversible.
You can stop prediabetes from developing into Type 2 diabetes with simple, proven lifestyle changes.
People can have prediabetes for years but have no clear symptoms, so it often goes unnoticed until serious health problems show up. That’s why it’s important to talk to your doctor about getting your blood sugar tested if you have any of the risk factors for prediabetes, which include:
- Being overweight
- Being 45 years or older
- Having a parent or sibling with type 2 diabetes
- Being physically active fewer than 3 times a week
- Ever having gestational diabetes or giving birth to a baby who weighed more than 9 pounds
If you do have prediabetes, you can enroll in a free online diabetes prevention program called TurnAround Health. Alaskans can take advantage of a free one-year subscription with the promo code Alaska2015. Sign up today at alive.turnaroundhealth.com.
Aetna Nurse Line
A registered nurse is available to you by phone 24 hours a day, free of charge. Nurses can be a great resource when considering options for care or helping you decide whether you or your dependent needs to visit your doctor, an urgent care facility, or the emergency room. They can also provide information on how you can care for yourself or your dependent. Information is available on prescription drugs, tests, surgery, and many other health related topics. This service is completely confidential.
Call (800) 556-1555!
The information provided on this page may or may not be up-to-date. If you are unsure, please contact us.