Information for Health Care Providers - Medicare HMO
Thank you for partnering with Optima Health. Since our inception, Optima Health has worked to reduce health risks, improve health and wellbeing and prevent disease for those within the Sentara system, our valued employer groups and the communities we serve. We are committed to serving our community and improving the health of our members, your patients, every day. One way we help our community is through Optima Medicare. The comprehensive benefits, services, and new features will help our members live a healthier lifestyle, largely because they are backed by the support of our high-quality network, which means you. Now, let’s take a moment to review what we’ll cover in this brief presentation.
Over the next few minutes we will: Provide an Overview of Optima Medicare, Review Plan Benefits, Explain our Post Discharge Benefits program, Show how to identify Optima Health Medicare Members, Explain how to submit Medical Authorizations, Review Case Management, Discuss our Partnership, Including, Value Based Contracting, Risk Adjustment, and the Benefits of thorough Coding, And provide a reminder of the importance of Cultural Competency.
First, its important to understand Original Medicare. Original Medicare is the standard hospital (Part A) and medical (Part B) individual coverage offered by the federal government. Original Medicare does not cover some routine services, such as vision and dental. Medicare Advantage Plans – also called Part C - are offered through private insurance companies, offering a full range of benefits beyond Parts A & B, including Part D prescription drug coverage and important supplemental benefits generally eliminating the need for a Medicare Supplement policy, also known as MediGap. Optima Medicare - Medicare Advantage plans that fit with Original Medicare by offering hospital, doctor, prescription and medical coverage; as well as a full range of added benefits.
Optima Medicare Includes: Fitness and Wellness Programs, Virtual telemedicine doctor appointments, Comprehensive Dental Benefits and Vision and hearing Benefits, And member cost share allows for more predictable out-of-pocket costs.
While eligibility will vary by region or the specific plan a member has selected, Optima Health offers a wide range of post-discharge benefits. Eligible members may receive the following: A Personal Emergency Response System in-home monitoring device to connect them to help 24 hours a day. Post discharge meals for up to two per day for a maximum of 28 days post discharge, per admission. There are a limited number of trips to medical appointments. We provide 24 non-health-related one-way trips for members who are chronically ill. There is support from the Optima Health Readmission Prevention Program immediately after an emergency department visit . And, members can use their over-the-counter drug card to order items and have over the counter medications delivered directly to their home.
Optima Health has created member education flyers to help remind our members, your patients, of these benefits when the need arises. This member material is unique to each plan and we have highlighted a portion of the flyer for the Northern Virginia and Central/Halifax regions. If you would like to receive a supply for your patients, please ask your assigned network educator.
Now that you have an overview of Optima Medicare, its important that you can identify our members when they present their member ID card at your office as well as know how to navigate our business operations. So, let’s start with the member ID card. The annual enrollment period has begun and members will begin to present the member ID card in your office in January. Please take a moment to familiarize yourself with the Optima Medicare 2021 member ID cards for Medicare Advantage and D-SNP.
As you are aware, prior authorizations will sometimes be required. Optima Health prior authorization forms are located on our provider portal under the “Authorizations” tab at the top of the page. You may fax the form to the phone number that is listed on the form or submit them online through the Provider Connection portal. You must register for Provider Connection to take advantage of this online convenience.
Case managers are available to assist members and help providers navigate our benefits. Case managers will assist members by: Arranging transportation to appointments. Assisting with locating participating providers. Providing patient education and motivation to stick to the treatment plan between visits. Helping them understand their benefits and navigate the health care system. Arranging meals after discharge from the hospital. Setting up Personal Emergency Response Systems for members at risk for falls or wandering. Case managers also collaborate with providers to ensure members close their HEDIS gaps. Case management can be contacted by email, phone or fax.
Preventive and chronic care management are critical steps in the path to helping our shared customers achieve optimal health. That’s why Optima Health is proud to partner with you in the delivery of high-quality healthcare services and benefits. HEDIS, Stars and Risk Adjustment are tools that contribute to the meaningful organizational changes we are striving to achieve together. Healthcare Effectiveness Data and Information Set (HEDIS) includes more than 90 performance measures across six domains of care. CMS Stars Ratings reflect the experiences of beneficiaries and their family members using a five star rating system. The measures target clinical quality, customer satisfaction, regulatory compliance, and other beneficiary experience areas. And finally, Optima Health employs risk adjustment strategies to quantify overall health status of an individual or population to predict expected healthcare spending using medical complexity, reflected by ICD-10-CM diagnoses, and demographic factors.
Coding will tie everything together. There are multiple data “buckets” used to measure how we’re performing as partners. Thorough coding during care delivery supports all data collection methods and helps to improve outcomes as well as significantly reduce the need to pull and review medical records for value-based contracting and risk adjustment initiatives.
And finally, the cultural competence of everyone on your staff is of critical importance. As a provider you are encouraged to: Offer health education materials in languages that are common to your patient population. Be aware of the tendency to unknowingly stereotype certain cultures, and Ensure your staff is receiving the required continued education in providing culturally competent care and attest to completing this training with Optima Health. You may locate training modules accepted by Optima Health on our provider portal. Select the Provider Support tab and then locate “Education.”
Thank you for partnering with Optima Health! If you do not know your network educator, you may locate him or her by calling (877) 865-9075 and select Option 2.