All Participating Providers are responsible for verifying a customer’s eligibility at each and every visit. Please note that customer data is subject to change. The Centers for Medicare and Medicaid Services (CMS) retroactively terminates customers for various reasons. When this occurs, Cigna-HealthSpring’s claim recovery unit will request a refund from the provider. The provider must then contact CMS Eligibility to determine the customer’s actual benefit coverage for the date of service in question.
How to Verify Customer Eligibility
You can verify customer eligibility the following ways:
You must call the Health Plan to verify eligibility when the customer cannot present identification or does not appear on your monthly eligibility list. Please note: the Health Plan should have the most updated information; therefore, call the Health Plan for accuracy.
- Use HSConnect. The Cigna-HealthSpring web portal, HSConnect, allows our providers to verify customer eligibility online by visiting https://healthspring.hsconnectonline.com/HSConnect.
- Ask to see the customer’s Identification Card. Each customer is provided with an individual customer identification card. Noted on the ID card is the customer’s identification number, plan code, name of PCP, copayment, and effective date. Since changes do occur with eligibility, the card alone does not guarantee the customer is eligible.
- Pursue additional proof of identification. Each PCP and Specialist office is provided with a monthly Eligibility Report upon request, which lists new and current Cigna-HealthSpring customers with their effective dates. Please be sure to refer to the most current month’s Eligibility Report.
Medicare Advantage and Prescription Drug (MAPD)
Medicare Advantage (MA Only)
Medicare Advantage and Prescription Drug (MAPD) - Kansas City
Medicare Advantage (MA ONLY) - Kansas City
The Maximum Out-of-Pocket (MOOP) benefit is now a part of all Cigna-HealthSpring benefit plans. Customers have a limit on the amount they will be required to pay out-of-pocket each year for medical services which are covered under Medicare Part A and Part B. Once this Maximum Out-of-pocket expense has been reached, the customer is no longer responsible for any out-of- pocket expenses, including any cost shares, for the remainder of the year for covered Part A and Part B services (excluding the customer’s Medicare Part B premium and Cigna-HealthSpring plan premium).
Participating Providers are prohibited from balance billing Cigna-HealthSpring customers including, but not limited to, situations involving non-payment by Cigna-HealthSpring, insolvency of Cigna-HealthSpring, or Cigna-HealthSpring’s breach of its Agreement. Provider shall not bill, charge, collect a deposit from, seek compensation or reimbursement from, or have any recourse against customers or persons, other than Cigna-HealthSpring, acting on behalf of customers for Covered Services provided pursuant to the Participating Provider’s Agreement. The provider is not, however, prohibited from collecting copayments, coinsurances or deductibles for covered services in accordance with the terms of the applicable customer’s Benefit Plan.
At Cigna-HealthSpring, we know our customers’ privacy is extremely important to them, and we respect their right to privacy when it comes to their personal information and health care. We are committed to protecting our customers’ personal information. Cigna-HealthSpring does not disclose customer information to anyone without obtaining consent from an authorized person(s), unless we are permitted to do so by law. Because you are a valued provider to Cigna-HealthSpring, we want you to know the steps we have taken to protect the privacy of our customers. This includes how we gather and use their personal information. Cigna-HealthSpring’s privacy practices apply to all of our past, present, and future customers.
When a customer joins a Cigna-HealthSpring Medicare Advantage plan, the customer agrees to give Cigna-HealthSpring access to Protected Health Information. Protected Health Information ("PHI"), as defined by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), is information created or received by a health care provider, health plan, employer or health care clearinghouse, that: relates to the past, present, or future physical or behavioral health or condition of an individual, the provision of health care to the individual, or the past, present or future payment for provision of health care to the individual; (ii) identifies the individual, or with respect to which there is a reasonable basis to believe the information can be used to identify the individual; and (iii) is transmitted or maintained in an electronic medium, or in any form or medium.
Access to PHI allows Cigna-HealthSpring to work with providers, like yourself, to decide whether a service is a covered service and pay your clean claims for covered services using the customers’ medical records. Medical records and claims are generally used to review treatment and to conduct quality assurance activities. It also allows Cigna-HealthSpring to look at how care is delivered and carry out programs to improve the quality of care Cigna-HealthSpring’s customers receive. This information also helps Cigna -HealthSpring manage the treatment of diseases to improve our customers’ quality of life.
Cigna-HealthSpring’s customers have additional rights over their health information. They have the right to:
- Send Cigna-HealthSpring a written request to see or get a copy of information about them, or amend their personal information that they believe is incomplete or inaccurate. If we did not create the information, we will refer Cigna-HealthSpring’s customer to the source of the information.
- Request that we communicate with them about medical matters using reasonable alternative means or at an alternative address, if communications to their home address could endanger them.
- Receive an accounting of Cigna-HealthSpring’s disclosures of their medical information, except when those disclosures are for treatment, payment, or health care operations, or the law otherwise restricts the accounting.
As a Covered Entity under HIPAA, providers are required to comply with the HIPAA Privacy Rule and other applicable laws in order to protect customer PHI. To discuss any breaches of the privacy of our customers, please contact our HIPAA Privacy Officer at 1-860-787-6801.
Cigna-HealthSpring customers have the following rights:
The right to be treated with dignity and respect
Customers have the right to be treated with dignity, respect, and fairness at all times. Cigna-HealthSpring must obey laws against discrimination that protect customers from unfair treatment. These laws state that Cigna-HealthSpring cannot discriminate against customers (treat customers unfairly) because of a person’s race, disability, religion, gender, sexual orientation, health, ethnicity, creed, age, or national origin. If customers need help with communication, such as help from a language interpreter, they should be directed to call Customer Service. Customer Service can also help customers file complaints about access to facilities (such as wheel chair access). Customers can also call the Office for Civil Rights at 1-800-368-1019 or TTY/TDD 1-800-537-7697, or theOffice for Civil Rights in their area for assistance.
The right to the privacy of medical records and personal health information
There are federal and state laws that protect the privacy of customer medical records and personal health information. Cigna-HealthSpring keeps customers’ personal health information private as required under these laws. Any personal information that a customer gives Cigna-HealthSpring is protected. Cigna-HealthSpring staff will make sure that unauthorized people do not see or change customer records. Generally, we will get written permission from the customer (or from someone the customer has given legal authority to make decisions on their behalf) before we can give customer health information to anyone who is not providing the customer’s medical care. There are exceptions allowed or required by law, such as releasing health information to government agencies that are checking on quality of care.
The laws that protect customer privacy give them rights related to accessing information and controlling how their health information is used. Cigna-HealthSpring is required to provide customers with a notice that informs them of these rights and explains how Cigna-HealthSpring protects the privacy of their health information. For example, customers have the right to look at their medical records, and obtain copies of the records (there may be a fee charged for making copies). Customers also have the right to ask plan providers to make additions or corrections to their medical records (if customers ask plan providers to do this, they will review customer requests and figure out whether the changes are appropriate). Customers have the right to know how their health information has been given out and used for routine and non-routine purposes. If customers have questions or concerns about privacy of their personal information and medical records, they should be directed to call Customer Service. Cigna-HealthSpring will release a customer’s information, including prescription drug event data, to Medicare, which may release it for research and other purposes that follow all applicable federal statutes and regulations.
The right to see Participating Providers, get covered services, and get prescriptions filled within a reasonable period of time
Customers will get most or all of their health care from Participating Providers, that is, from doctors and other health providers who are part of Cigna-HealthSpring. Customers have the right to choose a participating provider (Cigna-HealthSpring will work with customers to ensure they find physicians who are accepting new patients).
Customers have the right to go to a women’s health Specialist (such as a gynecologist) without a referral. Customers have the right to timely access to their providers and to see Specialists when care from a Specialist is needed. Customers also have the right to timely access to their prescriptions at any network pharmacy. “Timely access” means that customers can get appointments and services within a reasonable amount of time. The Evidence of Coverage explains how customers access Participating Providers to get the care and services they need, and their rights to receive care for a medical emergency and urgently needed care.
The right to know treatment choices and participate in decisions about their health care
Customers have the right to receive full information from their providers when they receive medical care, and the right to participate fully in treatment planning and decisions about their health care. Cigna-HealthSpring providers must explain treatment choices, planning, and health care decisions in a way that customers can understand. Customers have the right to know about all of the treatment choices that are recommended for their condition including all appropriate and medically necessary treatment options, regardless of the cost or whether they are covered by Cigna-HealthSpring. This includes the right to know about the different medication management treatment programs Cigna-HealthSpring offers and those in which customers may participate. Customers have the right to be told about any risks involved in their care. Customers must be told in advance if any proposed medical care or treatment is part of a research experiment and be given the choice to refuse experimental treatments.
Customers have the right to receive a detailed explanation from Cigna-HealthSpring if they believe that a plan provider has denied care that they believe they are entitled to receive or care they believe they should continue to receive. In these cases, customers must request an initial decision. “Initial decisions” are discussed in the customers’ Evidence of Coverage.
Customers have the right to refuse treatment. This includes the right to leave a hospital or other medical facility, even if their doctor advises them not to leave. This also includes the right to stop taking their medication. If customers refuse treatment, they accept responsibility for what happens as a result of refusing treatment.
The right to use Advance Directives (such as a Living Will or a Power of Attorney)
Customers have the right to ask someone such as a family customer or friend to help them with decisions about their health care. Sometimes, people become unable to make health care decisions for themselves due to accidents or serious illness. A customer may use a special form to give someone they trust the legal authority to make decisions for them if they ever become unable to make decisions for themselves. Customers also have the right to give their doctors written instructions mandating how to handle their medical care if they become unable to make decisions for themselves. The legal documents that customers can use to give their directions in advance of these situations are called “advance directives,” and they include “living wills” and “powers of attorney for health care.”
Customers may obtain advance directivesfrom their lawyer, from a social worker, from Cigna-HealthSpring, from some office supply stores, or potentially from organizations that give people information about Medicare. Since advance directives are legal documents, customers should consider having a lawyer help them prepare them. It is important to sign this form and keep a copy at home. Customers should give a copy of the form to their doctor and to the person they name as the ultimate decision maker. Customers may want to give copies to close friends or family customers as well.
If customers know in advance that they are going to be hospitalized and they have signed an advance directive, they should take a copy with them to the hospital. If customers are admitted to the hospital, the hospital will ask them whether they have signed an advance directive and whether they have it with them. If customers have not signed an advance directive or do not have a copy available during admission, the hospital has forms available and will ask if the customer wants to sign one.
Remember, it is a customer’s choice whether he/ she wants to fill out an advance directive (including whether they want to sign one if they are in the hospital). According to law, no one can deny them care or discriminate against them based on whether or not they have signed an advance directive. If customers have signed an advance directive and they believe that a doctor or hospital has not followed the instructions in it, customers may file a complaint with their State Board of Medicine or appropriate state agency (this information can be found in the customer’s Evidence of Coverage).
The right to make complaints
Customers have the right to make a complaint if they have concerns or problems related to their coverage or care. Customers or an appointed/authorized representative may file appeals, grievances, concerns and Coverage Determinations. If customers make a complaint or file an appeal or Coverage Determination, Cigna-HealthSpring must treat them fairly and is prohibited from discriminating against them because they made a complaint or filed an appeal or Coverage Determination. To obtain information relative to appeals, grievances, concerns and/or Coverage Determinations, customers should call Customer Service.
The right to obtain information about their health care coverage and cost
The Evidence of Coverage tells customers what medical services are covered and what they have to pay. If they need more information, they should be directed to call Customer Service. Customers have the right to an explanation from Cigna-HealthSpring about any bills they receive for services not covered by Cigna-HealthSpring. Cigna-HealthSpring must tell customers in writing why Cigna-HealthSpring will not pay for or allow them to get a service, and how they can file an appeal to ask Cigna-HealthSpring to change this decision. Provider’s staff should inform customers on how to file an appeal, if asked, and should direct customers to review their Evidence of Coverage for more information about filing an appeal.
The right to obtain information about Cigna-HealthSpring, plan providers, drug coverage, and costs
Customers have the right to obtain information about the Cigna-HealthSpring plans and operations. This includes information about our financial condition, about the services we provide, and about our health care providers and their qualifications. Customers have the right to know how we pay our doctors. To obtain any of this information, customers should be directed to call Customer Service. Customers have the right to obtain information from us about their Part D prescription coverage. This includes information about our financial condition and about our network pharmacies. To obtain any of this information, staff should direct customers to call Customer Service.
The right to receive more information about customers’ rights
Customers have the right to receive information about their rights and responsibilities. If customers have questions or concerns about their rights and protections, they should be directed to call Customer Service. Customers can also get free help and information from their State Health Insurance Assistance Program (SHIP). Additionally, customers can obtain a free copy of the Customer Medicare Rights and Protections booklet by calling 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. Customers can call 24 hours a day, 7 days a week, or customers can visit www.medicare.gov to order this booklet or print it directly from their computer.
The right to take action if a customer thinks they have been treated unfairly or their rights are not being respected
If customers think they have been treated unfairly or their rights have not been respected, there are options for what they can do.
- If customers think they have been treated unfairly due to their race, color, national origin, disability, age, or religion, we must encourage them to inform us immediately. They can also call the Office for Civil Rights in their area
- For any other kind of concern or problem related to their Medicare rights and protections described in this section, customers should call Customer Service. Customers can also get help from their State Health Insurance Assistance Program (SHIP).
Along with certain rights, there are also responsibilities associated with being a customer of Cigna-HealthSpring.
Customers are responsible for the following:
- Becoming familiar with their Cigna-HealthSpring coverage and the rules they must follow to get care as a customer. Customers can use their Cigna-HealthSpring Evidence of Coverage and other information that we provide them to learn about their coverage, what we have to pay, and the rules they need to follow. Customers should call Customer Service if they have any questions or complaints.
- Advising Cigna-HealthSpring if they have other insurance coverage.
- Notifying providers when seeking care (unless it is an emergency) that they are enrolled with Cigna-HealthSpring and present their plan enrollment card to the provider.
- Giving their doctors and other providers the information they need to provide care for them and to follow agreed upon treatment plans and instructions. Customers must be encouraged to ask questions of their doctors and other providers whenever the customer has them.
- Acting in a way that supports the care given to other patients and helps the smooth running of their doctor’s office, hospitals, and other offic
- Paying their plan premiums and any copayments or coinsurances they may have for the Covered Services they receive. Customers must also meet their other financial responsibilities that are described in their Evidence of Coverage.
- Informing Cigna-HealthSpring if they have any questions, concerns, problems, or suggestions regarding their rights, responsibilities, coverage, and/or Cigna-HealthSpring operations.
- Notifying Cigna-HealthSpring Customer Service and their providers of any address and/or phone number changes as soon as possible.
- Using their Cigna-HealthSpring plan only to access services, medications and other benefits for themselves.
The Federal Patient Self-Determination Act grants patients the right to participate in health care decision-making, including decisions about withholding resuscitative services or declining/withdrawing life sustaining treatment. In accordance with guidelines established by the Centers for Medicare & Medicaid Services (CMS), and our own policies and procedures, Cigna-HealthSpring requires all participating providers to have a process in place pursuant to the intent of the Patient Self Determination Act.
All providers contracted directly or indirectly with Cigna-HealthSpring may be informed by the customer that the customer has executed, changed, or revoked an advance directive. At the time a service is provided, the provider should ask the customer to provide a copy of the advance directive to be included in his/her medical record.
If the Primary Care Physician (PCP) and/or treating provider cannot as a matter of conscience fulfill the customer’s written advance directive, he/she must inform the customer and Cigna-HealthSpring. Cigna-HealthSpring and the PCP and/or treating provider will arrange for a transfer of care. Participating Providers may not condition the provision of care or otherwise discriminate against an individual based on whether the individual has executed an advance directive. However, nothing in The Patient Self-Determination Act precludes the right under state law of a provider to refuse to comply with an advance directive as a matter of conscience.
To ensure providers maintain the required processes to advance directives, Cigna-HealthSpring conducts periodic patient medical record reviews to confirm that required documentation exists.
All Cigna-HealthSpring customers receive benefits and services as defined in their Evidence of Coverage (EOC). Each month, Cigna-HealthSpring makes available to each participating Primary Care Physician a list of their active customers. Along with the customer’s demographic information, the list includes the name of the plan in which the customer enrolled. Please be aware that recently terminated customers may appear on the list. (See “Eligibility Verification” section of this manual).
Cigna-HealthSpring encourages its customers to call their Primary Care Physician to schedule appointments. However, if a Cigna-HealthSpring customer calls or comes to your office for an unscheduled non-emergent appointment, please attempt to accommodate the customer and explain to them your office policy regarding appointments. If this problem persists, please contact Cigna-HealthSpring.
An emergency is defined by Cigna-HealthSpring as the sudden onset of a medical condition with acute symptoms (the full definition of Emergency Services is located in your Agreement). A customer may reasonably believe that the lack of immediate medical attention could result in:
- Permanently placing the customer’s health in jeopardy
- Causing serious impairments to body functions
- Causing serious or permanent dysfunction of any body organ or part
In the event of a perceived emergency, customers have been instructed to first contact their Primary Care Physician for medical advice. However, if the situation is of such a nature that it is life threatening, customers have been instructed to go immediately to the nearest emergency room facility. Customers who are unable to contact their PCP prior to treatment have been instructed to contact their PCP as soon as is medically possible or within forty-eight (48) hours after receiving care. The PCP will be responsible for providing and arranging any necessary follow-up services.
For emergency services within the service area, the PCP is responsible for providing, directing, or authorizing a customer’s emergency care. The PCP or his/her designee must be available twenty-four (24) hours a day, seven days a week to assist customers needing emergency services. The hospital may attempt to contact the PCP for direction. Customers have a copayment responsibility for outpatient emergency visits unless an admission results.
For emergency services outside the service area, Cigna-HealthSpring will pay reasonable charges for emergency services received from Non-Participating Providers if a customer is injured or becomes ill while temporarily outside the service area. Customers may be responsible for a copayment for each incident of outpatient emergency services at a hospital’s emergency room or urgent care facility.
Urgent care services
Urgent Care services are for the treatment of symptoms that are non-life threatening but that require immediate attention. The customer must first attempt to receive care from his/her PCP. Treatment at a participating Urgent Care Center will be covered by Cigna-HealthSpring without a referral.
Continuing or follow-up treatment
Continuing or follow-up treatment, except by the PCP, whether in or out of the service area, is not covered by Cigna-HealthSpring unless specifically authorized or approved by Cigna-HealthSpring. Payment for covered benefits outside the service area is limited to medically necessary treatment required before the customer can reasonably be transported to a participating hospital or returned to the care of the PCP.
In addition to any exclusion or limitations described in the customer’s EOC, the following items and services are not covered under the Original Medicare Plan or by Cigna-HealthSpring:
- Services which are not reasonable and necessary, according to the standards of the Original Medicare Plan, unless these services are otherwise listed by our plan as a covered service.
- Experimental or investigational medical and surgical procedures, equipment, and medications, unless covered by the Original Medicare Plan or unless, for certain services, the procedures are covered under an approved clinical trial. The Centers for Medicare and Medicaid Services (CMS) will continue to pay through Original Medicare for clinical trial items and services covered under the September 2000 National Coverage Determination that is provided to plan customers. Experimental procedures and items are those items and procedures determined by our plan and the Original Medicare Plan to not be generally accepted by the medical community.
- Surgical treatment of morbid obesity unless medically necessary or covered under the Original Medicare Plan.
- Private room in a hospital, unless medically necessary.
- Private duty nurses.
- Personal convenience items, such as a telephone or television in a customer’s room at a hospital or skilled nursing facility.
- Nursing care on a full-time basis in a customer’s home.
- Custodial care unless it is provided in conjunction with covered skilled nursing care and/or skilled rehabilitation services. This includes care that helps people with activities of daily living like walking, getting in and out of bed, bathing, dressing, eating, using the bathroom, preparation of special diets, and supervision of medication that is usually self-administered.
- Homemaker services.
- Charges imposed by immediate relatives or customers of the customer’s household.
- Meals delivered to the customer’s home.
- Elective or voluntary enhancement procedures, services, supplies, and medications including but not limited to: weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging, and mental performance unless medically necessary.
- Cosmetic surgery or procedures, unless needed because of accidental injury or to improve the function of a malformed part of the body. All stages of reconstruction are covered for a breast after a mastectomy, as well as for the unaffected breast to produce a symmetrical appearance.
- Routine dental care (i.e. cleanings, fillings, or dentures) or other dental services unless otherwise specified in the EOC. However, non-routine dental services received at a hospital may be covered.
- Chiropractic care is generally not covered under the plan with the exception of manual manipulation of the spine and is limited according to Medicare guidelines.
- Routine foot care is generally not covered under the plan and is limited according to Medicare guidelines.
- Supportive devices for the feet; orthopedic shoes unless they are part of a leg brace and included in the cost of the brace.
Exception: Orthopedic or therapeutic shoes are covered for people with diabetic foot disease.
- Hearing aids and routine hearing examinations unless otherwise specified in the E
- Eyeglasses, with the exception of after cataract surgery, routine eye examinations, radical keratotomy, LASIK surgery, vision therapy, and other low vision aids and services unless otherwise specified in the E
- Self-administered prescription medication for the treatment of sexual dysfunction, including erectile dysfunction, impotence, and anorgasmy or hyporgasmy unless otherwise included in the customer’s Part D ben Please see the formulary for details.
- Reversal of sterilization measures, sex change operations, and non-prescription contraceptives
- Naturopath service
- Services provided to veterans in Veterans Affairs (VA) fa However, in the case of emergency situations received at a VA hospital, if the VA cost-sharing is more than the cost-sharing required under the plan, the plan will reimburse veterans for the difference. Customers are still responsible for our plan cost-sharing amount.
Any of the services listed above that are not covered will remain not covered even if received at an emergency facility. For example, non-authorized, routine conditions that do not appear to a reasonable person to be based on a medical emergency are not covered if received at an emergency facility.
All telephonic inquiries received by Cigna- HealthSpring’s Medicare Advantage Customer Service Department will be resolved on an informal basis, except for inquiries that involve “Appealable” issues. Appealable issues will be routed through either the standard or expedited appeal process. An expedited appeal is processed within 72 hours of receipt for situations where waiting longer for a response could result in serious health consequences. Standard appeals are resolved within 30 days of receipt for services not yet received and within 60 days for services that have been provided prior to submitting the appeal. In situations where a customer is not in agreement with the informal resolution, the customer must submit a written request for reconsideration. Written requests for reconsideration should be sent to:
PO Box 20002
Nashville, TN 37202
All other written correspondence received by Cigna-HealthSpring will be documented and routed through the appropriate Appeal or grievance channels.
Cigna-HealthSpring customers have the right to file a complaint, also referred to as a grievance, regarding any problems they observe or experience with the health plan. Situations for which a grievance may be filed include but are not limited to:
- Complaints about services in an optional Supplementary Benefit package.
- Dissatisfaction with the office experience such as excessive wait times, physician behavior or demeanor, or inadequacy of facilities.
- Involuntary disenrollment situations.
- Poor quality of care or services received.
Cigna-HealthSpring customers have the right to appeal any decision about Cigna-HealthSpring’s failure to provide what they believe are benefits contained in the basic benefit package. These include:
- Reimbursement for urgently needed care outside of the service area or Emergency Services worldwide.
- A denied claim for any health services furnished by a non-participating provider or supplier they believe should have been provided, arranged for, or reimbursed by Cigna-HealthSpring.
- Services not received, but believed to be the responsibility of Cigna-HealthSpring.
- A reduction or termination of a service a customer feels is medically necessary.
In addition, a customer may Appeal any decision related to a hospital discharge. In this case, a notice will be given to the customer with instructions for filing an Appeal. The customer will remain in the hospital while the Appeal documentation is reviewed. The customer will not be held liable for charges incurred during this period, regardless of the outcome of the review. Please refer to the Cigna-HealthSpring Evidence of Coverage (EOC) for additional benefit information.
Many of your patients may have Cigna-HealthSpring as their primary insurance payer and Medicaid as their secondary payer. You must coordinate the benefits of these “dual eligible” Cigna-HealthSpring customers by determining whether the customer should be billed for the deductibles, copayments, or coinsurances associated with their benefit plan. Providers may not assess a QMB (Qualified Medicare Beneficiary) or QMB-Plus for Cigna-HealthSpring copayments, coinsurances, and/or deductibles.
Providers will accept as payment in full Cigna-HealthSpring’s payment and will not seek additional payment from the state or dual eligible customers. Additional information concerning Medicaid provider participation is available at: www.cignahealthspring.com.
For Alabama and Florida: Providers are prohibited from billing, charging, collecting a deposit, seeking compensation or remuneration from, or having any recourse against any Cigna-HealthSpring customer for fees that are the responsibility of Cigna-HealthSpring.
For Alabama: Providers must accept payment from Cigna-HealthSpring as payment in full. A customer’s level of Medicaid eligibility can change due to their medical and financial needs. Cigna-HealthSpring encourages you to verify customers’ Medicaid eligibility when rendering services which will help you determine if the customer owes a deductible or copay.
Medicaid eligibility can be obtained by using the Medicaid telephonic Eligibility Verification System. If you do not have access to the system, please contact your State Medicaid provider for additional information.
Please note: Each state varies in their decision to cover the cost-share for populations beyond QMB and QMB+.
|Patient’s Medicaid plan||Patient’s liability Patient owes deductibles and copayments associated with benefit plan||Medicaid provides benefits patient not liable for deductibles and copayments associated with benefit plan|
Full Benefit Dual Eligibles (FBDE)
An “FBDE” is an individual who is eligible for Medicaid either categorically or through optional coverage groups such as Medically-Needy or special income levels for institutionalized or home and community- based waivers, but who does not meet the income or resource criteria for QMB or SLMB. Obligations may effectively be covered by the state Medicaid benefit, but certain conditions must be met including:
- The service is also covered by Medicaid;
- The provider is a Medicaid provider; and
- The Medicaid fee schedule amount is greater than the Medicare amount paid.
Qualified Medicare Beneficiary (QMB Only)
A “QMB” is an individual who is entitled to Medicare Part A, has income that does not exceed 100% of the Federal Poverty Level (FPL), and whose resources do not exceed twice the Supplemental Security Income (SSI) limit. A QMB is eligible for Medicaid payment of Medicare premiums, deductibles, coinsurance, and copayments (except for Part D). QMBs who do not qualify for any additional Medicaid benefits are called “QMB Only”. Providers may not assess a QMB for Cigna-HealthSpring deductibles, copayments, or coinsurances.
Qualified Medicare Beneficiary Plus (QMB+)
A “QMB+” is an individual who meets standards for QMB eligibility and also meets criteria for full Medicaid benefits in the state. These individuals often qualify for full Medicaid benefits by meeting Medically Needy standards, or through spending down excess income to the Medically Needy level.
Specified Low-Income Medicare Beneficiary (SLMB Only)
An “SLMB” is an individual who is entitled to Medicare Part A, has income that exceeds 100% FPL but is less than 120% FPL, and whose resources do not exceed twice the SSI limit. The only Medicaid benefit for which a SLMB is eligible is payment of Medicare Part B premiums. SLMBs who do not qualify for any additional Medicaid benefits are called “SLMB Only.”
Specified Low-Income Medicare Beneficiary Plus (SLMB+)
A “SLMB+” is an individual who meets the standards for SLMB eligibility, but who also meets the criteria for full state Medicaid benefits. Such individuals are entitled to payment of the Medicare Part B premium, as well as full state Medicaid benefits. These individuals often qualify for Medicaid by meeting the Medically Needy standards, or through spending down excess income to the Medically Needy level.
Qualifying Individual (QI)
A “QI” is an individual who is entitled to Part A, has income that is at least 120% FPL but less than 135% FPL, resources that do not exceed twice the SSI limit, and who is not otherwise eligible for Medicaid. A QI is similar to an SLMB in that the only benefit available is Medicaid payment of the Medicare Part B premium; however, expenditures for QIs are 100% federally funded and the total expenditures are limited by statute.
Other Full Benefit Dual Eligibles (FBDE)
An “FBDE” is an individual who is eligible for Medicaid either categorically or through optional coverage groups such as Medically-Needy or special income levels for institutionalized or home and community-based waivers, but who does not meet the income or resource criteria for QMB or SLMB.
Qualified Disabled and Working Individual (QDWI)
A “QDWI” is an individual who lost Medicare Part A benefits due to returning to work, but who is eligible to enroll in and purchase Medicare Part A. The individual’s income may not exceed 200% FPL and resources may not exceed twice the SSI limit. The individual may not be otherwise eligible for Medicaid. QDWIs are eligible only for Medicaid payment of Part A premium.
COORDINATION OF CARE WITH STAR+PLUS MEDICAID
The state of Texas’ goal for managed Medicaid services is to integrate acute care and Long Term Services and Supports, including services provided through Medicare Advantage Dual Special Needs Plans (MA-
Dual SNP); provide continuity of care; and ensure timely access to quality care through an adequate provider network that includes behavioral health services and disease management services.
The term “dual eligible” refers to someone who is enrolled in both Medicaid and Medicare. Some dual eligible clients are eligible for STAR+PLUS. Dual eligible clients must choose a STAR+PLUS MCO, but do not choose a PCP because they receive acute care services from their Medicare providers. The STAR+PLUS MCO covers only Long-Term Services and Supports (LTSS) for dual eligible customers.
Certain Medicaid clients are excluded from enrolling in STAR+PLUS. This includes:
- Clients of Medicaid 1915(c) waiver services other than Community-Based Alternatives services.
- Clients not eligible for full Medicaid benefits, such as Frail Elderly program customers, Qualified Medicare Beneficiaries, Specified Low-IncomeMedicare Beneficiaries, Qualified Disabled Working Individuals and undocumented aliens.
- Children in state foster care.
- People not eligible for Medicaid.
- Undocumented immigrants.
In service areas where STAR+PLUS is available, customers are eligible for Community-Based Long-Term Care Services and Supportsthrough their STAR+PLUS MCO.
Long-term Care Services available to all STAR+PLUS customers include:
- Providers offering Personal Attendant Services (PAS) assist customers with the performance of activities of daily living and household chores necessary to maintain the home in a clean, sanitary, and safe environment. The level of assistance provided is determined by the customer’s needs and plan of care. Services may also include the provision of nursing tasks delegated by a registered nurse in accordance with state rules promulgated by the Texas Board of Nursing, and protective supervision provided solely to ensure the health and welfare of a customer with cognitive/ memory impairment and/or physical weakness.
- Day Activity and Health Services (DAHS) include nursing and personal care services, physical rehabilitation services, nutrition services, transportation services, and other supportive services.
These services are offered by facilities licensed by the Texas Department of Human Services and certified by Texas Department of Aging and Disability Services. Except for holidays, these facilities must have services available at least 10 hours a day, Monday through Friday.
Long-term Care Services Available to STAR+PLUS customers who qualify under the HCBS STAR+PLUS Waiver (SPW) (previously known as 1915 (c) Nursing Facility Waiver program):
Adaptive aids and medical equipment include devices, controls, or medically necessary supplies that enable customers with functional impairments to perform activities of daily living or to perceive, control, or communicate with the environment in which they live. A complete listing of covered adaptive aids and medical equipment is available in the STAR+PLUS Handbook which is available at www.dads.state.tx.us/handbooks/sph.
Adult Foster Care
Adult foster care is a 24-hour living arrangement in a Department of Human Services (DHS) foster home for people who, because of physical or mental limitations, are unable to continue residing in their own homes. Services may include meal preparation, housekeeping, personal care, help with activities of daily living, supervision, and the provision or arrangement of transportation.
Assisted living (AL) is a twenty-four (24) hour living arrangement in a licensed personal care facility in which personal care, home management, escort, social and recreational activities, twenty-four (24) hour supervision, supervision of, assistance with, and direct administration of medications, and the provision or arrangement of transportation are provided. Under the HCBS STAR+PLUS Waiver (SPW), personal care facilities may contract to provide services in two distinct types of living arrangements: (1) assisted living apartments, (2) assisted living non-apartment settings.
The services provided by a dentist to preserve teeth and meet the medical need of the customer. Allowable services include emergency dental treatment necessary to control bleeding, relieve pain and eliminate acute infection; preventive procedures required to prevent the imminent loss of teeth; the treatment of injuries to teeth or supporting structures; dentures and the cost of preparation and fitting; and routine procedures necessary to maintain good oral health.
Emergency Response Services
Emergency Response Services (ERS) are electronic monitoring systems for use by functionally impaired individuals who live alone or are isolated in the community. In an emergency, the customer can press a call button to signal for help. The electronic monitoring system, which has a twenty-four (24) hour, seven (7) day per week capability, helps ensure that the appropriate persons or service agency responds to an alarm call from the customer.
Financial Management Services
Assistance to customers with managing funds associated with services elected for self-direction and is provided by the consumer directed services agency. This service includes initial orientation and ongoing training related to the responsibilities of being an employer and adhering to legal requirements for employers.
Home Delivered Meals
Home delivered meals are provided to people who are unable to prepare their own meals and for whom there are no other persons available to do so or where the provision of a home delivered meal is the most costeffective method of delivering a nutritionally adequate meal. Modified diets, where appropriate, will be provided to meet the customer’s individual requirements.
Minor home modifications are services that assess the need for, arrange for, and provide modifications and/or improvements to an individual’s residence to enable them to reside in the community and to ensure safety, security and accessibility.
Medical supplies not available under the 1915(b) Waiver program.
In-home Nursing Services include, but are not limited to, assessing and evaluating health problems and the direct delivery of nursing tasks, providing treatments and health care procedures ordered by a physician and/ or required by standards of professional practice or state law, delegating nursing tasks to unlicensed persons according to state rules promulgated by the Texas Board of Nursing, developing the health care plan and teaching customers about proper health maintenance.
Respite Services offer temporary relief to persons caring for functionally impaired adults in community settings other than Adult Foster Care (AFC) homes or Assisted Living /Residential Care (AL/RC) facilities. Respite services are provided on an in-home basis and out-of-home basis and are limited to thirty (30) days per year. Room and board is included in the Waiver program payment for out-of-home settings.
Support Consultation is an optional service component that offers practical skills training and assistance to enable an individual to successfully direct those services the individual elects for participantdirection. This service is provided by a certified support advisor, and includes skills training related to recruiting, screening, and hiring workers, preparing job descriptions, verifying employment eligibility and qualifications, completion of documents required to employ an individual, management of workers, and development of effective back-up plans for services considered critical to the individual’s health and welfare in the absence of the regular provider or an emergency situation. Support consultation is provided only by a certified support advisor certified by the Department of Aging and Disability.
- Physical therapy includes specialized techniques for the evaluation and treatment of chronic conditions related to functions of the neuromusculoskeletal systems. Services include the full range of activities provided by a physical therapist or a licensed physical therapy assistant under the direction of a licensed physical therapist, within the scope of the therapist’s state licensure.
- Occupational therapy includes interventions and procedures for chronic conditions to promote or enhance safety and performance in instrumental activities of daily living, education, work, play, leisure and social participation. Services include the full range of activities provided by an occupational therapist or a licensed occupational therapy assistant under the direction of a licensed occupational therapist, within the scope of the therapist’s state licensure.
- Speech therapy includes evaluation and treatment of impairments, disorders or deficiencies related to a customer’s speech and language which are chronic conditions. Services include the full range of activities provided by speech and language pathologists under the scope of their state licensure.
Transition Assistance Services (TAS)
Offers a maximum of $2,500 to enhance the ability of nursing facility residents to transition and receive services in the community. TAS helps defray the costs associated with setting up a household for those customers establishing an independent residence. TAS include, but are not limited to, payment of security deposits to lease an apartment, purchase of essential furnishings (table, eating utensils), payment of moving expenses, etc.
Employment Assistance Services is a service that assists individuals to obtain competitive integrate employment and includes, but are not limited to the following: Identifying a member’s employment preferences, job skills, and requirements for a work setting and work conditions; locating prospective employers offering employment compatible with a member’s identified preferences, skills, and requirements; and contacting a prospective employer on behalf of a member and negotiating employment.
Supported Employment Services are assistive services provided in order to sustain paid employment, to a member who, because of a disability, requires intensive, ongoing support to be self-employed, work from home, or perform in a work setting at which members without disabilities are employed. Supported Employment includes employment adaptations, supervision, and training related to a member’s diagnosis.
Cognitive Rehabilitation Therapy
Cognitive rehabilitation therapy is a service that assists an individual in learning or relearning cognitive skills that have been lost or altered as a result of damage to brain cells/chemistry in order to enable the individual to compensate for the lost cognitive functions.d Cognitive rehabilitation therapy is provided when determined to be medically necessary through an assessment an appropriate professional.d Cognitive rehabilitation therapy is provided in accordance with the plan of care developed by the assessor, and includes reinforcing, strengthening, or reestablishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems conducted by an appropriate professional. Cognitive rehabilitation therapy is provided in accordance with the plan of care developed by the assessor, and includes reinforcing, strengthening, or reestablishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems.
Targeted Case Management
Targeted Case Management (TCM) are services designed to assist Members who are diagnosed with dSevere and Persistent Mental Illness (SPMI) and Severe Emotional Disturbance (SED) with gaining access to needed medical, social, educational and other services and supports.
Mental Health Rehabilitative Service
Mental Health Rehabilitative Services are those ageappropriate services determined by HHSC and Federallyapproved protocol as medically necessary to reduce a Member’s disability resulting from severe mental illness or serious emotional or behavioral disorders that help to increase the Member’s level of functioning and maintain independence in the home and the community. These services include the following: medication training and support, psychosocial rehabilitative services, skills training and development, crisis intervention, and day programming for acute episodes.
Community First Choice (CFC)
Community First Choice (CFC) allows provider to provide home and community-based attendant services and supports to Medicaid recipients with disabilities. All CFC services will be provided in a home or community based setting, which does not include a nursing facility, hospital providing long-term services, institution for mental disease, an condition, or a setting with the characteristics of an institution. Community First Choice Services include: help with activities of daily living and health-realted tasks through hands-on assistance, supervision or cueing; services to help the individual learn how to care for themselves; backup systems or ways to ensure continuity of services and supports; training on how to select, manage and dismiss attendants.