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Medicare Advantage Plans
MEDICARE ADVANTAGE PLANS
Lower Prescription Drug Costs for Medicare Members With Part D
Medicare Prescription Payment Plan
Coordinating Care for Members
Health Survey for Medicare and Special Needs Plan Members
ConnectiCare Member Rewards Program
Care Management Plans for D-SNP Members
Medicare Connect Concierge
Claims and Billing
Do Not Bill Dual Eligible and QMB Members for Any Medicaid Cost-Sharing
Dispute Resolution
Formularies
Help Members Stick with Their Medication Regimen by Using Our Mail Order Pharmacies and Free Pill Box
Fraud, Waste, and Abuse
Required: SNP MOC Training
Cultural Competency Education
Medicare Outpatient Observation Notice (MOON)
Requirement for Medicare Providers Caring for Special Needs Plans Members
Lower Prescription Drug Costs for Medicare Members With Part D
Plan benefits and cost-sharing change every year. See 2025 Drugs Covered by Medicare Plans. One of the big changes 2025 brings is the lower out-of-pocket costs for members with prescription drug coverage. The new threshold is $2,000, after which all covered prescription drugs will be available at $0 copay.
Medicare Prescription Payment Plan
In addition to having lower costs, Medicare Advantage members with prescription drug coverage can opt in to Medicare Prescription Payment Plan — a new option to pay out-of-pocket costs throughout the year. Not all members will benefit from this program. Our pharmacy benefits manager (PBM) will be happy to review the program and projected costs with members. Resources are available to learn more about the program and to apply.
Coordinating Care for Members
For helpful resources in coordinating care for ConnectiCare members, see Clinical Information and Coverage Guidelines. For EmblemHealth members, see Clinical Corner and the Utilization and Care Management chapter of the EmblemHealth Provider Manual
Health Survey for Medicare and Special Needs Plan Members
Medicare special needs plan members will receive a call from ConnectiCare asking them to complete a health assessment (HA). Please encourage your patients to complete this survey. Members can complete the survey online by signing in to the member portal. This will help our Care Management team better address members' needs and direct them to appropriate care and support services. Medicare members may be eligible for ConnectiCare’s Member Rewards Program when completing their HA within the first 90 days of enrollment. D-SNP members may also be eligible for a reward when completing an annual HA.
ConnectiCare Member Rewards Program
In 2025, ConnectiCare will continue to offer the ConnectiCare Member Rewards Program to encourage Medicare members to receive primary care and key health screenings. Please reach out to your patients to schedule these important preventive exams.
Care Management Plans for D-SNP Members
Enrollees covered under our dual-eligible special needs plans (D-SNPs) have care plans on file with our Care Management team.
We make care plans available to providers on our provider portal unless they contain sensitive information.
If you do not see an expected care plan posted on the portal, contact us to receive a copy by:
Email: hmpreferrals@connecticare.com
Phone: 800-390-3522
Medicare Connect Concierge
Our Medicare members will have continued support from Medicare Connect Concierge in 2025. This is the one phone number members can call when they need help solving their health care needs. Medicare Connect Concierge can help:
- Schedule a doctor’s appointment.
- Coordinate preauthorizations.
- Answer benefit questions.
- Update mailing address.
- Arrange transportation for members with Medicaid when covered.
To reach Medicare Connect Concierge, please call 800-224-2273 (TTY: 711). From Oct. 1 to March 31, you can call us seven days a week from 8 a.m. to 8 p.m. From April 1 to Sept. 30, you can call us Monday through Saturday from 8 a.m. to 8 p.m.
Claims and Billing
For helpful resources regarding claims for ConnectiCare members, see Billing and Claims and Our Policies. For EmblemHealth members, see Claims Corner and the Claims chapter of the EmblemHealth Provider Manual.
Contracted time frames in provider agreements will supersede time frames in this guide if your provider agreement provides for a longer time period. For facility time frames, see the Provider Manual or applicable agreement.
Clinic Visit Policy
If you provide clinic visits to our Medicare Advantage members that are owned and operated by a hospital, please review our clinic visit policy and correct coding requirements. ConnectiCare will monitor compliance with this policy and may recoup payment from providers for not following it.
Reminder: For services rendered in place of service (POS) 19, off-campus hospital-owned locations, claims billed with the G0463 clinic code should include the Modifier PO.
Do Not Bill Dual Eligible and QMB Members for Any Medicaid Cost-Sharing
Medicare-Medicaid full dual eligible and QMB individuals who qualify to have their Medicare Parts A and B cost-share covered by their state Medicaid are not responsible for paying their Medicare Advantage plan cost-shares for Medicare-covered Part A and Part B services. Please do not balance bill these members.
Federal and state laws prohibit providers from balance billing Medicare-Medicaid dual eligible individuals for any Medicare deductibles, coinsurance, or copayments. All Medicare and Medicaid payments, if any, received for services provided to dual eligible individuals must be accepted as payment in full. To comply with this requirement, providers treating dual eligible and QMB individuals enrolled in ConnectiCare Medicare Advantage plans must do the following:
- Verify plan and Medicaid/QMB eligibility prior to providing a service.
- Do not bill the member or collect cost-sharing during the visit.
- Bill Connecticut State Medicaid for the member’s cost-share.
- Consider the claim as “paid in full,” regardless of the Medicaid or plan payment.
- Notify member in writing if you do not accept Medicaid and member is not a QMB.
Federal law and provider contracts prohibit Medicare (ConnectiCare) providers from balance billing beneficiaries with Medicare and QMB, and Medicaid providers from balance billing dual eligibles. Providers may reference Section 1902(n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997.
For ConnectiCare members, you can contact the Connecticut Department of Social Services at 800-842-8440 or visit their website.
Dispute Resolution
See Provider Appeals Process. Contracted time frames in provider agreements will supersede time frames in this guide to the extent that your provider agreement provides for more time.
Formularies
See our Medicare Formularies.
Help Members Stick with Their Medication Regimen by Using Our Mail Order Pharmacies and Free Pill Box
Taking medicines as prescribed (medication adherence) is important for treating and controlling chronic conditions. Clinicians play an important role in helping members stay adherent. Here are some steps as clinicians you can take to help members remain adherent:
- Talk to members about the importance of taking their medicines on time as prescribed.
- Remind members to track their refills and make an appointment for a new prescription before they run out.
- Educate members on the side effects of the medicines and how to treat them.
- Help identify and resolve barriers to members not taking their medicines as prescribed.
- Consider prescribing 90-day supply prescriptions for maintenance medicines.
- Consider prescribing generic drugs or less-expensive brand-name drugs on the member’s formulary if cost is a barrier.
- Talk to the member about potential state drug assistance programs or pharmaceutical prescription assistance programs that may be able to help with the cost of medicines.
- Educate members on pharmacy-based adherence tools that may help:
- Medicine synchronization (limit the member’s trip to the pharmacy for medicines).
- Compliance packing or blister packs.
- Auto refills.
- Encourage members to leverage available technologies (medicine reminder apps on their phone or tablet, like the Express Scripts mobile app).
Many of our plans offer generic drugs (Tier 1 and Tier 2) for $0 copay for members who get their refills through Express Scripts Preferred Mail Order pharmacy. Please help your members stay adherent and save on their prescription drugs by recommending members switch to preferred mail order:
Express Scripts Home Delivery Service
PO Box 66577
St. Louis, MO 63166-6577
or
Call: 877-866-5828 (TTY: 711)
SortPak – new mail delivery pharmacy
We have added a new compliance packaging pharmacy, SortPak, to help our Medicare providers and members organize medication refills and support medication adherence.
SortPak’s services include:
- Coordinating prescription and nonprescription maintenance medication refills, up to a 90-day supply, to ensure member receives all medicines at one time.
- Sorting medications into individual pouches organized by the day and hour.
- Delivering medications to the member’s doorstep with no additional delivery cost.
- Conducting medication adherence assessments.
- Contacting prescriber(s) at least one month in advance to check on the need for refills and sending refill reminders to the members.
If you have a member who could benefit from this type of service, you can:
- Call: 877-570-7787
- Fax: 877-475-2382
- Send e-scripts using:
- NCPDP/NABP: 0524733
- NPI number: 1063407252
- Mail: 124 S. Glendale Ave., Glendale, CA 91205
Free pill boxes
If you have a patient who needs help keeping their pills organized, let them know we offer free pill boxes to everyone, regardless of coverage.
A form for ordering the pill boxes along with a helpful video on medication adherence can be found on this web page:
Fraud, Waste, and Abuse
ConnectiCare expects its contracted providers to prevent and address fraud, waste, and abuse and to meet their annual training requirement. To learn about this important topic, see Medicare Learning Network’s Web-Based Training:
- Combating Medicare Parts C and D Fraud, Waste, & Abuse (Contact hours 30 min.)
Learn to spot fraud, waste, and abuse (FWA), identify methods to prevent FWA, identify how to report FWA, recognize how to correct FWA, and know potential consequences and penalties associated with violations. - Medicare Fraud & Abuse: Prevent, Detect, Report (Contact hours 88 min.)
Learn how to identify what Medicare considers fraud and abuse, provisions and penalties, and prevention methods and recognize how to report fraud and abuse.
If you have concerns about compliance issues that you wish to bring to our attention, please call toll-free, 24/7, at 844-I-COMPLY (844-426-6759). You can also report online at emblemhealth.alertline.com.
If you would specifically like to report concerns about fraud, waste, or abuse, please call 888-4KO-FRAUD (888-456-3728) or email the Special Investigations Unit at: kofraud@emblemhealth.com.
EmblemHealth/ConnectiCare will not retaliate against anyone who in good faith reports a compliance concern.
Required: SNP MOC Training
CMS requires Medicare providers to complete Special Needs Plan (SNP) Model of Care (MOC) training each year for each health plan’s MOC. Providers who care for ConnectiCare’s Medicare Advantage members with Choice Dual (HMO D-SNP) plan must complete this training. Choice Dual Vista members will be automatically enrolled into Choice Dual due to the closure of the former plan.
Notices are sent to providers months in advance of the due date. However, some providers have still not completed their training. Providers who do not complete the 2024 training by Nov. 30, 2024, will be referred to the ConnectiCare Credentialing Committee.
Cultural Competency Education
See these Cultural Competency Continuing Education and Resources to help you provide our members with care in the context of their cultural and linguistic needs.
Medicare Outpatient Observation Notice (MOON)
CMS requires all hospitals and critical access hospitals to provide Medicare beneficiaries, including Medicare Advantage enrollees, with the OMB-approved Medicare Outpatient Observation Notice (MOON). The MOON and instructions for completing it are available on CMS’ website.
Requirement for Medicare Providers Caring for Special Needs Plans Members
EmblemHealth and ConnectiCare Special Needs Plan (SNP) member benefits include coverage for face-to-face encounters between members and providers for the delivery of health care, care management, or care coordination services. Face-to-face encounters must occur, as practical and with the member’s consent, on at least an annual basis beginning within the first 12 months of SNP enrollment.
A face-to-face encounter must be either in-person or through a virtual (visual, real-time, and interactive) encounter. Medicare providers caring for SNP members will be required to obtain the member’s consent for face-to-face virtual encounters.
When a provider reaches out to conduct a face-to-face virtual encounter with a SNP member, consent must be obtained from the SNP member prior to, or when scheduling, the encounter. At the time of the scheduled virtual encounter, the provider must inform the member on the purpose and intended outcomes of the visit.
At least annually, EmblemHealth and ConnectiCare care managers will review member usage history data to identify members who require outreach and face-to-face scheduling. All data collected will be reviewed with providers during the interdisciplinary care team (ICT) meetings.
Additional requirements
As a reminder, when caring for SNP members, providers must also:
- Actively participate in the SNP member’s ICT and individualized care plan (ICP) development and implementation.
- Follow care transitions protocol.
- Use guidance from:
- ConnectiCare’s medical coverage criteria and clinical practice guidelines.
- EmblemHealth’s medical policies and clinical practice guidelines.
- Complete SNP model of care training annually for ConnectiCare and EmblemHealth.
- Encourage SNP members to complete their surveys:
- Health assessment
- Consumer Assessment of Healthcare Providers and Systems (CAHPS®).
- Health Outcomes Survey (HOS).
Below are some additional resources to help you manage the health of your SNP patients:
