Section 6: Blue Shield Medicare Advantage Plan Table of Contents 6.1 Blue Shield Medicare Advantage Plan Program Overview Introduction ...................................................................................................................................... 6.1 - 1 Blue Shield Medicare Advantage Plan Program Overview ............................................................. 6.1 - 1 Blue Shield Medicare Advantage Plan Service Areas ..................................................................... 6.1 - 2 Blue Shield Medicare Advantage Plan Provider Network ............................................................... 6.1 - 3 Medicare Part D Prescriber Preclusion List ..................................................................................... 6.1 - 3 Blue Shield Medicare Advantage Plan Compliance Program .......................................................... 6.1 - 4 Auditing and Monitoring ........................................................................................................... 6.1 - 6 Confirmation of Eligibility of Participation in the Medicare Program ..................................... 6.1 - 6 Fraud, Waste, and Abuse........................................................................................................... 6.1 - 7 Medicare Compliance and Fraud, Waste, and Abuse Training Requirements .......................... 6.1 - 8 Model of Care ........................................................................................................................... 6.1 - 8 6.2 Blue Shield Medicare Advantage Plan Benefits and Exclusions Blue Shield Medicare Advantage Plan Benefits .............................................................................. 6.2 - 1 Medicare Part D Covered Drug ................................................................................................. 6.2 - 1 Medication Therapy Management Program .............................................................................. 6.2 - 2 Premiums and Copayments or Coinsurance .............................................................................. 6.2 - 3 Inpatient Benefits ...................................................................................................................... 6.2 - 4 Outpatient Benefits .................................................................................................................... 6.2 - 4 Outpatient Prescription Drugs ................................................................................................... 6.2 - 4 Non-Formulary Outpatient Prescription Drugs ......................................................................... 6.2 - 5 Vision Services.......................................................................................................................... 6.2 - 7 Hearing Services ....................................................................................................................... 6.2 - 7 Optional Buy-Up Services (Group Members Only) .................................................................. 6.2 - 7 National Medicare Coverage Determinations .................................................................................. 6.2 - 8 Exclusions to Blue Shield Medicare Advantage Plan Benefits ........................................................ 6.2 - 9 General Benefit Exclusions ....................................................................................................... 6.2 - 9 Prescription Drug Benefit Exclusions ....................................................................................... 6.2 - 11 6.3 Blue Shield Medicare Advantage Plan Enrollment and Eligibility Blue Shield Medicare Advantage Plan Eligibility Criteria .............................................................. 6.3 - 1 Lock-In Election Rules .................................................................................................................... 6.3 - 2 Enrollment Periods ........................................................................................................................... 6.3 - 3 Annual Election Period (AEP) .................................................................................................. 6.3 - 3 Initial Coverage Election Period (ICEP) ................................................................................... 6.3 - 3 Initial Enrollment Period for Part D (IEP for Part D) ............................................................... 6.3 - 3 Open Enrollment Period for Institutionalized Individuals (OEPI) ............................................ 6.3 - 4 Special Election Periods (SEP) ................................................................................................. 6.3 - 4 Medicare Advantage Open Enrollment Period (MA OEP) ....................................................... 6.3 - 5 Effective Date of Coverage .............................................................................................................. 6.3 - 6 Monthly Eligibility Reports ............................................................................................................. 6.3 - 7 Blue Shield Medicare Advantage Plan Coordination of Benefits (COB) ........................................ 6.3 - 8 Blue Shield of California Section 6 TOC Page 1 HMO IPA/Medical Group Manual May 2021 Section 6: Blue Shield Medicare Advantage Plan Table of Contents (cont’d.) 6.4 Blue Shield Medicare Advantage Plan Network Administration IPA/Medical Group Responsibilities ............................................................................................... 6.4 - 1 Access to Medical Services ....................................................................................................... 6.4 - 1 Provider Requests to Transfer or Disenroll Blue Shield Medicare Advantage Plan Members ............................................................................................................................. 6.4 - 2 Exclusion of Providers from the Network ................................................................................. 6.4 - 6 Exclusions from Medicare and Limitations on Medicare Payment. ......................................... 6.4 - 7 Continuation of Benefits ........................................................................................................... 6.4 - 8 Transition of Care / Financial Responsibility Upon Enrollment /Disenrollment ...................... 6.4 - 8 Member Billing ......................................................................................................................... 6.4 - 9 Hospice Billing .......................................................................................................................... 6.4 - 10 Physician Billing Instructions for Non-Hospice Services ......................................................... 6.4 - 11 Subcontracting Requirements ................................................................................................... 6.4 - 12 Division of Financial Responsibility ................................................................................................ 6.4 - 12 IPA/Medical Group Reimbursement ................................................................................................ 6.4 - 12 Blue Shield Medicare Advantage Plan Claims Administration ....................................................... 6.4 - 13 Medicare Regulations and Payment to Non-Contracted Providers ........................................... 6.4 - 13 Professional Stop-Loss Requirements for Blue Shield Medicare Advantage Plan Members ............................................................................................................................. 6.4 - 14 6.5 Blue Shield Medicare Advantage Plan Medical Care Solutions Blue Shield Medicare Advantage Plan Medical Care Solutions Program ....................................... 6.5 - 1 Health Risk Assessment ............................................................................................................ 6.5 - 1 Individualized Care Plan for Dual Eligible Special Needs Plan (D-SNP Members) ................ 6.5 - 1 Medical Care Solutions Guidelines .................................................................................................. 6.5 - 2 Emergency Services .................................................................................................................. 6.5 - 2 Skilled Nursing Facility (SNF) Admissions/Transfers .............................................................. 6.5 - 2 Second Opinions ....................................................................................................................... 6.5 - 2 IPA/Medical Group Responsibilities ............................................................................................... 6.5 - 3 Reporting End Stage Renal Disease (ESRD) Members ............................................................ 6.5 - 10 Blue Shield Medicare Advantage Plan Responsibilities .................................................................. 6.5 - 11 6.6 Blue Shield Medicare Advantage Plan Member Rights and Responsibilities Member Rights and Responsibilities ............................................................................................... 6.6 - 1 Member Grievance Procedures ........................................................................................................ 6.6 - 9 Member Complaint and Appeals Resolution ..................................................................................