Introduction

Gateway Health Plan Medicare Assured^® HMO’s success, as measured by the benefits received by the practitioners, members, the Centers for Medicare and Medicaid Services (CMS) and Gateway Health Plan^® (“Gateway”), is dependent upon strong educational processes. Understanding Gateway’s policies and procedures is essential. Gateway’s Provider Relations, Provider Services, Member Services, and Member Outreach staff, among others, is committed to providing accurate, up-to-date, and comprehensive information to our member and practitioner populations through prompt and dedicated service. The Provider Office Policy and Procedure Manual is one way of providing participating practitioner offices with information regarding Gateway’s policies and procedures. This manual should be considered as a general guideline for practitioner offices. The manual is a ready reference and is designed to be updated as needed. Please retain all updates with your manual.

This Manual and any updates can also be found at our website: www.gatewayhealthplan.com. Choose the link for Medicare Assured^® HMO.

Overview of Gateway Health Plan Medicare Assured^® HMO

History

In 2005, Gateway Health Plan^® was awarded a contract by CMS to provide Medicare Part A, Part B and Part D services to dual eligible beneficiaries in Pennsylvania beginning January 2006. Gateway Health Plan^® expanded into Ohio effective January 2007.

Gateway Health Plan Medicare Assured^® HMO is a Medicare Advantage HMO Special Needs Plan for individuals with Medicare Part A, Medicare Part B and Medicaid (Full Medicaid or Qualified Medicare Beneficiary (QMB)).

As of 2009 Gateway Health Plan Medicare Assured^® HMO is offered in 27 counties throughout the state of Pennsylvania, making it one of the largest plans of its kind in the country.

Gateway offers the following benefits to members enrolled in Medicare Assured^® HMO:

All the benefits of Original Medicare
Prescription drug coverage
Hearing, vision, and dental benefits
Health and wellness education, such as heart disease, diabetes and asthma programs, and smoking cessation
Bathroom safety products
Fitness Assured^®, a fitness program to help members stay active (including an @Home Pak for home-bound members)
Transportation

Gateway is dedicated to providing benefits to the Medicare and Medicaid populations to meet their medical and social needs. The specific needs of our membership have led to Gateway’s development of wellness, education and outreach programs to improve immunization compliance, to identify high-risk pregnant women, and to provide effective case management for members with chronic conditions such as Asthma, Diabetes, chronic heart conditions, and HIV/AIDS.

Mission

Gateway emphasizes the development and delivery of innovative programs to positively affect the personal health of its members. Gateway maintains a healthcare delivery system that ensures the availability of high quality medical care for the Gateway member, based upon access, quality and financial soundness.

Prospective Care Management

Gateway’s goal is to help improve the health and well-being of its members. In an ongoing effort to accomplish this goal, Gateway developed Prospective Care Management (PCM^®), a proactive holistic approach to healthcare. By identifying the Behavioral, Environmental, Economic, Medical, Social and Spiritual (BEEMSS^SM) issues a member faces, Gateway can design a plan to ensure that the member receives the care he or she needs.

Gateway Lines of Business
Gateway offers two products in Pennsylvania

Medicare Special Needs Plan
Medicaid HMO available

Unlike many health insurance companies, Gateway focuses entirely on serving the needs of the most vulnerable citizens – the poor, elderly and disabled. Since its inception, Gateway has focused on providing the best possible healthcare to a growing number of Medicaid members. Gateway offers care for all kinds of health needs – everything from regular doctor visits to emergency care.

In 1992, Gateway Health Plan^®, Inc. was established as an alternative to Pennsylvania’s Department of Public Welfare’s Medical Assistance Program. For more than 15 years, members have benefited from services such as disease management, health and wellness programs and preventive care. Gateway Health Plan^® holds an “Excellent” rating from the National Committee for Quality Assurance (NCQA), an independent agency that accredits and certifies managed care organizations, for its Medicaid HMO product. Gateway Health Plan^® is also recognized with a five-star “Excellent” Member Quality Rating from the 2008 CAHPS Survey.

Membership/Network

Gateway Health Plan Medicare Assured^® HMO serves more than 24,000 members in Pennsylvania. Gateway Health Plan^® has more than 255,000 members. Gateway’s provider network includes more than 8,000 health care providers, over 100 hospitals, a network of pharmacies, home healthcare agencies and other related healthcare providers.

Continuing Quality Care

Healthcare is an ever-changing field and Gateway strives to stay on top of its members’ needs. Gateway is committed to continuous improvement and providing high standards of quality in every aspect of service. This commitment is led by Gateway’s 18-member Quality Improvement/Utilization Management committee, made up of experts in a wide variety of medical fields. The QI/UM Committee evaluates Gateway’s ongoing efforts as well as new protocols and clinical guidelines in order to improve service and care for its members.

Wellness & Disease Management

Gateway is committed to improving the life of its members and working to find new ways to promote wellness, illness prevention and health education as demonstrated by the following programs:

Preventive health care guidelines
Free quit tobacco program
Pediatric and adult immunization reminders
Cardiac disease prevention program
Free personalized programs to assist patients with diabetes, asthma and depression

Health Care Disparities

Gateway understands that in order to help improve the quality of life in our members, we must take into account their cultural and linguistic differences. For this reason, addressing disparities in health care is high on our leadership’s agenda. We believe a strong patient-provider relationship is the key to reducing the gap in unequal health care access and health care outcomes due to cultural and language barriers. Gateway is continuously working to close the gap in health outcomes by focusing on education and prevention. One example of how we are working to close the quality gap can be seen in our culturally sensitive diabetes disease management programs. In order to improve information based interventions at the point of care, Gateway pays for primary care practitioners to perform in office HbA1c tests. Test results are available in five minutes and can be administered by a non-clinician. For more information, please contact your Provider Relations Representative. In addition, Gateway has cross-cultural education programs in place to increase awareness of racial and ethnic disparities in health care among our employees, members and providers.

Community Involvement

Gateway is an active partner in the community through many outreach and community based activities. Gateway strives to improve the health and quality of life of its members as well as the community-at-large.

Gateway participates in community events and sponsorships and provides assistance to community and social agencies that also serve a high-risk, vulnerable population.
Gateway continually develops a variety of outreach programs for adults and children to provide education on health, wellness and safety issues. These programs are offered to the community at no cost.
Gateway informs and partners with individuals and organizations through the Health Literacy Initiative. The goal of the initiative is to develop and implement programs that positively impact health and well-being by helping people better understand and navigate the healthcare system.

Benefits of Gateway Health Plan Medicare Assured^® HMO

Gateway is a "win-win" situation for all: the member, the practitioner and applicable state or federal agencies.

Benefits to the Gateway Health Plan Medicare Assured^® HMO Member: In addition to receiving added benefits currently not covered by Medicare, Gateway members enjoy improved access to primary medical care, health and wellness programs and 7-days a week assistance from Gateway's Member Services Department.

Benefits to the Practitioner: Timely payments, simplified administrative procedures and dedicated provider servicing are benefits of being a Gateway Health Plan Medicare Assured^® HMO practitioner.

Benefits to Gateway: Gateway benefits by fulfilling our mission, which ensures the availability of high quality medical care for the dual eligible population to positively affect the personal health of our members.

How Does Gateway Work?

Gateway's Medicare Assured^® HMO Practitioner Network

Gateway contracts directly with primary and specialty care practitioners, hospitals, and ancillary providers to provide care for our membership. Practitioners and other healthcare providers are chosen in such a manner that existing patterns of care, including patterns of hospital admissions, can be maintained. Participating practitioners treat patients in their offices as they do their non-Gateway patients, and agree not to discriminate in the treatment of or in the quality of services delivered to Gateway's members on the basis of race, sex, age, religion, place of residence, or health status. Because of the cultural diversity of our membership, participating practitioners must be culturally sensitive to the needs of our members. Participation in Gateway Health Plan Medicare Assured^® HMO in no way precludes participation in any other program that the practitioner is or may wish to affiliate.

Gateway Provider Relations Role

We are keenly aware that, to provide exceptional access and quality of health care to our members, it is essential that our providers and their staff have a solid understanding of the member’s needs, our contract requirements and other protocols, as well as applicable contract standards and Federal and/or State regulations.

Within 30 calendar days of successful completion of provider credentialing and approval to participate in our network our Provider Relations Department provides introductory training to providers and their office staff. The Provider Manual is delivered and reviewed in detail at this on-site orientation. This provider training familiarizes new providers and their staff with Gateway’s policies and procedures.

Each participating primary care practice, specialty care practice and hospital is assigned a Provider Relations Representative, who is responsible for ongoing education in their assigned Service Region. As a follow-up to the initial orientation session, the assigned Provider Relations Representative regularly contacts each provider and their staff to ensure that they fully understand the responsibilities outlined in the Provider Agreements and Manual.

Primary Care Practitioner's Role

The definition of a primary care practitioner is a "specific practitioner or practitioner group who is responsible for supervising, prescribing, and providing primary care services; locating, coordinating, and monitoring other medical care and rehabilitative services and maintaining continuity of care on behalf of a member. "The primary care practitioner is responsible for the coordination of a member's healthcare needs and access to services provided by hospitals, specialty care practitioners, ancillary services and other healthcare services.

Although members may obtain some healthcare services by self-referral, the majority of their healthcare services are obtained either directly from or upon referral by the primary care practitioner. With the exception of self-referred services, all the member's care must be provided or referred (a paper referral form is not required) by the primary care practitioner except in a true medical emergency when time does not permit a member to contact their primary care practitioner. To ensure continuity and coordination of care, when a member self-refers for care, a report should be forwarded to the primary care practitioner. By focusing all of a member's medical decisions through the primary care practitioner, Gateway is able to provide comprehensive and high quality care in a cost-effective manner.

Our goal is to work together with a dedicated group of practitioners to make a positive impact on the health of our membership and truly make a difference.

Outpatient Mental Health Providers

Gateway Health Plan Medicare Assured^® HMO provides coverage for outpatient mental health services for its Pennsylvania and Ohio membership through Community Behavioral Healthcare Network of Pennsylvania (CBHNP).

Please call CBHNP to access a participating network provider in the member's area.

Also, if you have a member who needs additional assistance in accessing an outpatient mental health provider or has questions, please direct the member to call CBHNP. (Refer to the Quick Reference section for the appropriate telephone number.)

Contracts/No Gag Clause

Gateway allows open practitioner-patient communication regarding appropriate treatment alternatives without penalizing practitioners for discussing medically necessary or appropriate care for the patient. All of Gateway’s contracts with practitioners and providers include an affirmative statement indicating that the practitioner can freely communicate with patients regarding the treatment options available to them, including medication treatment options available to them, regardless of benefit coverage limitations. There is no language in Gateway’s contracts that prohibits open clinical dialogue between practitioner and patient.

Quality Improvement

Purpose of the Quality Improvement Program

The Quality Improvement (QI) Program’s purpose is to ensure the quality, safety, appropriateness, timeliness, availability and accessibility of care and service provided to Gateway members. The comprehensive evaluation and assessment of clinical, demographic, and community data in conjunction with current scientific evidence is paramount to understanding the membership and developing effective programs to meet the identified needs. The development of health care programs must be done in collaboration with all partners including members, practitioners, community agencies, regulators, and Gateway staff, not only to meet the current health care needs of the members served but to begin to address the future needs of the members. Essential to the success of these partnerships and programs is the establishment of meaningful data collection and measurement of outcomes to assess the improvements in the quality of care and to identify where opportunities exist for improvement.

Goal of the Quality Improvement Program

The QI Program focuses on monitoring and evaluating the quality and appropriateness of care provided by Gateway’s health care provider network, and the effectiveness and efficiency of systems and processes that support the health care delivery system. Utilizing quality improvement concepts and appropriately recognized quality measurement tools and reports, Gateway focuses on assessing its performance outcomes to identify opportunities for improvement in the provision and delivery of health care and health plan services, satisfaction with care and services, and achieving optimum member health outcomes.

Of specific importance, the QI Program focuses on three key areas: (a) preventive health care, (b) prevalent chronic health care conditions and (c) service indicators. The Program strives to improve members’ compliance with preventive care guidelines and disease management strategies, therapies that are essential to the successful management of certain chronic conditions, and identify opportunities to impact racial and ethnic disparities in healthcare. Also, the QI Program strives to improve patient safety by educating members and practitioners in regard to safe practices, by assessing and identifying opportunities to improve patient safety throughout the practitioner/provider network and by communicating to members and practitioners safety activities and provisions that may be in place throughout the network.

By considering population demographics and health risks, utilization of health care resources, and financial analysis, the organization ensures that the major population groups are represented in QI activities and health management programs chosen for assessment and monitoring. This information, along with high-volume/high-cost medical and pharmaceutical reports, health risk appraisal data, disease management and care management data, satisfaction survey information, and other utilization reports, will be used to identify members with special needs and/or chronic conditions and develop programs and services to assist in managing their conditions.

Objectives of the Quality Improvement Program

The objectives of the QI Program are consistent with Gateway’s mission, commitment to effective use of health care resources, and to continuous quality improvement. To ensure that the current needs of the population are being reviewed, changes noted, programs implemented to address the needs of members, and to ensure continuous quality improvement, an annual QI/UM Work Plan is developed in conjunction with the Utilization Management Department. The QI/UM Program is assessed on an annual basis to determine the status of all activities and identify opportunities that meet the QI/UM Program objectives.

Objectives are as follows:
Implement a QI/UM Work Plan that identifies and assures completion of planned activities for each year:

Ensure processes are in place using Total Quality Management values to assess, monitor, and implement actions when opportunities are identified regarding the utilization of health care resources, quality of care, and access to services;
Based on assessment of the population, develop and update guidelines that address key health care needs, which are based on scientific evidence and recommendations from expert and professional organizations and associations;
Conduct studies to measure the quality of care provided, including established guideline studies, evaluate improvements made, determine barriers and opportunities and develop actions to address those opportunities;
Evaluate the utilization and quality performance of Gateway practitioners and vendors to assure Gateway standards are met and to identify both opportunities and best practices. In a group effort with practitioners and vendors, identify barriers, opportunities and apply interventions as needed;
Conduct satisfaction surveys to determine member and provider satisfaction with Gateway services, organizational policies, and the provision of health care. Review results for barriers, opportunities and apply interventions to increase satisfaction and to improve the quality of care and services provided.

Scope of the Quality Improvement Program

Implementation and evaluation of the QI Program is embedded into Gateway’s daily operations. The QI Program has available and will utilize appropriate internal resources, race and ethnic data, information systems, practitioners, and community resources to monitor and evaluate utilization of health care patterns, the continuous improvement process and to assure implementation of positive change. The scope of the program includes:

The scope of the Program includes:

Enrollment
Members' Rights and Responsibilities
Network Accessibility and Availability, including those related to Special Needs
Network Credentialing/Recredentialing
Medical Record Standards
Quality of Care Case Reviews
Member, Provider and Employee Education
Member and Provider Services
Claims Administration
Fair, Impartial and Consistent Utilization Review
Evaluating the Health Care Needs of Members
Preventive Health, Disease Management, and Case Management Services
Clinical Outcomes
Oversight of Delegated Activities
Patient Safety
Continuous Quality Improvement using Total Quality Management Principles

To request a copy of the Quality Improvement Program, Work Plan or Annual Evaluation please contact Gateway's Provider Services Department at 1-800-685-5205.

Quality Improvement Manual

The Quality Improvement Manual is designed as a resource to assist practitioners in caring for Gateway members. The manual consists of clinical practice and preventive guidelines that are developed using evidence-based clinical guidelines from recognized sources or through involvement of board-certified practitioners from appropriate specialties when the guidelines are not from recognized sources. The guidelines are evaluated on an ongoing basis and are developed based on the prevalent diseases or conditions and relevance to Gateway members. The use of guidelines permits Gateway Health Plan ^® to measure the impact of the guidelines on outcomes of care and may reduce inter-practitioner variation in diagnosis and treatment.

Clinical practice and preventive guidelines are not meant to replace individual practitioner judgment based upon direct patient contact. The manual consists of an introductory page, along with the following guidelines: Adult HIV Clinical Practice Guideline, Adult Preventive, Care of Adults with Diabetes Mellitus, Child Preventive, Cardiac Medical Management, Hypertension, Lead Screening and Follow-up Guideline, Management of the Patient with Asthma and, Prenatal Care. In addition to the guidelines, the Medical Record Review procedure and standards are included. To facilitate distribution of the most current version of these guidelines and standards, they have been added to Gateway’s web site at www.GatewayHealthPlan.com. A paper copy of the Quality Improvement Manual and individual guidelines are available upon request. For a paper copy, please contact the Quality Improvement Department at 412-255-1144.

Patient Safety

Patient safety is the responsibility of every healthcare professional. Health care errors can occur at any point in the health care delivery system and can be costly in terms of human life, function, and health care dollars. There is also a price in terms of lost trust and dissatisfaction experienced by both patients and health care practitioners.

There are ways practitioners can develop a Patient Safety Culture in their practice. Clear communication is key to safe care. Working in collaboration with members of the multidisciplinary care team, hospitals, other patient care facilities and including the patient as an important member of his care team are critical. Examples of safe practices include providing instructions to patients in terms they can easily understand, writing legibly when documenting orders or prescribing, and avoiding abbreviations that can be misinterpreted. Read all communications from specialists and send documentation to other providers, as necessary, to assure continuity and coordination of care. When calling orders over the telephone, have the person on the other end repeat the information back to you.

Collaborate with hospitals and support their safety culture. Bring patient safety issues to the committees you attend. Report errors to your practice or facility’s risk management department. Offer to participate in multidisciplinary work groups dedicated to error reduction. Ask Gateway’s Quality Improvement Department how you can support compliance with our safety initiatives.

Gateway also works to ensure patient safety by monitoring and addressing quality of care issues identified through pharmacy utilization data, continuity and coordination of care standards, sentinel/adverse event data, Disease Management Program follow-up, and member complaints.

If you would like to learn more about patient safety visit these web sites:

Institute of Medicine report: To Err is Human-Building a Safer Health Care System
http://www.nap.edu/books/0309068371/html

JCAHO National Patient Safety Goals
http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals

National Patient Safety Foundation
http://www.npsf.org

The Leapfrog Group for Patient Safety
http://www.leapfroggroup.org

Agency for Healthcare Research and Quality
http://www.ahrq.gov

Medical Record Reviews
Gateway performs several different medical record reviews to:

Help ensure quality services are provided
Allow for proper disease management
Respond to regulator’s requests
Facilitate accurate and complete data is sent to CMS
Allow for proper risk scoring by CMS of each member

Complete and accurate coding is essential for Gateway to accomplish the above objectives and our mission.

Living Will Declaration

Advance Directives

The Omnibus Budget Reconciliation Act (OBRA) of 1990 included substantive new law that has come to be known as the Patient Self-Determination Act and which largely became effective on December 1, 1991.

The Patient Self-Determination Act applies to hospitals, nursing facilities, providers of home health care or personal care services, hospice programs and health maintenance organizations that receive Medicare or Medicaid funds. The primary purpose of the act is to ensure that the beneficiaries of such care are made aware of advance directives and are given the opportunity to execute them if they so desire. It is also to prevent discrimination in care if the member chooses not to execute advance directives.

As a participating provider within the Gateway Health Plan Medicare Assured^® HMO network, you are responsible for determining if the member has executed an advance directive and for providing education when it is requested. You can also request a copy of a “Living Will” form from the Quality Improvement Department by calling 412-255-1144. There is no governmentally mandated form. A copy of the “Living Will” form should be maintained in the medical record. Gateway’s Medical Record Review Standards state that providers should ask members age 21 and older whether they have executed an advance directive and document the response.

Providers will receive educational material regarding member’s rights to advance directives upon entering the Gateway practitioner network.

Member Outreach

Gateway practitioners can request assistance from the Member Services Department to provide additional education to members who need further explanation on such issues as the importance of keeping scheduled appointments.

Practitioners can refer non-adherent members for additional education regarding their benefits and services by completing a Member Outreach Form, which can be found in the Forms and Reference Material Section of this Manual. A Gateway representative will contact the member and follow-up with the practitioner at the practitioner’s request.

For more information, or to request member outreach, please call Gateway’s Care Management Department at 1-800-685-5212 and press option 4. You can also fax the Member Outreach Form to the fax number listed on the Form.